Total Health Care Costs Research Articles

Initiating immunoglobulin replacement therapy helps reduce severe infections and shifts healthcare resource utilization to outpatient services among US patients with inborn errors of immunity

Aims Patients with inborn errors of immunity (IEI) are predisposed to severe recurrent/chronic infections, and often require hospitalization, resulting in substantial burden to patients/healthcare systems. While immunoglobulin replacement therapies (IgRTs) are the standard first-line treatment for most forms of IEI, limited real-world data exist regarding clinical characteristics and treatment costs for patients with IEI initiating such treatment. This retrospective analysis examined infection and treatment characteristics in US patients with IEI initiating IgRT with immune globulin infusion (human), 10% (IG10%). Healthcare resource utilization (HCRU) and associated costs before and after treatment initiation were compared. Additionally, the impact of COVID-19 on infection diagnoses was evaluated. Methods Patients with IEI initiating IG10% between July 2012 and August 2019 were selected from Merative MarketScan Databases using diagnosis/prescription codes. Patients were followed 6 months before and after first IG10% claim date. Demographic and clinical characteristics were described. Treatment characteristics and HCRU before and after IG10% initiation were compared. Infection diagnoses during 2020 and 2019 (March–December) were compared. Results The study included 1,497 patients with IEI diagnoses (mean age = 43.4 years) initiating IG10%, with frequently reported comorbidities like asthma (32.1%). Following IG10% initiation, fewer severe infection diagnoses (11.6% vs 19.9%), fewer infection-related inpatient (10.8% vs 19.5%) and outpatient services (71.6% vs 79.9%), and lower infection-related total healthcare costs ($7,849 vs $13,995; p < 0.001)—driven by lower inpatient costs ($2,746 vs $9,900)—were observed than before. Fewer patients had infection diagnoses during COVID-19 (22.8%) than the prior year (31.2%). Conclusion Patients with IEI are susceptible to severe infections leading to high disease burden and treatment costs. Following IG10% initiation, we observed fewer infections, lower infection-related treatment costs, and shift in care (inpatient to outpatient) leading to significant cost savings. Among patients with IEI, 27% fewer infection diagnoses were observed during the early COVID-19 lockdown period than the prior year.

Clinical and Economic Implications of Hydroxyurea Intolerance in Polycythemia Vera in Routine Clinical Practice.

Background/Objectives: Polycythemia vera (PV) is a chronic hematologic neoplasm commonly treated with hydroxyurea (HU). We utilized the advanced digitalized database of Maccabi Healthcare Services to retrospectively investigate the clinical and economic implications of HU intolerance in the routine clinical care of PV patients in Israel. Methods: We collected data on demographics, physician visits, hospitalizations, laboratory results, medication purchases, cardiovascular and thrombotic events, mental health, economic outcomes, and mortality. Outcomes included cardiovascular and other thrombotic events, disease progression, mental health events, economic outcomes, and overall mortality. Results: Of the 830 patients studied, 3 (0.4%) were resistant to HU treatment, 318 (38.3%) were intolerant to HU treatment, and 509 (61.3%) were stable on HU treatment. The venous thrombosis rate was significantly higher among HU-intolerant compared to HU-stable patients (1.58 vs. 0.47 per 100 person-years [PY], respectively; p < 0.001). The rate of progression to myelofibrosis was 6 vs. 0.9 per 100 PY in HU-intolerant patients vs. HU-stable patients, respectively (p < 0.001), and the rate of progression to acute myeloid leukemia (AML) was 1.16 vs. 0.2 per 100 PY in HU-intolerant patients vs. HU-stable patients, respectively (p < 0.001). The phlebotomy requirement, mortality rate, and total hospitalization days among HU-intolerant patients were significantly higher than in HU-stable patients (p = 0.049, p < 0.001, p < 0.001, respectively). More mental health-related events were noted in HU-intolerant patients vs. HU-stable patients (p = 0.007), and the total healthcare cost ratio was 2.65 for the HU-intolerant patients compared with HU-stable patients. Conclusions: This study suggests that HU-intolerant patients are more likely to have worse outcomes than HU-stable patients, highlighting the need for the close monitoring of these patients for disease-related complications or progression.

The impact of frailty on rectal prolapse repair: a retrospective analysis of the national inpatient sample for clinical outcomes and health resource utilization

PurposeRectal prolapse commonly affects elderly, frail patients. The impact of frailty alone on surgical outcomes for rectal prolapse has not been thoroughly investigated. The aim of this study was to utilize the National Inpatient Sample and the modified frailty index (mFI-11) to compare postoperative outcomes between frail and robust patients undergoing surgery for rectal prolapse.MethodsWe conducted a retrospective population-based cohort study using the Healthcare Cost and Utilization Project (HCUP) NIS from 2015 to 2019. The mFI-11 was utilized to classify patients as frail or robust. The primary outcomes were overall in-hospital postoperative morbidity and mortality. The secondary outcomes included system-specific postoperative morbidity, length of stay (LOS), total in-hospital healthcare cost, and discharge disposition. These were assessed using univariable and multivariable regressions.ResultsA total of 2130 patients, 239 frail (mFI > 0.27) and 1,891 robust patients (mFI < 0.27) who underwent rectal prolapse repair were analyzed. After adjustment, frail patients had a higher rate of in-hospital mortality (OR 10.38, 95% CI 0.65–166.59, p = 0.098) and morbidity (OR 2.18, 95% CI 1.31–3.63, p = 0.003), longer LOS (MD 1.60 days, 95% CI 1.05–2.44, p = 0.028), and greater cost of treatment (MD $15,561.56, 95% CI − 6023.12–37,146.25, p = 0.157) than robust patients.ConclusionFrailty increases postoperative morbidity and mortality and cost more to the healthcare system overall for patients undergoing rectal prolapse repair. This retrospective study is limited by selection bias and residual confounding. Consideration of preoperative optimization programs for frail patients undergoing surgery for rectal prolapse is an important next step to mitigate these poor outcomes.

The impact of normothermic machine perfusion and acuity circles on waitlist time, mortality, and cost in liver transplantation: A multicenter experience.

Ex situ normothermic machine perfusion (NMP) helps increase the use of extended criteria donor livers. However, the impact of an NMP program on waitlist times and mortality has not been evaluated. Adult patients listed for liver transplant (LT) at 2 academic centers from January 1, 2015, to September 1, 2023, were included (n=2773) to allow all patients ≥6 months follow-up from listing. Routine NMP was implemented on October 14, 2022. Waitlist outcomes were compared from pre-NMP pre-acuity circles (n=1460), pre-NMP with acuity circles (n=842), and with NMP (n=381). Median waitlist time was 79 days (IQR: 20-232d) at baseline, 49 days (7-182) with acuity circles, and 14 days (5-56) with NMP ( p <0.001). The rate of transplant-per-100-person-years improved from 61-per-100-person-years to 99-per-100-person-years with acuity circles and 194-per-100-person-years with NMP ( p <0.001). Crude mortality without transplant decreased from 18.3% (n=268/1460) to 13.3% (n=112/843), to 6.3% (n=24/381) ( p <0.001) with NMP. The incidence of mortality without LT was 15-per-100-person-years before acuity circles, 19-per-100 with acuity circles, and 9-per-100-person-years after NMP ( p <0.001). Median Model for End-Stage Liver Disease at LT was lowest with NMP, but Model for End-Stage Liver Disease at listing was highest in this era ( p <0.0001). The median donor risk index of transplanted livers at baseline was 1.54 (1.27-1.82), 1.66 (1.42-2.16) with acuity circles, and 2.06 (1.63-2.46) with NMP ( p <0.001). Six-month post-LT survival was not different between eras ( p =0.322). The total cost of health care while waitlisted was lowest in the NMP era ($53,683 vs. $32,687 vs. $23,688, p <0.001); cost-per-day did not differ between eras ( p =0.152). The implementation of a routine NMP program was associated with reduced waitlist time and mortality without compromising short-term survival after liver transplant despite increased use of riskier grafts. Routine NMP use enables better waitlist management with reduced health care costs.

Implementing teleophthalmology services to improve cost-effectiveness of the national eye care system

Background and purposeOptometrist-assisted and teleophthalmology-enabled referral pathway (OTRP) for community optometry referrals has the potential to improve the capacity and efficiency of eye care delivery systems through risk stratification and limiting the number of improved referrals. This study investigates the expected future costs and benefits of implementing OTRP under various possible organizational set-ups relevant to a Danish context.MethodsA decision-analytic model (decision tree) with a one-year time horizon was constructed to portray alternative future patient referral pathways for people examined in optometry stores for suspected ocular posterior segment eye disease. The main outcomes were total healthcare costs per patient, average waiting time from eye examination in store until the start of treatment or end of referral pathway, and quality-adjusted life-years (QALY) gained. The economic evaluation compares the general ophthalmologist referral pathway (GO-RP) with a potential reimbursement model for the optometrist-assisted teleophthalmology referral pathways (R-OTRP) and a procurement model for the optometrist-assisted teleophthalmology referral pathways (P-OTRP).ResultsThe cost per individual with suspected ocular posterior segment eye disease was estimated to be £116 for GO-RP and £75 and £94 for P-OTRP and R-OTRP respectively. The average waiting time for diagnosis or end of referral pathway was 25 weeks for GO-RP and 5.8 and 5.7 for P-OTPR and R-OTPR respectively. QALY gain was 0.15 for P-OTRP/R-OTRP compared to 0.06 for GO-RP.ConclusionOTRP is effective in reducing unnecessary referrals and waiting times, increasing patients’ HRQoL, and decreasing the costs of diagnosing individuals with suspected ocular posterior segment eye disease.

Stepped, evidence-based and integrated care service model vs. usual care for mental disorders: A randomized controlled trial (RECOVER)

Stepped, evidence-based and integrated care service models have the potential to be used as a reference for mental health services. RECOVER aimed to evaluate cost savings, effectiveness, and cost-effectiveness of such a model within a two arm, assessor- and data analysist-blinded RCT in Hamburg, Germany. Participants aged 16–79 years with mental disorders were randomly assigned either to RECOVER or treatment as usual (TAU). Primary outcomes comprised costs, effectiveness (combined symptoms, functioning, quality of life), and cost-effectiveness, hierarchically ordered. Outcomes were evaluated according to the ITT principle, group differences regarding costs with adjusted generalized linear models, effectiveness with ANCOVA models, and cost-effectiveness with the incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curves (CEACs). Between 1/1/2018 and 12/31/2020, n = 891 were finally included (n = 477 in RECOVER, n = 444 in TAU). RECOVER was associated with significantly lower annual total costs (-22 %), health and social care costs (-25 %) and hospital costs (-50 %). Effectiveness analyses showed a significantly better outcome for RECOVER with the fully imputed data . The CEACs descriptively demonstrated that RECOVER was cost-effective with a probability of >95 %. Treatment in RECOVER resulted in substantial cost reductions with better cost-effectiveness. RECOVER can be recommended as a reference model for comprehensive and integrated mental health services.

A nationwide analysis of demographic and treatment patterns in admissions for malignant pleural effusions from 2016-2020.

1618 Background: Malignant pleural effusions are an indicator of metastatic malignancy, with poor survival and need for palliative procedures to alleviate symptoms. Our study aims to identify the disparities in the utilization of these procedures and their effects on hospitalization outcomes. Methods: The Nationwide Inpatient Sample (NIS) was used to identify all adult hospitalizations with malignant pleural effusion (MPL) between the years 2016-2020. We studied patient demographics and treatment modalities during admission. The study's primary outcome measure was to identify the difference in the total length of stay (LOS) and total healthcare cost (THC)incurred during admission. The secondary outcome was mortality rates among patients undergoing these procedures. Statistical analysis was done using multivariate linear and logistic regression models. Results: A total of 439,245 admissions for MPL were identified, constituting 0.2% of all U.S. admissions. Among these, 59.6% were females and mean age was 67.3 years. There were 68% Whites, 15% Blacks, 8% Hispanics, 4% Asians or Pacific Islanders, 0.4% Native Americans, and 2.9% others. About 61% had Medicare, 11.2% Medicaid, 25.7% Private insurance, and 1.9% Self-pay. Most admissions occurred in teaching hospitals (76.3%), urban settings (94.5%), and hospitals with larger bed strength (56.1%). The most common primary admission diagnosis was sepsis (8.3%). The most common primary malignancies were Lung (39.9%), breast (27.9%), gastrointestinal (9%), and hematopoietic malignancies (7.1%). We studied rates of thoracocentesis, Pleurodesis, Decortication, and intrapleural chemotherapy. The mean LOS and THC increased in admissions where procedures were performed, highest for decortication (12.1 days, p&lt;0.01). However, the odds of death in hospitals significantly reduced. When compared to primary lung cancer causing malignant effusions, primary G.I., renal, urinary, and upper aerodigestive malignancies with MPL had significantly higher mortality rates (p&lt;0.05). Disparities were observed in procedures performed, with women having 29% lower odds of undergoing decortication (p&lt;0.001). African Americans had lower odds of undergoing any procedures for MPL when adjusted for age, sex insurance status, compared to whites. Teaching hospitals had 10.9 times higher odds of performing thoracocentesis but lower odds of performing pleurodesis and decortication (p&lt;0.05). Conclusions: This investigation provides insights into the favorable impact of invasive procedures on in-hospital mortality for malignant pleural effusions, suggesting a possibility that patients with better performance status underwent such interventions. We also noted racial and sex-based disparities in the performance of these procedures. Further studies are essential to identify the reasons for this disparity to help promote equitable care.

Real-world clinical outcomes and economic burden of early discontinuation of taxane therapy among patients with metastatic castration-resistant prostate cancer.

e17043 Background: Despite comprising an important part of the treatment paradigm for metastatic castration-resistant prostate cancer (mCRPC) for over a decade, real-world use of taxanes is hindered by adverse events (AEs). AEs may lead to early treatment discontinuation, which may adversely affect outcomes. The two goals of this study were to determine the proportion of mCRPC patients who discontinue taxanes early (defining the early discontinuation threshold relative to efficacy results associated with androgen receptor pathway inhibitors [ARPIs]) and to evaluate the impact of early discontinuation on clinical outcomes, AEs, and healthcare costs. Methods: This was a retrospective, observational study of adult men with mCRPC treated with an ARPI as their first-line (1L) therapy and who initiated second-line (2L) therapy with another ARPI or a taxane. The Flatiron Health electronic health record database (07/01/2012–06/30/2020) was used to estimate Kaplan-Meier overall survival (OS) curves for the taxane cohort by the number of cycles received; these were compared with patients who received ARPI at 2L. Cox regression modeling and median PFS and OS values were used to identify the number of taxane cycles needed to achieve comparable OS to ARPI. The number of taxane cycles with similar OS outcomes to ARPI was then considered the threshold for early discontinuation. In addition, the IQVIA PharMetrics Plus claims database (01/01/2013–08/31/2021) was used to estimate taxane-related AEs (based on product information) and associated healthcare costs among patients who did and did not discontinue taxanes early. Results: From Flatiron, 473 2L ARPI patients and 214 2L taxane patients were included. Similar clinical characteristics – e.g., prostate-specific antigen level, ECOG performance status, and Gleason score – were observed between the two cohorts. Overall, 2L ARPI was associated with longer median OS (15.4 vs. 13.6 months) than 2L taxane. The number of taxane cycles needed to reach comparable OS to ARPI was determined to be 8. Patients receiving &gt;8 cycles (n=48; 22%) compared to those receiving ≤8 cycles (n=166; 78%) had longer median OS (18.4 vs. 11.9 months, respectively) and PFS (9.0 vs. 4.3 months, respectively). From PharMetrics, 158 2L taxane patients were included. Patients receiving &gt;8 cycles (n=20; 13%) were more likely to experience an AE (95% vs. 88%) than those receiving ≤8 cycles (n=138; 87%) but had lower mean AE-related total healthcare costs per patient per month ($3,429 vs. $6,334). Conclusions: These results suggest that mCRPC patients need to receive &gt;8 cycles of taxane at 2L to receive more clinical benefit than 2L ARPI. However, the vast majority of patients in the study discontinued taxane early, resulting in shorter survival outcomes compared to ARPI.

Cost-effectiveness of an oral THC: CBD cannabis extract for secondary prevention of refractory, chemotherapy-induced nausea and vomiting.

TPS11188 Background: The CannabisCINV trial showed the incorporation of a THC:CBD (tetrahydrocannabinol:cannabidiol) cannabis extract in addition to usual, guideline-recommended antiemetic prophylaxis, reduced the incidence of refractory chemotherapy-induced nausea and vomiting. The aim of this within-trial cost-effectiveness analysis was toassess the incremental costs and benefits of oral THC: CBD versus placebo, for preventing chemotherapy-induced nausea and vomiting. Methods: The analysis was performed from a health system perspective, using prospectively collected data from the CannabisCINV trial and linked Medicare data. The evaluation focused on the costs and benefits associated with oral THC: CBD cannabis extract versus placebo in addition to usual care, on complete response: defined as no emesis and no use of rescue medications during the overall treatment phase (0-120 h, cycle 1). The primary economic outcome was an incremental cost-effectiveness ratio (ICER) of achieving a complete response. One-way sensitivity analyses and non-parametric bootstrapping (with 1,000 replications) were conducted to assess the robustness of results. Results: Of 147 participants randomized, 60 of 73 assigned THC:CBD and 66 of 74 assigned placebo consented to Medicare data linkage. The incidence of complete response was higher for THC:CBD than placebo (24% vs 5%, absolute difference 19%, 95%CI 13 to 26%). The mean cost (AUD) of hospitalisation was $580 (SD $7,831) for the intervention group and $1,873 (SD $7,235) for placebo. The mean healthcare costs (AUD) were $1,464 (SD $4,667) for THC:CBD group and $2,725 (SD $9,237) for the placebo. The THC:CBD group had a mean total healthcare cost saving of $1,261 per patient (95% CI -$3,550 to $1029) compared with the placebo group. THC:CBD was less expensive and more effective than placebo (i.e. dominant), in the primary analysis, and over the range of pre-specified sensitivity analyses. Conclusions: This within-trial analysis indicates oral THC: CBD is cost-effective for the treatment of refractory, chemotherapy-induced nausea and vomiting from a health system perspective and supports reimbursement in this setting. The trial and economic evaluation were prospectively registered in the Australian and New Zealand. Clinical trial information: ACTRN12616001036404.

#1002 End of life healthcare utilisation and costs of older patients receiving kidney replacement therapy—analysis of Dutch health insurance claims data

Abstract Background and Aims The increasing prevalence of chronic kidney disease (CKD), an aging population and advancements in treatment options collectively contribute to a rise in older patients with a functioning kidney transplant (KTX) or undergoing dialysis. These treatments are associated with extensive healthcare utilisation, placing substantial demands on both patients and the healthcare system. Healthcare utilisation typically increases near the end of life, and is associated with increased costs. However, little is known about the end-of-life healthcare utilisation of patients receiving kidney replacement therapy (KRT). Therefore, our study aims to assess healthcare utilisation and costs during the last year of life. Method We analysed Dutch health insurance claims data from patients aged &amp;gt;65 years on KRT who deceased between June 2016 and December 2021. We matched each patient with two controls, defined as individuals who died within the same calendar year without any insurance claims related to CKD or KRT. Matching was performed on sex, age and socio-economic status. The primary outcomes were healthcare utilisation and costs in the last twelve months of life for patients treated with different KRT modalities and compared to matched controls. Healthcare utilisation was detailed at hospital and intensive care unit (ICU) admissions, emergency department (ED) and outpatient department (OPD) visits, hospital daycare and institutionalised care. Healthcare costs encompassed costs related to primary care, hospital care (inpatient and outpatient), mental care, institutionalised care, prescription medication, transportation and other costs. Hospital care costs were categorised as KRT-related and -unrelated costs. Results In total 7279 decedents were included; 4614 haemodialysis patients (HD), 766 peritoneal dialysis (PD) patients and 1899 KTx recipients. KRT patients had a mean age of 77.6 ± 6.6 years, with 64% being male, and had significantly more comorbidities than the control group. In the year preceding death, KRT patients had significantly more hospital admissions, ICU admissions, ED visits, outpatient visits, hospital daycare and institutionalised care than controls (see Fig. 1). When comparing across KRT-modalities, KTx patients were more often admitted to the ICU than HD and PD patients (p = 0.001 and p = 0.024, respectively). For both HD, PD and KTx patients, the mean number of days admitted to the hospital and ICU, as well as ED visits and OPD visits significantly increased in last three months preceding death, compared to the initial nine months of the last year of life (p &amp;lt; 0.0001). Mean total healthcare costs in the last year of life were €59.489 for KTx patients, €108.294 for PD and €117.520 for HD patients, compared to €19.820 for the controls. The majority of costs for dialysis patients were attributed to KRT, accounting for 55.5% (€65.216) and 60.0% (€64.559) of the total expenditures for HD and PD patients, respectively. In contrast, KRT-related costs constituted 25.7% (€15.262) of the total expenses in KTx patients. Besides substantial KRT-related costs, KRT-patients also incurred higher costs for specialist care in the hospital, primary care, medication and transport, compared to controls. Conclusion Healthcare utilisation is substantial for older KRT patients and intensifies during the last year of life. This is accompanied with elevated costs. Further research is necessary to evaluate the impact of healthcare utilisation on the quality of life and whether advanced care planning could prevent overutilisation.

The Association of Ancillary Diagnostic Tests With Outcome in Dementia

ObjectivesDementia is a clinical diagnosis without curative treatment. It is uncertain whether ancillary testing is beneficial for patients. This study investigates the association between use of diagnostic tests and time to poor outcome and health care costs. DesignNationwide register-based cohort study using health care reimbursement data in the Netherlands. Setting and ParticipantsAll Dutch hospitals, including 13,312 patients diagnosed with dementia in 2018. MethodsDiagnostic testing included computed tomography or magnetic resonance imaging (CT/MRI), neuropsychological examination (NPE), nuclear imaging (PET/SPECT), electroencephalography (EEG), and cerebrospinal fluid (CSF) testing. We compared time to poor outcome (institutionalization or death) and costs per month from 2018 to 2021 between those who underwent a specific diagnostic test in previous years to controls, propensity score matched for age, sex, type of hospital, and comorbidity. ResultsTime to poor outcome in those who underwent CT/MRI, EEG, or CSF testing was similar to those who did not, but was longer for those who underwent NPE. Time to poor outcome was shorter in patients who underwent PET/SPECT. Patients who underwent CSF testing or PET/SPECT had higher mean total health care costs as compared to controls (CSF €248, 95% CI 64-433; PET/SPECT: €315, 95% CI 179-451). NPE during the diagnostic trajectory was associated with lower total health care cost (–€127, 95% CI –62, –193). Conclusion and ImplicationsNPE was associated with longer time to poor outcome and lower health care costs, potentially due to confounding by indication. Patients who underwent neuroimaging (CT, MRI, SPECT/PET), CSF testing, or EEG for dementia diagnostics did not experience a longer time to poor outcome or lower health care costs. This emphasizes the importance of clinical examination as anchor for the diagnosis of dementia.

Rationale and design of the FRENch CoHort of myocardial Infarction Evaluation (FRENCHIE) study

BackgroundDespite major advances in prevention and treatment, cardiovascular diseases – particularly acute myocardial infarction – remain a leading cause of death worldwide and in France. Collecting contemporary data about the characteristics, management and outcomes of patients with acute myocardial infarction in France is important. AimsThe main objectives are to describe baseline characteristics, contemporary management, in-hospital and long-term outcomes of patients with acute myocardial infarction hospitalized in tertiary care centres in France; secondary objectives are to investigate determinants of prognosis (including periodontal disease and sleep-disordered breathing), to identify gaps between evidence-based recommendations and management and to assess medical care costs for the index hospitalization and during the follow-up period. MethodsFRENCHIE (FRENch CoHort of myocardial Infarction Evaluation) is an ongoing prospective multicentre observational study (ClinicalTrials.gov Identifier: NCT04050956) enrolling more than 19,000 patients hospitalized for acute myocardial infarction with onset of symptoms within 48hours in 35 participating centres in France since March 2019. Main exclusion criteria are age<18 years, lack of health coverage and procedure-related myocardial infarction (types 4a and 5). Detailed information was collected prospectively, starting at admission, including demographic data, risk factors, medical history and treatments, initial management, with prehospital care pathways and medication doses, and outcomes until hospital discharge. The follow-up period (up to 20 years for each patient) is ensured by linking with the French national health database (Système national des données de santé), and includes information on death, hospital admissions, major clinical events, healthcare consumption (including drug reimbursement) and total healthcare costs. FRENCHIE is also used as a platform for cohort-nested studies – currently three randomized trials and two observational studies. ConclusionsThis nationwide large contemporary cohort with very long-term follow-up will improve knowledge about acute myocardial infarction management and outcomes in France, and provide a useful platform for nested studies and trials.

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: A Propensity Score Weighted Cohort Study

BackgroundUnplanned hospital readmissions are associated with adverse patient outcomes and substantial healthcare costs. It remains unknown whether physician financial incentives for enhanced discharge planning can reduce readmission risk. MethodsIn 2012, policymakers in British Columbia, Canada, introduced a $75 fee-for-service physician payment to incentivize enhanced discharge planning (the “G78717” fee code). We used population-based administrative health data to compare outcomes among G78717-exposed and G78717-unexposed patients. We identified all nonelective hospitalizations potentially eligible for the incentive over a 5-year study interval. We examined the composite risk of unplanned readmission or death and total direct healthcare costs accrued within 30 days of discharge. Propensity score overlap weights and adjustment were used to account for differences between exposed and unexposed patients. ResultsA total of 5262 of 24,787 G78717-exposed and 28,096 of 136,541 unexposed patients experienced subsequent unplanned readmission or death, suggesting exposure to the G78717 incentive did not reduce the risk of adverse outcomes after discharge (crude percent, 21.1% vs 20.6%; adjusted odds ratio, 0.97; 95% CI, 0.93-1.01; P = .23). Mean direct healthcare costs within 30 days of discharge were $3082 and $2993, respectively (adjusted cost ratio, 1.00; 95% CI, 0.95-1.05; P = .93). ConclusionsA physician financial incentive that encouraged enhanced hospital discharge planning did not reduced the risk of readmission or death, and did not significantly decrease direct healthcare costs. Policymakers should consider the baseline prevalence and effectiveness of enhanced discharge planning, the magnitude and design of financial incentives, and whether auditing of incentivized activities is required when implementing similar incentives elsewhere. Trial RegistrationClinicalTrials.gov ID, NCT03256734

Psychological Burden among Pediatric Thalassemia Major Patients in Indonesia: A Review

Thalassemia a common hereditary blood disorder resulting in anemia. It is an important public health problem, with a high prevalence in Southeast Asia and Mediterranean countries, and preventable through screening programs. However, due to its chronic nature, permanent physical changes, troublesome complications, and lifelong treatment, pediatric patients with thalassemia major are more prone to mental disorders and cognitive impairment. Internalizing and externalizing problems are higher in pediatric patients with thalassemia. Children with β-thalassemia major exhibit lower IQ scores than healthy children. Neurophysiology and neuroimaging examinations have shown abnormal results in children with thalassemia. Co-morbidity with mental disorders increases the mortality, morbidity, and total healthcare costs of patients with thalassemia. Therefore, routine evaluation of mental health problems is recommended to accommodate the early detection and prompt treatment of mental disorders. A multidisciplinary approach for thalassemia patients and families should be delivered by providing appropriate medical care, psychosocial support, and good transition care to improve survival and well-being, assist good social integration and daily functioning, and cope with the stress of chronic disease.

Telehealth Expansion and Medicare Beneficiaries’ Care Quality and Access

Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems. To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use. This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B. Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries. The primary outcomes were quality (ambulatory care-sensitive [ACS] hospitalizations and emergency department [ED] visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis. In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean [SD] age in 2019, 71.04 [1.67] years; mean [SD] percentage female in 2019, 53.83% [2.14%]) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1.63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1.03-2.22 hospitalizations), more clinician encounters (0.30 additional encounters per beneficiary per semester; 95% CI, 0.23-0.38 encounters), and higher total cost of care ($164.99 higher cost per beneficiary per semester; 95% CI, $101.03-$228.96). There was no statistically significant difference in ACS ED visits between the low and high groups. In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.

A Study on a Health Impact Assessment and Healthcare Cost Calculation of Beijing–Tianjin–Hebei Residents under PM2.5 and O3 Pollution

Excessive fine particulate matter (PM2.5) and ozone (O3) are invisible killers affecting our wellbeing and safety, which cause great harm to people’s health, cause serious healthcare and economic losses, and affect the sustainable development of the social economy. The effective evaluation of the impact of pollutants on the human body, the associated costs, and the reduction of regional compound air pollution is an important research direction. Taking Beijing–Tianjin–Hebei (BTH) as the research area, this study constructs a comprehensive model for measuring the healthcare costs of PM2.5 and O3 using the Environmental Benefits Mapping and Analysis Program (BenMAP) as its basis. First, this study establishes a health impact assessment model and calculates the number of people affected by PM2.5 and O3 exposure using the health impact function in the BTH region. Then, the willingness to pay (WTP) and cost of illness (COI) methods are used to estimate the healthcare costs inflicted by the two pollutants upon residents from 2018 to 2021. The calculation results show that the total healthcare costs caused by PM2.5 and O3 pollution in BTH accounted for 1%, 0.7%, 0.5%, and 0.3% of the regional GDP in 2018, 2019, 2020, and 2021, respectively. Based on the research results, to further reduce these high healthcare costs, we propose policy suggestions for PM2.5 and O3 control in the BTH region.

Comparison of Long-Term Healthcare Cost and Utilisation of Nonoperative and Surgical Management of Thumb CMC Arthritis.

Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).

Cost-effectiveness of medication therapy management among Medicare population and across racial/ethnic groups.

Inappropriate medication utilization among older adults is a pressing concern in the United States, owing to its high prevalence and the consequential detrimental impact it engenders. The adverse effects stemming from the inappropriate use of medication may be unequally borne by racial/ethnic minority populations, calling for greater efforts towards promoting equity in healthcare. The study objective was to assess the cost-effectiveness of Medication Therapy Management (MTM) services among Medicare beneficiaries and across racial/ethnic groups. Medicare administrative data from 2016 to 2017 linked to Area Health Resources Files were used to analyze Medicare fee-for-service patients aged 65 or above with continuous Parts A/B/D coverage. The intervention group included new MTM enrollees in 2017; the control group referred to patients who met the general MTM eligible criteria but did not enroll in 2016 or 2017. The 2 groups were matched using a propensity score method. Effectiveness was evaluated as the proportion of appropriate medication utilization based on performance measures developed by the Pharmacy Quality Alliance. Costs were computed as total healthcare costs from Medicare perspective. A multivariable net benefit regressions with a classic linear model and Bayesian analysis were utilized. Net benefit was calculated based on willingness-to-pay thresholds at various multiples of the gross domestic product in 2017. Three-way interaction terms among dummy variables for MTM enrollment, 2017, and racial/ethnic minority groups were incorporated in a difference-in-differences study design. After adjusting for patient characteristics, the findings indicate that MTM receipt was associated with incremental net benefit among each race and ethnicity. For instance, the net benefit of MTM among the non-Hispanic White patients was $2498 (95% confidence interval = $1609, $3386) at a willingness-to-pay value of $59,908. The study found no significant difference in net benefits for MTM services between minority and White patients. The study provides evidence that MTM is a cost-effective tool for managing medication utilization among the Medicare population. However, MTM may not be cost-effective in reducing racial/ethnic disparities in medication utilization in the short term. Further research is needed to understand the long-term cost-effectiveness of MTM on racial/ethnic disparities.

Health Care Utilization by Patients With Chronic Pelvic Pain.

To describe the patterns of health care utilization among patients with chronic pelvic pain. Deidentified administrative claims data from the OptumLabs Data Warehouse were used. Adult female patients who had their first medical claim for chronic pelvic pain between January 1, 2016, and December 31, 2019, were included. Utilization was examined for 12 months after the index diagnosis. The greedy nearest neighbor matching method was used to identify a control group of individuals without chronic pelvic pain. Comparisons were made between those with and those without chronic pelvic pain using χ2 tests for categorical data and Wilcoxon rank-sum tests for continuous data. In total, 18,400 patients were analyzed in the chronic pelvic pain cohort. Patients with chronic pelvic pain had a higher rate of chronic overlapping pain conditions. Patients with chronic pelvic pain had higher rates of health care utilization across all queried indices. They had more outpatient office visits; 55.5% had 10 or more office visits. Patients with chronic pelvic pain showed higher utilization of the emergency department (ED) (6.3 visits vs 1.9 visits; P<.001). Urine culture and pelvic ultrasonography were the most utilized tests. One-third of patients with chronic pelvic pain utilized physical therapy (PT), and 13% utilized psychological or behavioral therapy. Patients with chronic pelvic pain had higher rates of hysterectomy (8.9% vs 0.6%). The average total health care costs per patient with chronic pelvic pain per year was $12,254. Patients with chronic pelvic pain have higher rates of chronic overlapping pain conditions and undergo more ED visits, imaging tests, and hysterectomies than patients without chronic pelvic pain. Improving access to multidisciplinary care, increasing utilization of interventions such as PT and psychological or behavioral therapy, and reducing ED utilization may be possible targets to help reduce overall health care costs and improve patient care.

Defragmentation of care in complex patients with ESKD improves clinical outcomes.

Given the problematic fragmentation of care for patients with end-stage kidney disease (ESKD), a kidney care organization and an integrated health system within a large accountable care organization partnered to best utilize their individual capabilities to collaborate around their shared patients in a coordinated care approach. Ultimately, the goal of the program is to allow care teams to achieve the triple aim of improving the patient experience, improving clinical outcomes, and reducing the total cost of health care. This is a retrospective examination of the first year of the Shared Patient Care Coordination (SPCC)program. The analysis consisted of 2 parts. First, rates of hospitalizations and emergency department visits were compared between the SPCC patients and other patients of the integrated health system who had ESKD but did not participate in SPCC. Second, rates of clinical indicators-central venous catheter (CVC) use, home dialysis, advance care planning, and missed dialysis treatments-were benchmarked vs normative data taken by bootstrap sampling of the kidney care organization's patient population. Overall, dialysis patients participating in the SPCC program had a 15% lower rate of hospital admissions than those not participating ( P = .02). Additionally, the bootstrap analysis showed that by the second year, dialysis patients in the program had favorable rates (above the 95th percentile) of CVC use, dialysis treatment absenteeism, and completion of advance care plans. Enhanced and structured communication between dialysis providers and patient care teams provides a unique opportunity to coordinate patient-centered care and improve patient outcomes.