Subsequent Health Care Costs Research Articles

Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study.

BackgroundLow health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans’ health literacy and their subsequent VHA health care costs across a three-year period.MethodsThis retrospective study used a Generalized Linear Model to estimate the relative association between a patient’s health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years.ResultsIn a study of 92,749 veterans with service utilization from 2007–2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans’ with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy.ConclusionsAnalyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.

Are Needs Assessments Cost Effective in Reducing Distress Among Patients With Cancer? A Randomized Controlled Trial Using the Distress Thermometer and Problem List

Patients with cancer have a high prevalence of distress. We evaluated whether distress monitoring and needs assessment using the Distress Thermometer and Problem List (DT&PL) improved patient outcomes. We conducted an unblinded, two-arm, parallel randomized controlled trial at two sites among patients starting radiotherapy or chemotherapy. The intervention group completed the DT&PL, rating distress and discussing sources of distress with a trained radiographer/nurse. No specific triage algorithms were followed. The control group received usual care. The main outcome measure was psychological distress (Profile of Mood States [POMS], short form) up to 12 months; secondary outcomes were quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30) and health care costs. Of 220 patients randomly assigned, 112 patients were allocated to the DT&PL. Ninety-five percent completed the primary outcome at 12 months. The DT&PL took 25 minutes; one third of patients had high levels of distress, and most reported physical (84%) or emotional (56%) problems. There was no evidence of an effect of the DT&PL on adjusted POMS scores over follow-up (difference between groups, -1.84; 95% CI, -5.69 to 2.01; P = .35) or in secondary outcomes. The DT&PL cost £19 ($28) per patient and did not lower subsequent health care costs. Few patients (< 3%) in either arm of the trial were referred to a clinical psychologist. Patients with cancer have a high prevalence of distress. Needs assessment can be performed quickly and inexpensively. However, the DT&PL was not cost effective in improving patient mood states. It is important to explore the reasons for this so that oncology units can design better services to support patients.

Screening Alone Is Not Enough: The Importance of Appropriate Triage, Referral, and Evidence-Based Treatment of Distress and Common Problems

Hollingworth et al are to be commended on their careful execution of this study, including an adequately powered sample size, long follow-up period, and the addition of a thorough economic analysis, which is rarely undertaken in the context of psychosocial interventions. This is particularly important in countries with nationalized health care systems such as the United Kingdom, where changes to practice may often be widely implemented without knowledge of the economic implications. In general, psychosocial interventions tend to pay for themselves many times over in subsequent cost-offsets, but this needs to be examined carefully on a case-by-case basis before widespread implementation. In this study, implementation of the screening-for-distress program did not result in lower subsequent health care costs. However, despite several strengths, major study design limitations may explain this result, temper interpretations, and inform further clinical implementation of screening for distress programs. Though the authors have called their program a needs assessment in their report, the background literature, tools chosen, and the analysis and outcome measures seem to have been designed to test a distress-screening intervention, and my editorial considers the shortcomings of the study in such light. For distress screening programs to be efficacious, three things have to happen: broad identification of patients potentially in need (using the screening tool), further assessment and triage to appropriate services (by adequately trained staff), and evidence-based treatment of symptoms and problems (also by adequately trained professionals across a variety of disciplines). Specific evidence-based treatments would depend on the problems identified but could include cognitive-behavioral therapy, stress reduction, fatigue management, exercise, resource counseling, or family counseling. While step one was followed in this trial, step two did not happen, and therefore step three didn’t even have a chance. The major design limitations around these omissions include confounding of treatment and control arms; lack of training of implementation staff; and, most seriously, not following evidence-based triage and referral algorithms (ie, screening and assessment applied as if it were treatment). The staff who delivered the intervention was the same in both the treatment arm, which implemented the screening tool, and the control arm, which did not. Hence, there is concern of a contamination or spill-over effect into the usual care control arm from the distress-screening training for the intervention, which would theoretically increase sensitivity toward psychosocial issues. This would be more of an issue in a trial that showed benefit in both arms. In this case, the result was no benefit in either arm, which mitigates concerns about contamination but raises questions of the adequacy of staff training. Indeed, the training received by the nurses and radiographers was one four-hour seminar “including an audiovisual example of Distress Thermometer and Problem List administration, role playing, and advice on dealing with strong emotions.” Hollingworth et al developed a directory of resources providing information on selfmanagement techniques, guidance for staff on when to refer patients, and lists of information resources and patient support groups. However, “referrals were at the discretion of the clinician,” so no specific triage algorithms were followed. Subsequent to this, staff members were expected to manage all arising patient concerns. Given this scenario and its departure from best practices in staff training, it is not at all surprising that no treatment effects were found. Regarding training, there has been a consistent call for staff education as a critical component in promoting effective and sustainable screening programs. It is widely acknowledged that successful implementation of screening programs depends on health professionals’ knowledge and skills; however, health professionals themselves have reported a perceived lack of skills in identifying distress and a lack of guidance around referral pathways. It is recommended that in addition to initial training, conducting ongoing training sessions may help to maintain the fidelity of the intended behavior change. In a recent implementation study of routine screenings for distress in the clinical environment using existing staff, we used a quality improvement methodology to address challenges in following screening protocols, which involved continually identifying and addressing areas in which process change was required. The work utilized continuing cycles of “plan-do-study-act,” in which clinical processes were reviewed and modified as required over a 6-month implementation period. In terms of how well standardized evidence-based triage and referral was implemented in this trial, although 37% of patients had high levels of distress and 84% and 56% reported physical or JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 31 NUMBER 29 OCTOBER 1

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD

The 2012 KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for Anemia in Chronic Kidney Disease provides clinicians with comprehensive evidence-based recommendations to improve patient care. In this commentary, we review these recommendations and the underlying evidence. Most recommendations are well reasoned. For some, the evidence is unclear and recommendations require some qualification. While the KDIGO guideline stresses the potential risks of intravenous iron therapy, withholding iron might have its own risks. The recommendation to avoid hemoglobin levels falling below 9 g/dL sets a lower bound of "acceptability" that may increase blood transfusion. Given the lack of research supporting the optimal transfusion strategy for end-stage renal disease patients, it is difficult to weigh the risks and benefits of red blood cell transfusion. We find a paucity of evidence that hemoglobin concentration targeted between 11 and 11.5 g/dL is associated with a safety risk. Although the evidence that erythropoiesis-stimulating agent use improves patient quality of life is poor, it is possible that the instruments used to measure quality of life may not be well attuned to the needs of chronic kidney disease or dialysis patients. Our last section focuses specifically on the recommendations to treat anemia in children.

Tibia shaft fractures: costly burden of nonunions

BackgroundTibia shaft fractures (TSF) are common for men and women and cause substantial morbidity, healthcare use, and costs. The impact of nonunions on healthcare use and costs is poorly described. Our goal was to investigate patient characteristics and healthcare use and costs associated with TSF in patients with and without nonunion.MethodsWe retrospectively analyzed medical claims in large U.S. managed care claims databases (Thomson Reuters MarketScan®, 16 million lives). We studied patients ≥ 18 years old with a TSF diagnosis (ICD-9 codes: 823.20, 823.22, 823.30, 823.32) in 2006 with continuous pharmaceutical and medical benefit enrollment 1 year prior and 2 years post-fracture. Nonunion was defined by ICD-9 code 733.82 (after the TSF date).ResultsAmong the 853 patients with TSF, 99 (12%) had nonunion. Patients with nonunion had more comorbidities (30 vs. 21, pre-fracture) and were more likely to have their TSF open (87% vs. 70%) than those without nonunion. Patients with nonunion were more likely to have additional fractures during the 2-year follow-up (of lower limb [88.9% vs. 69.5%, P < 0.001], spine or trunk [16.2% vs. 7.2%, P = 0.002], and skull [5.1% vs. 1.3%, P = 0.008]) than those without nonunion. Nonunion patients were more likely to use various types of surgical care, inpatient care (tibia and non-tibia related: 65% vs. 40%, P < 0.001) and outpatient physical therapy (tibia-related: 60% vs. 42%, P < 0.001) than those without nonunion. All categories of care (except emergency room costs) were more expensive in nonunion patients than in those without nonunion: median total care cost $25,556 vs. $11,686, P < 0.001. Nonunion patients were much more likely to be prescribed pain medications (99% vs. 92%, P = 0.009), especially strong opioids (90% vs. 76.4%, P = 0.002) and had longer length of opioid therapy (5.4 months vs. 2.8 months, P < 0.001) than patients without nonunion. Tibia fracture patterns in men differed from those in women.ConclusionsNonunions in TSF’s are associated with substantial healthcare resource use, common use of strong opioids, and high per-patient costs. Open fractures are associated with higher likelihood of nonunion than closed ones. Effective screening of nonunion risk may decrease this morbidity and subsequent healthcare resource use and costs.

Initial Management Decisions After a New Consultation for Low Back Pain: Implications of the Usage of Physical Therapy for Subsequent Health Care Costs and Utilization

ObjectivesTo describe the utilization of physical therapy following a new primary care consultation for low back pain (LBP) and to examine the relations between physical therapy utilization and other variables with health care utilization and costs in the year after consultation. DesignRetrospective cohort obtained from electronic medical records and insurance claims data. SettingSingle health care delivery system. ParticipantsIndividuals (N=2184) older than 18 years with a new consultation for LBP from 2004 to 2008. InterventionsPatients were categorized as receiving initial physical therapy management if care occurred within 14 days after consultation. Main Outcome MeasuresTotal health care costs for all LBP-related care received in the year after consultation were calculated from claims data. Predictors of utilization of emergency care, advanced imaging, epidural injections, specialist visits, and surgery were identified using multivariate logistic regression. The generalized linear model was used to compare LBP-related costs based on physical therapy utilization and identify other cost determinants. ResultsInitial physical therapy was received by 286 of the 2184 patients (13.1%), and was not a determinant of LBP-related health care costs or utilization of specific services in the year after consultation. Older age, mental health, or neck pain comorbidity and initial management with opioids were determinants of cost and several utilization outcomes. ConclusionsInitial physical therapy management was not associated with increased health care costs or utilization of specific services following a new primary care LBP consultation. Additional research is needed to examine the cost consequences of initial management decisions made following a new consultation for LBP.

Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries

To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs; and to gain participants' perspective on experiencing whiplash injury, NHS treatment, and recovery within the context of the Managing Injuries of the Neck Trial (MINT). Two linked, pragmatic, randomised controlled trials. In Step 1, emergency departments (EDs) were cluster randomised to usual care advice (UCA) or The Whiplash Book advice (WBA)/active management advice. In Step 2, participants were individually randomised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions. An economic evaluation and qualitative study were run in parallel with the trial. Twelve NHS trusts in England comprising 15 EDs. People who attended EDs with an acute whiplash injury of whiplash-associated disorder grades I-III were eligible for Step 1. People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2. In Step 1, the control intervention was UCA and the experimental intervention was a psycho-educational intervention (WBA/active management advice). In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments. The primary outcome was the Neck Disability Index (NDI), which measures severity and frequency of pain and symptoms, and a range of activities including self-care, driving, reading, sleeping and recreation. Secondary outcomes included the mental and physical health-related quality-of-life (HRQoL) subscales of the Short Form questionnaire-12 items (SF-12) and the number of work days lost. A total of 3851 patients were recruited to Step 1 of the trial. 1598 patients attending EDs were randomised to UCA, and 2253 were randomised to WBA/active management. Outcome data were obtained at 12 months for 70% and 80% of participants at Step 1 and Step 2, respectively. The majority of people recovered from the injury. Eighteen per cent of the Step 1 cohort had late whiplash syndrome. There was no statistically or clinically significant difference observed in any of the outcomes for participants attending EDs randomised to UCA or active management advice [difference in NDI 0.5, 95% confidence interval (CI) -1.8 to 2.8]. In Step 2 the physiotherapy package resulted in improvements in neck disability at 4 months compared with a single advice session, but these effects were small at the population level (difference in NDI -3.2, 95% CI -5.8 to -0.7). The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up (difference -40.2, 95% CI -44.3 to -35.8). MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries. A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session. However, from a health-care perspective, the physiotherapy package was not cost-effective at current levels of willingness to pay. Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life. However, an important benefit of the physiotherapy package was a reduction in work days lost; consequently, the intervention may prove cost-effective at the societal level. Current Controlled Trials ISRCTN33302125. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 49. See the HTA programme website for further project information.

Long-term healthcare costs and functional outcomes associated with lack of remission in schizophrenia: a post-hoc analysis of a prospective observational study

BackgroundLittle is known about the long-term outcomes for patients with schizophrenia who fail to achieve symptomatic remission. This post-hoc analysis of a 3-year study compared the costs of mental health services and functional outcomes between individuals with schizophrenia who met or did not meet cross-sectional symptom remission at study enrollment.MethodsThis post-hoc analysis used data from a large, 3-year prospective, non-interventional observational study of individuals treated for schizophrenia in the United States conducted between July 1997 and September 2003. At study enrollment, individuals were classified as non-remitted or remitted using the Schizophrenia Working Group Definition of symptom remission (8 core symptoms rated as mild or less). Mental health service use was measured using medical records. Costs were based on the sites’ medical information systems. Functional outcomes were measured with multiple patient-reported measures and the clinician-rated Quality of Life Scale (QLS). Symptoms were measured using the Positive and Negative Syndrome Scale (PANSS). Outcomes for non-remitted and remitted patients were compared over time using mixed effects models for repeated measures or generalized estimating equations after adjusting for multiple baseline characteristics.ResultsAt enrollment, most of the 2,284 study participants (76.1%) did not meet remission criteria. Non-remitted patients had significantly higher PANSS total scores at baseline, a lower likelihood of being Caucasian, a higher likelihood of hospitalization in the previous year, and a greater likelihood of a substance use diagnosis (all p < 0.05). Total mental health costs were significantly higher for non-remitted patients over the 3-year study (p = 0.008). Non-remitted patients were significantly more likely to be victims of crime, exhibit violent behavior, require emergency services, and lack paid employment during the 3-year study (all p < 0.05). Non-remitted patients also had significantly lower scores on the QLS, SF-12 Mental Component Summary Score, and Global Assessment of Functioning during the 3-year study.ConclusionsIn this post-hoc analysis of a 3-year prospective observational study, the failure to achieve symptomatic remission at enrollment was associated with higher subsequent healthcare costs and worse functional outcomes. Further examination of outcomes for schizophrenia patients who fail to achieve remission at initial assessment by their subsequent clinical status is warranted.

Systematic review of serious games for medical education and surgical skills training

The application of digital games for training medical professionals is on the rise. So-called 'serious' games form training tools that provide a challenging simulated environment, ideal for future surgical training. Ultimately, serious games are directed at reducing medical error and subsequent healthcare costs. The aim was to review current serious games for training medical professionals and to evaluate the validity testing of such games. PubMed, Embase, the Cochrane Database of Systematic Reviews, PsychInfo and CINAHL were searched using predefined inclusion criteria for available studies up to April 2012. The primary endpoint was validation according to current criteria. A total of 25 articles were identified, describing a total of 30 serious games. The games were divided into two categories: those developed for specific educational purposes (17) and commercial games also useful for developing skills relevant to medical personnel (13). Pooling of data was not performed owing to the heterogeneity of study designs and serious games. Six serious games were identified that had a process of validation. Of these six, three games were developed for team training in critical care and triage, and three were commercially available games applied to train laparoscopic psychomotor skills. None of the serious games had completed a full validation process for the purpose of use. Blended and interactive learning by means of serious games may be applied to train both technical and non-technical skills relevant to the surgical field. Games developed or used for this purpose need validation before integration into surgical teaching curricula.

The Role of Continuing Care in 9-year Cost Trajectories of Patients With Intakes Into an Outpatient Alcohol and Drug Treatment Program

The importance of a continuing care approach for substance use disorders (SUDs) is increasingly being recognized. Our prior research found that a Continuing Care model for SUDs that incorporates 3 components (regular primary care, and specialty SUD and psychiatric treatment as needed) is beneficial to long-term remission. The study builds on this work to examine the cost implications of this model. To examine associations between receiving Continuing Care and subsequent health care costs over 9 years among adults entering outpatient SUD treatment in a private nonprofit, integrated managed care health plan. We also compare the results to a similar analysis of a demographically matched control group without SUDs. Longitudinal observational study. Measures collected over 9 years include demographic characteristics, self-reported alcohol and drug use and Addiction Severity Index, and health care utilization and cost data from health plan databases. Within the treatment sample, SUD patients receiving all components of Continuing Care had lower costs than those receiving fewer components. Compared with the demographically matched non-SUD controls, those not receiving Continuing Care had significantly higher inpatient costs (excess cost = $65.79/member-month; P < 0.01) over 9 years, whereas no difference was found between those receiving Continuing Care and controls. Although a causal link cannot be established between receiving Continuing Care and reduced long-term costs in this observational study, the findings reinforce the importance of access to health care and development of interventions that optimize patients receiving those services and that may reduce costs to health systems.

Cell Surface Glycosylation and Glycosaminoglycan Composition Profiles in Immature and Mature Intervertebral Disks

Introduction Back pain is a predominant cause of disability, and the major cause of this disability is intervertebral disk (IVD) degeneration.1 Proteoglycan (PG) content of the IVD is decreased during degeneration, and glycosaminoglycan (GAG) composition is altered.2 In this study, the cell surface glycosylation and GAG composition profiles of immature and mature ovine IVD tissue were profiled in an effort to understand potential signals involved in cell-extracellular matrix cross-talk during maturation and degeneration. Materials and Methods IVD tissue from L3-L4 and L4-L5 lumbar segments were harvested from 3- and 11-month-old animals. One portion of the tissue was fixed for histochemical profiling with a panel of fluorescently-labeled lectins ( Maackia amurensis agglutinin, Sambucus nigra agglutinin I, Ulex europaeus agglutinin I, Concanavalin A (jack bean lectin), Wisteria floribunda agglutinin). The remaining portion was digested with proteinase K and the sulfated GAG (s-GAG) content was quantified by dimethylmethylene blue (DMMB) assay. The digested tissue was treated with chondroitinase ABC (ChABC) and analyzed by HPLC. Results The glycosylation expression level differed between annulus fibrosus (AF) and nucleus pulposus (NP) tissue as indicated by quantitative analysis using lectin histochemistry. All lectins stained cells and extracellular matrix (ECM) of the IVD independently of the tissue type. The cells demonstrated greater lectin binding compared to the ECM and the intensity of staining differed according to the tissue-type. With maturity, the expression profiles of cell surface glycosylation changed, notably for the n a-(2?6)-linked sialic acid (SNA-I) and terminal GalNAc (WFA staining) expression with a 10-fold and 2-fold increase of expression at 11 months old, respectively. DMMB assay showed that NP tissue contained threefold more s-GAGs than AF and cartilage in 3-month-old samples. In the 11-month-old IVD samples, no difference was observed between AF and NP, but overall content of s-GAG was higher than cartilage. HPLC analysis of the ChABC-digested IVD tissue revealed that the quantity and ratio of s-GAG components differed from NP to AF tissue. Moreover, a change in sulfation pattern was observed with the maturity of the disk ( Fig. 1 ). Indeed, an inversion of the occurrence of Ddi-4S and Ddi-6S disaccharides was observed. A significant increase of Ddi-4S disaccharides with a significant decrease of Ddi-6S disaccharides was noted in the 11-month-old IVD AF tissue compared to 3 month old. A similar trend, albeit not significant, was observed for the NP tissue. Cartilage tissue did not present a significant difference in percentage of sulfated disaccharides with maturity. [Figure: see text] Conclusion GAG sulfation pattern was shown to change with maturation. Sulfation is critical for maintaining water content and specific patterns of sulfation are influential in cellular signaling and differentiation events. Furthermore, high changes in glycosylation profiles at a cellular and extracellular level were observed. A better understanding of these phenomena (sulfation and glycosylation profiles changes) will allow us to design therapeutic strategies for IVD regeneration. Acknowledgements AO Foundation (S-09-7P), Science Foundation Ireland, Research Frontiers Programme (07/RFP/ENMF482), Science Foundation Ireland, 07/SRC/B1163. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Fritz JM, et al., Physical therapy for ccute low back pain: Associations with subsequent healthcare costs. Spine 2008;33(16):1800–1805 O'Halloran D, et al. Tissue-engineering approach to regenerating the intervertebral disk. Tissue Engineering 2007;13(8):1927–1954

Cell Surface Glycosylation and Glycosaminoglycan Composition Profiles in Immature and Mature Intervertebral Disks

IntroductionBack pain is a predominant cause of disability, and the major cause of this disability is intervertebral disk (IVD) degeneration.1 Proteoglycan (PG) content of the IVD is decreased during degeneration, and glycosaminoglycan (GAG) composition is altered.2 In this study, the cell surface glycosylation and GAG composition profiles of immature and mature ovine IVD tissue were profiled in an effort to understand potential signals involved in cell-extracellular matrix cross-talk during maturation and degeneration.Materials and MethodsIVD tissue from L3-L4 and L4-L5 lumbar segments were harvested from 3- and 11-month-old animals. One portion of the tissue was fixed for histochemical profiling with a panel of fluorescently-labeled lectins (Maackia amurensis agglutinin, Sambucus nigra agglutinin I, Ulex europaeus agglutinin I, Concanavalin A (jack bean lectin), Wisteria floribunda agglutinin). The remaining portion was digested with proteinase K and the sulfated GAG (s-GAG) content was quantified by dimethylmethylene blue (DMMB) assay. The digested tissue was treated with chondroitinase ABC (ChABC) and analyzed by HPLC.ResultsThe glycosylation expression level differed between annulus fibrosus (AF) and nucleus pulposus (NP) tissue as indicated by quantitative analysis using lectin histochemistry. All lectins stained cells and extracellular matrix (ECM) of the IVD independently of the tissue type. The cells demonstrated greater lectin binding compared to the ECM and the intensity of staining differed according to the tissue-type. With maturity, the expression profiles of cell surface glycosylation changed, notably for the n a-(2?6)-linked sialic acid (SNA-I) and terminal GalNAc (WFA staining) expression with a 10-fold and 2-fold increase of expression at 11 months old, respectively.DMMB assay showed that NP tissue contained threefold more s-GAGs than AF and cartilage in 3-month-old samples. In the 11-month-old IVD samples, no difference was observed between AF and NP, but overall content of s-GAG was higher than cartilage. HPLC analysis of the ChABC-digested IVD tissue revealed that the quantity and ratio of s-GAG components differed from NP to AF tissue. Moreover, a change in sulfation pattern was observed with the maturity of the disk (Fig. 1). Indeed, an inversion of the occurrence of Ddi-4S and Ddi-6S disaccharides was observed. A significant increase of Ddi-4S disaccharides with a significant decrease of Ddi-6S disaccharides was noted in the 11-month-old IVD AF tissue compared to 3 month old. A similar trend, albeit not significant, was observed for the NP tissue. Cartilage tissue did not present a significant difference in percentage of sulfated disaccharides with maturity.DownloadOpen in new tabDownload in PowerPointFigure 1 Percentage of nonsulfated and sulfated chondroitin sulfate in ovine nucleus pulposus (A), annulus fibrosus (B), and cartilage (C) at 3- and 11-month-old. Data were represented relative to the total sGAG and as mean ± standard error of the mean. *, ** represent significant differences at p < 0.05 and p < 0.01, respectively.ConclusionGAG sulfation pattern was shown to change with maturation. Sulfation is critical for maintaining water content and specific patterns of sulfation are influential in cellular signaling and differentiation events. Furthermore, high changes in glycosylation profiles at a cellular and extracellular level were observed. A better understanding of these phenomena (sulfation and glycosylation profiles changes) will allow us to design therapeutic strategies for IVD regeneration.Acknowledgements AO Foundation (S-09-7P), Science Foundation Ireland, Research Frontiers Programme (07/RFP/ENMF482), Science Foundation Ireland, 07/SRC/B1163.I confirm having declared any potential conflict of interest for all authors listed on this abstractYesDisclosure of InterestNone declaredFritz JM, et al., Physical therapy for ccute low back pain: Associations with subsequent healthcare costs. Spine 2008;33(16):1800–1805O'Halloran D, et al. Tissue-engineering approach to regenerating the intervertebral disk. Tissue Engineering 2007;13(8):1927–1954

Associations of Renal Function at 1-Year After Kidney Transplantation With Subsequent Return to Dialysis, Mortality, and Healthcare Costs

Improved early kidney transplant outcomes limit the contemporary utility of standard clinical endpoints. Quantifying the relationship of renal function at 1 year after transplant with subsequent clinical outcomes and healthcare costs may facilitate cost-benefit evaluations among transplant recipients. Data for Medicare-insured kidney-only transplant recipients (1995-2003) were drawn from the United States Renal Data System. Associations of estimated glomerular filtration rate (eGFR) level at the first transplant anniversary with subsequent death-censored graft failure and patient death in posttransplant years 1 to 3 and 4 to 7 were examined by parametric survival analysis. Associations of eGFR with total health care costs defined by Medicare payments were assessed with multivariate linear regression. Among 38,015 participants, first anniversary eGFR level demonstrated graded associations with subsequent outcomes. Compared with patients with 12-month eGFR more than or equal to 60 mL/min/1.73 m, the adjusted relative risk of death-censored graft failure in years 1 to 3 was 31% greater for eGFR 45 to 59 mL/min/1.73 m (P<0.0001) and 622% greater for eGFR 15 to 30 mL/min/1.73 m (P<0.0001). Associations of first anniversary eGFR level with graft failure and mortality remained significant in years 4 to 7. The proportions of recipients expected to return to dialysis or die attributable to eGFR less than 60 mL/min/1.73 m over 10 years were 23.1% and 9.4%, respectively, and were significantly higher than proportions attributable to delayed graft function or acute rejection. Reduced eGFR was associated with graded and significant increases in health care spending during years 2 and 3 after transplant (P<0.0001). eGFR is strongly associated with clinical and economic outcomes after kidney transplantation.

Adherence to Statins, Subsequent Healthcare Costs, and Cardiovascular Hospitalizations

Statins are the primary agents used to decrease low-density lipoprotein cholesterol. Although adherence to statins improves the clinical outcomes, the affect of statin adherence on healthcare costs has not been well studied. To examine the relation among statin adherence, subsequent hospitalizations, and healthcare costs, we conducted a retrospective cohort study of 381,422 patients, aged 18 to 61 years, using an integrated pharmacy and medical claims database. We measured adherence using the medication possession ratio (MPR) for 12 months and the healthcare costs and cardiovascular disease-related hospitalizations during the subsequent 18 months. Of those studied, 258,013 (67.6%) were adherent (MPR ≥80%), 65,795 (17.3%) had an MPR of 60% to 79%, and 57,614 (15.1%) had an MPR of <60%. The adjusted all-cause total healthcare costs were lowest in the adherent group at $10,198 ± $39.4 (mean ± SE) versus $10,609 ± $77.7 (p <0.001) for an MPR of 60% to 79%, and $11,102 ± $84.3 (p <0.001) for an MPR of <60%. The adherent group had greater statin costs at $838 ± $1.0 versus $664 ± $2.0 (p <0.001) and $488 ± $2.2 (p <0.001). When evaluated by 5 levels of MPR, 0% to 59% and increments of 10% >60%, the adjusted total healthcare costs were lowest for the MPR 90% to 100% group and significantly greater statistically (p <0.001) for each lower level of adherence. Compared to the statin-adherent patients, cardiovascular disease-related hospitalizations were more likely for the patients with an MPR of 60% to 79% (odds ratio 1.12, 95% confidence interval 1.08 to 1.16) and an MPR of 0% to 59% (odds ratio 1.26, 95% confidence interval 1.21 to 1.31). In conclusion, statin adherence is associated with reductions in subsequent total healthcare costs and cardiovascular disease-related hospitalizations.

Opioid Utilization and Health-Care Costs among Patients with Diabetic Peripheral Neuropathic Pain Treated with Duloxetine vs. Other Therapies

This retrospective cohort study assessed subsequent opioid utilization and health-care costs among patients with diabetic peripheral neuropathic pain (DPNP) who initiated duloxetine vs. other standard of care (SOC) treatments. Medical and pharmacy claims were analyzed for commercially-insured individuals aged 18-64. Two study cohorts were constructed from DPNP patients who initiated duloxetine or SOC medications (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin) between March 1, 2005 and December 31, 2005. Initiation was defined as a prior 90-day period without access of the medication. The dispense date of the first initiation was denoted as the index date. Patients with opioids dispensed in the prior 90 days were excluded. Opioid utilization including total days, number of prescriptions filled, and morphine equivalent dosage was assessed for overall, long-acting, and short-acting opioids. Health-care costs and opioid use in the 12-month post-index period were examined via multivariate regression analyses. Four hundred and ninety-nine DPNP patients (272 duloxetine, 227 SOC) were identified. SOC patients had higher prevalence of comorbidities and pre-index health-care costs than duloxetine patients. Controlling for cross-cohort differences, duloxetine patients were significantly less likely to use any opioids than SOC patients. Also, duloxetine patients had 20 fewer adjusted opioid supply days (largely due to the use of short-acting opioids, P < 0.05) and significantly lower adjusted total costs ($8,088, P < 0.05) and diabetes-related costs ($3,092, P < 0.05) in the 12-month post-index period, with most of the cost differences from lower outpatient costs. DPNP patients who initiated duloxetine therapy were less likely to have subsequent opioid use and had lower health-care costs than SOC patients.

The Influence of Worksite Health Promotion Program Management and Implementation Structure Variables on Medical Care Costs at PPG Industries

To evaluate the relationship between critical factors for successful worksite health promotion programs such as management support and program implementation and health care costs at PPG Industries. We analyzed survey data from 37 PPG worksites measuring management support and program implementation. We estimated the relationship between management and implementation scores in 2007 and subsequent health care costs in 2008 using ordinary least squares regression. High program implementation scores were associated with higher health care costs (P < 0.01) as were high management scores (P < 0.05). However, sites with a combination of high management and implementation scores had lower health care costs, while sites with low scores on these dimensions had higher cost trends. Employers should consider administering worksite health promotion structural assessments to identify gaps in management support and program implementation that may influence program effectiveness.

Ability to Walk 1/4 Mile Predicts Subsequent Disability, Mortality, and Health Care Costs

Mobility, such as walking 1/4 mile, is a valuable but underutilized health indicator among older adults. For mobility to be successfully integrated into clinical practice and health policy, an easily assessed marker that predicts subsequent health outcomes is required. To determine the association between mobility, defined as self-reported ability to walk 1/4 mile, and mortality, functional decline, and health care utilization and costs during the subsequent year. Analysis of longitudinal data from the 2003-2004 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. Participants comprised 5895 community-dwelling adults aged 65 years or older enrolled in Medicare. Mobility (self-reported ability to walk 1/4 mile), mortality, incident difficulty with activities of daily living (ADLs), total annual health care costs, and hospitalization rates. Among older adults, 28% reported difficulty and 17% inability to walk 1/4 mile at baseline. Compared to those without difficulty and adjusting for demographics, socioeconomic status, chronic conditions, and health behaviors, mortality was greater in those with difficulty [AOR (95% CI): 1.57 (1.10-2.24)] and inability [AOR (CI): 2.73 (1.79-4.15)]. New functional disability also occurred more frequently as self-reported ability to walk 1/4 mile declined (subsequent incident disability among those with no difficulty, difficulty, or inability to walk 1/4 mile at baseline was 11%, 29%, and 47% for instrumental ADLs, and 4%, 14%, and 23% for basic ADLs). Total annual health care costs were $2773 higher (95% CI $1443-4102) in persons with difficulty and $3919 higher (CI $1948-5890) in those who were unable. For each 100 persons, older adults reporting difficulty walking 1/4 mile at baseline experienced an additional 14 hospitalizations (95% CI 8-20), and those who were unable experienced an additional 22 hospitalizations (CI 14-30) during the follow-up period, compared to persons without walking difficulty. Mobility disability, a simple self-report measure, is a powerful predictor of future health, function, and utilization independent of usual health and demographic indicators. Mobility disability may be used to target high-risk patients for care management and preventive interventions.

Low Back Pain in Primary Care

Cost of illness study alongside a randomized controlled trial. To describe the costs of care for patients with low back pain (1) and to identify patient characteristics as predictors for high health care cost during a 1-year follow-up (2). Low back pain (LBP) is one of the leading causes of high health care costs in industrialized countries (Life time prevalence, 70%). A lot of research has been done to improve primary health care and patients' prognosis. However, the cost of health care does not necessarily follow changes in patient outcomes. General practitioners (n = 126) recruited 1378 patients consulting for LBP. Sociodemographic data, pain characteristics, and LBP-related cost data were collected by interview at baseline and after 6 and 12 months. Costs were evaluated from the societal perspective. Predictors of high cost during the subsequent year were studied using logistic regression analysis. Mean direct and indirect costs for LBP care are about twice as high for patients with chronic LBP compared to acutely ill patients. Indirect costs account for more than 52% to 54% of total costs. About 25% of direct costs refer to therapeutic procedures and hospital or rehabilitational care. Patients with high disability and limitations in daily living show a 2- to 5-fold change for subsequent high health care costs. Depression seems to be highly relevant for direct health care utilization. Interventions designed to reduce high health care costs for LBP should focus on patients with severe LBP and depressive comorbidity. Our results add to the economic understanding of LBP care and may give guidance for future actions on health care improvement and cost reduction.

Changes in opioid use and healthcare costs among U.S. patients with diabetic peripheral neuropathic pain treated with duloxetine compared with other therapies

Objective:To examine changes in opioid use and healthcare costs among commercially insured patients with diabetic peripheral neuropathic pain (DPNP) who initiated duloxetine versus other standard of care (SOC) medications (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin).Research design and methods:Using an administrative claims database, patients with DPNP aged 18–64 who initiated duloxetine or SOC between March 1, 2005 and December 31, 2005 were identified. Initiation was defined as a 90-day clean period without the available study medication. Selected patients had 12 months of continuous enrollment before and after the index date, and at least one opioid dispensed in the prior 90 days. Duloxetine and SOC patients were further classified into continuous and non-continuous users based on whether the medication possession ratio was ≥0.8. Total opioid days, number of opioid prescriptions dispensed, and cumulative morphine equivalents were examined over the 12-month pre- and post-index periods. Multivariate regressions were applied to assess the changes (pre-index minus post-index) in opioid use (total, short-acting vs. long-acting) and healthcare costs, controlling for demographic and clinical characteristics.Results:The study sample included 1281 patients: 98 duloxetine continuous, 243 duloxetine non-continuous, 195 SOC continuous, and 745 SOC non-continuous users. Controlling for demographic and clinical characteristics, duloxetine non-continuous and SOC (continuous and non-continuous) patients had significantly less reduction in total opioid days (−24.4, −23.7, −18.5, respectively, all p < 0.05) from the 12-month pre-index to the post-index period than duloxetine continuous patients. Compared with duloxetine non-continuous, SOC continuous, and SOC non-continuous users, duloxetine continuous users had a greater reduction in short-acting hydrocodone use (difference between the 12 month pre-index and post-index periods) in terms of the total number of prescriptions dispensed (adjusted differences: 1.5, 1.7, 1.7, respectively, all p < 0.05), total supply days (adjusted differences: 28.1, 27.3, 29.7, respectively, all p < 0.05), and morphine equivalent dosage (adjusted differences: 1290 mg, 1132 mg, 1127 mg, respectively, all p < 0.05). Duloxetine non-continuous patients had significantly higher adjusted total ($12,729, p < 0.05) and inpatient costs ($14,993, p < 0.05) than duloxetine continuous patients.Limitations:Due to the use of a retrospective administrative claims database, this study is subject to selection bias between study cohorts, misidentification of DPNP and/or other comorbidities, and an inability to confirm adherence to therapy or assess indirect costs and costs of over-the-counter medications.Conclusions:Among commercially insured patients with DPNP, continuous treatment with duloxetine was associated with a reduction in opioid use between the 12-month pre- and post-index periods compared with treatment with SOC or non-continuous treatment with duloxetine. Duloxetine continuous patients also incurred lower subsequent healthcare costs than non-continuous duloxetine patients.

Evaluation of hospitalization and follow-up care costs among patients hospitalized with ACS treated with a stent and clopidogrel

Objective:This retrospective claims study was performed to evaluate the initial and subsequent healthcare costs in patients with acute coronary syndrome (ACS) who had been treated with stent placement and clopidogrel following discharge from the hospital.Method and results:This was a retrospective, administrative claims-based analysis from a large, geographically diverse US managed care plan affiliated with i3 Innovus. Study subjects were commercially insured enrollees, aged ≥ 18, who were hospitalized for ACS between 1 January 2000 and 31 December 2004 with a stent placed, and had at least one filled prescription for clopidogrel within 7 days of discharge from the index hospitalization. Of the 9135 subjects included in the cost analysis, 2241 subjects experienced a subsequent event. On average, subjects with a second event incurred $32,495 more in medical costs over 2 years and $39,742 more in medical costs over 3 years versus those who did not have a second event. Excluding ischemic hospitalizations, subjects with a second event incurred $7257 and $9724 more in medical costs than patients without a second event during the 2 and 3 years following discharge from the index hospitalization, respectively.Conclusions:Significant cost increases were observed among patients who had a subsequent hospitalization for an ischemic event compared to those without a subsequent hospitalization. Cost increases were still present after excluding costs of the ischemic hospitalizations. The findings of this study must be considered within the limitations of database analysis as claims data are collected for the purpose of payment and not research.