Total Outpatient Costs Research Articles

Resource utilization of patients with hypochondriacal health anxiety and somatization.

To examine the resource utilization of patients with high levels of somatization and health-related anxiety. Consecutive patients on randomly chosen days completed a self-report questionnaire assessing somatization and health-related, hypochondriacal anxiety. Their medical care utilization in the year preceding and following completion of the questionnaire was obtained from an automated patient record. The utilization of patients above and below a predetermined threshold on the questionnaire was then compared. Eight hundred seventy-six patients attending a primary care clinic in a large, urban, teaching hospital. Number of ambulatory physician visits (primary care and specialist), outpatient costs (total, physician services, and laboratory procedures), proportion of patients hospitalized, and proportion of patients receiving emergency care. Patients in the uppermost 14% of the clinic population on somatization and hypochondriacal health anxiety had appreciably and significantly higher utilization in the year preceding and the year following completion of the somatization questionnaire than did the rest of the patients in the clinic. After adjusting for group differences in sociodemographic characteristics and medical comorbidity, significant differences in utilization remained. In the year preceding the assessment of somatization, their adjusted total outpatient costs were $1,312 (95% CI $1154, $1481) versus $954 (95% CI $868, $1057) for the remainder of the patients and the total number of physician visits was 9.21 (95% CI 7.94, 10.40) versus 6.33 (95% CI 5.87, 6.90). In the year following the assessment of somatization, those above the threshold had adjusted total outpatient costs of $1,395 (95% CI $1243, $1586) versus $1,145 (95% CI $1038, $1282), 9.8 total physician visits (95% CI 8.66, 11.07) versus 7.2 (95% CI 6.62, 7.77), and had a 24% (95% CI 19%, 30%) versus 17% (95% CI 14%, 20%) chance of being hospitalized. Primary care patients who somatize and have high levels of health-related anxiety have considerably higher medical care utilization than nonsomatizers in the year before and after being assessed. This differential persists after adjusting for differences in sociodemographic characteristics and medical morbidity.

Two methods of estimating health costs linked to alcoholism in France (with a note on social costs)

The health costs of alcohol-related problems in France were estimated using two cost evaluation approaches: (1) estimate based on the proportion of cases attributable to alcohol abuse (the alcohol abuse factor); (2) estimate based on prevalence of alcohol abuse for in- and out-patients. For a 10% prevalence of alcohol abuse in the general population, the minimum cost in 1996 was about US$ 2300 million; for a prevalence of 15% it was US$ 2700 million. This cost concerns the health disorders that are linked directly or indirectly to alcohol abuse. It did not allow for injuries from accidents caused by alcohol intoxication and undervalued the cost of out-patient care. Based on the prevalence of alcohol-related disorders seen at hospitals, a percentage of the total in-patient and out-patient costs due to effects of alcohol could be estimated. However, this did not permit an estimate of the cost of care in which alcohol abuse was a risk factor only. Based on the available data showing that between 3% and 10% of inpatients have a directly alcohol-related condition, estimates of in-patient treatment costs varied from US$ 1300 to 2100 million. Among adult out-patients, 20% present with a disorder in which alcohol is a factor or suffer from an alcohol-related illness, which corresponds to a cost of about US$ 1600 million. Thus, these methods yield minimum year's cost estimated between US$ 2500 and 3300 million. These costs are high, compared to the low level of financing for the specialized facilities offering treatment to people in difficulty due to alcohol excess, which was US$ 23 million in that year. As regards social and total costs, estimates from four Western countries have found that about 75% of the total costs of alcohol abuse was attributable to social harm, and 25% to medical costs. Applying this ratio to the French data gives an estimated total cost to French society of about US$ 13 200 million, i.e. 1.04% of the gross national product.

Ambulatory Intravenous Antibiotic Therapy in Quebec: The Hôpital Charles LeMoyne Experience in 1996

From January 1, 1996 to December 31, 1996, 343 patients received outpatient intravenous antibiotic therapy at Charles LeMoyne Hospital, a 436‐bed, acute care hospital in Greenfield Park, south of Montréal, Québec. The infectious diseases department saved 2660 bed‐days using outpatient therapy. The mean duration of outpatient therapy was 7.76 days; 81.6% of patients were admitted to the program directly from the emergency room, or outpatient hospital clinics or private offices in the community. Hospitalized patients constituted only 18.4% of admissions to the outpatient intravenous antibiotic therapy program. Forty per cent of the surgical/medical staff participated in the program and they were able to generate a significant impact by diverting patients to outpatient therapy. Two types of patients can benefit from an outpatient intravenous antibiotic therapy program. One group of patients needs empirical short term therapy and can be switched to oral sequential therapy after two to five days of outpatient intravenous antibiotic therapy. A second group of patients needs specific long term therapy for the full duration of the antibiotic therapy. Empirical short term therapy can be managed by emergency department or hospital‐based primary physicians, or medical/surgical specialists. Specific long term therapy can be managed by microbiology/infectious disease specialists or medical/surgical specialists. Hospitals that want to relieve pressure on emergency rooms and hospital bed demands should create facilities for both types of patients. Cefazolin and gentamicine/tobramycine were the most commonly used antibiotics in empirical short term therapy and in terms of number of patients treated. Ceftriaxone and vancomycin were most commonly used for long term therapy. The Drug acquisition antibiotic cost was $73,117 but constituted only 20% of the total outpatient intravenous antibiotic therapy cost. The per diem ambulatory cost was $140/patient/day.

Costs of health care use by women HMO members with a history of childhood abuse and neglect.

Early childhood maltreatment has been associated with adverse adult health outcomes, but little is known about the magnitude of adult health care use and costs that accompany maltreatment. We examined differences in annual health care use and costs in women with and without histories of childhood sexual, emotional, or physical abuse or neglect. A random sample of 1225 women members of a health maintenance organization completed a 22-page questionnaire inquiring into childhood maltreatment experiences as measured by the Childhood Trauma Questionnaire. Health care costs and use data were obtained from the automated cost-accounting system of the health maintenance organization, including total costs, outpatient and primary care costs, and emergency department visits. Women who reported any abuse or neglect had median annual health care costs that were $97 (95% confidence interval, $0.47-$188.26) greater than women who did not report maltreatment. Women who reported sexual abuse had median annual health care costs that were $245 (95% confidence interval, $132.32-$381.93) greater than costs among women who did not report abuse. Women with sexual abuse histories had significantly higher primary care and outpatient costs and more frequent emergency department visits than women without these histories. Although the absolute cost differences per year per woman were relatively modest, the large number of women in the population with these experiences suggests that the total costs to society are substantial.

New studies show cost effectiveness of psoriasis treatments

P soriasis is common, incurable and often psychologically devastating. For example, between 2 and 4% of Caucasians suffer from psoriasis. Some patients learn to live with the disfiguring plaques. However, psoriasis dramatically undermines other patients’ quality of life - especially among women and younger sufferers. 1 Moreover, psoriasis imposes a heavy economic burden. In the US, annual outpatient costs for psoriasis range from $US1100 to $US6600 per patient depending on the treatment, with the total outpatient cost reaching $US3.2 billion in 1993 alone. 2

New studies show cost effectiveness of psoriasis treatments

Psoriasis is common, incurable and often psychologically devastating. For example, between 2 and 4% of Caucasians suffer from psoriasis. Some patients learn to live with the disfiguring plaques. However, psoriasis dramatically undermines other patients’ quality of life - especially among women and younger sufferers. 1 Moreover, psoriasis imposes a heavy economic burden. In the US, annual outpatient costs for psoriasis range from $US1100 to $US6600 per patient depending on the treatment, with the total outpatient cost reaching $US3.2 billion in 1993 alone. 2

Treatment cost of acute exacerbations of chronic bronchitis

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients aged >65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged <65 years. We calculated a total treatment cost of $1.2 billion for patients aged ≥65 years and $419 million for patients aged <65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $ 1.1 billion for the 207,540 patients aged ≥65 years, and $408 million for the 73,299 patients aged <65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients aged >65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those aged ≥65 years and 237,000 visits for those aged <65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those aged ≥65 years and 4.2 million visits for those aged <65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.

Cost of health care for a community of older adults in an urban academic healthcare system.

Urban academic medical centers provide care for large populations of vulnerable older adults. These patients often suffer a disproportionate share of chronic illnesses, disabilities, and social stressors that may increase health care costs. To describe the distribution and content of total healthcare costs accrued over a 4-year period by a community of older adults cared for in an urban academic healthcare system and to describe high-cost patients and utilization patterns. A cohort study. A tax-supported public healthcare system consisting of a 450-bed hospital and seven community-based ambulatory care centers. 12,581 patients aged 60 years and older who had at least two ambulatory visits and/or one hospitalization within the healthcare system from 1993 through 1995. Patient demographic and clinical characteristics, hospital and ambulatory utilization rates, and all healthcare costs accrued from 1993 through 1996 were determined. Costs were estimated from the perspective of the healthcare system using cost to charge ratios. The mean patient age was 70 years, 60% were women, 44% were Black, and 83% were covered by Medicare and/or Medicaid. Nearly 25% of patients were obese, 15.8% had a history of smoking, and 15.5% had evidence of malnutrition. The mean number of ambulatory visits per year was 4.3 (+/-7.2), and 38.1% of patients had been hospitalized one or more times. Within the 4-year window, 24.1% of patients had missed five or more appointments with their primary care physicians, 32.7% of patients had five or more unscheduled clinic visits, and 12.5% had five or more emergency room visits. Total health care costs for 4 years for this cohort of older adults was $125.2 million dollars, with per capita annual mean costs of $3893. Expenditures associated with hospitalizations accounted for 63.6% of healthcare costs. Total inpatient and outpatient costs for the 38% of patients hospitalized at least once accounted for 85.3% of all health care expenditures. Patients who died in the hospital did not accrue significantly greater costs than patients who died out of the hospital. Simulations of a random 5% adverse selection of high-cost patients among two capitated systems resulted in cost shifts of $11.1 million. Recorded smoking history, obesity, and low serum albumin were significantly associated with excess costs. Healthcare costs are concentrated in a significant minority of older adults. Costs accrued in conjunction with hospital stays dominate healthcare expenditures for this cohort of older adults. However, most older adults (83%) have one or fewer hospital episodes in a 4-year period. Although patients who died accrued greater healthcare costs, these costs were not higher when the death occurred in the hospital. Self-care behaviors are an important target for interventions to reduce costs.

The cost of treating community-acquired pneumonia

Community-acquired pneumonia (CAP) is responsible for an average of 4.5 million visits annually to physicians' offices, emergency departments, and outpatient clinics. However, there have been few studies using national data on the costs of treating CAP. Without such data, it is difficult to assess whether new therapies and treatment strategies are needed to improve patient outcomes. We conducted a retrospective analysis based on national incidence data and paid claims data for patients treated for CAP to assess the frequency of services rendered and costs to the health-care system. Records were selected for the study based on a primary diagnosis of CAP according to the International Classification of Diseases, 9th Revision. Incidence data were derived from the National Health and Nutrition Examination Survey III. Medicare was the primary source of data for patients aged ≥65 years. Data from the National Healthcare Cost and Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used to determine the cost of treating patients aged <65 years. We arrived at a total cost of $4.8 billion for treating patients aged ≥65 years and $3.6 billion for treating patients aged <65 years. These calculations were based on the following: 1.1 million hospital discharges resulting in inpatient costs of $4.4 billion (52.4% of the $8.4 billion) for the 0.6 million patients aged ≥65 years and $3.1 billion (36.9% of the $8.4 billion) for the 0.5 million patients aged <65 years. The average hospital length of stay was 7.8 days with an average cost of $7166 for patients aged ≥65 years and 5.8 days with an average cost of $6042 for younger patients. Room and board represented the largest percentage of the average hospital bill for patients with CAP. Inpatient physician service costs were $305 million and $192 million for the ≥65 and <65 groups, respectively. Based on 1.1 million outpatient office visits for those aged ≥65 years and 3.3 million visits for those aged <65, total outpatient costs were $119 million and $266 million, respectively. Given the overwhelming cost burden for CAP in the hospital setting, any new therapy that allows patients to be treated in the outpatient setting could result in significant savings, especially for patients aged ≥65 years.

A cost analysis of a Helicobacter pylori eradication strategy in a large health maintenance organization

Objectives: We sought to describe the effect of a Helicobacter pylori eradication strategy on health care costs among a cohort of health maintenance organization (HMO) members with peptic ulcer disease (PUD). Methods: Patients were identified from an outpatient diagnosis database and verified at chart review to have new-onset PUD by upper endoscopy or upper gastrointestinal radiographic series. Health plan registration and accounting databases were used to track costs over 12 months after initial diagnosis. Costs were analyzed separately for an initial 2-month interval and a 10-month follow-up period. Inpatient and pharmacy costs are those directly attributable to PUD (either a PUD-related discharge diagnosis or an antiulcer medication prescription). Outpatient costs are total costs. All cost differences were adjusted for age and gender. Results: Twenty-seven of 93 patients meeting selection criteria received H. pylori treatment. During the 2-month treatment window, adjusted PUD-related inpatient costs were higher for the H. pylori treated group (difference, $234.00/person), whereas total outpatient costs and PUD-related pharmacy costs were similar. During the 10-month follow-up period, PUD-related inpatient and pharmacy adjusted costs were similar, but adjusted outpatient costs in the H. pylori treated group were lower than in the untreated group (difference, $508.00/person). Total adjusted follow-up period costs were $555.00/person less in the H. pylori treated group ( p = 0.05). Total 12-month costs in the H. pylori treated group were $285.00/per person less than in untreated patients, ( p > 0.2); 30% of H. pylori treated patients were still receiving antisecretory therapy 1 yr after diagnosis, compared to 41.9% of untreated patients. Conclusions: H. pylori treatment is associated with a decreased cost of follow-up care for patients with PUD, primarily due to decreased outpatient utilization.

A cost analysis of a Helicobacter pylori eradication strategy in a large health maintenance organization.

We sought to describe the effect of a Helicobacter pylori eradication strategy on health care costs among a cohort of health maintenance organization (HMO) members with peptic ulcer disease (PUD). Patients were identified from an outpatient diagnosis database and verified at chart review to have new-onset PUD by upper endoscopy or upper gastrointestinal radiographic series. Health plan registration and accounting databases were used to track costs over 12 months after initial diagnosis. Costs were analyzed separately for an initial 2-month interval and a 10-month follow-up period. Inpatient and pharmacy costs are those directly attributable to PUD (either a PUD-related discharge diagnosis or an antiulcer medication prescription). Outpatient costs are total costs. All cost differences were adjusted for age and gender. Twenty-seven of 93 patients meeting selection criteria received H. pylori treatment. During the 2-month treatment window, adjusted PUD-related inpatient costs were higher for the H. pylori treated group (difference, $234.00/person), whereas total outpatient costs and PUD-related pharmacy costs were similar. During the 10-month follow-up period, PUD-related inpatient and pharmacy adjusted costs were similar, but adjusted outpatient costs in the H. pylori treated group were lower than in the untreated group (difference, $508.00/person). Total adjusted follow-up period costs were $555.00/person less in the H. pylori treated group (p = 0.05). Total 12-month costs in the H. pylori treated group were $285.00/per person less than in untreated patients, (p > 0.2); 30% of H. pylori treated patients were still receiving antisecretory therapy 1 yr after diagnosis, compared to 41.9% of untreated patients. H. pylori treatment is associated with a decreased cost of follow-up care for patients with PUD, primarily due to decreased outpatient utilization.

Cost-Minimization and the Number Needed to Treat in Uncomplicated Hypertension

The goal of this study was to compare the direct costs associated with the prescription of thiazide diuretics, β-receptor blockers (β-blockers), angiotensin converting enzyme inhibitors (ACEI), α-receptor blockers (α-blockers), and calcium channel blockers (CCB) for the prevention of stroke, myocardial infarction (MI) and premature death in uncomplicated hypertension. We performed a cost-minimization analysis based on numbers-needed-to-treat (NNT) derived from the metaanalysis of 15 major clinical trials of hypertension treatment, and the average wholesale prices of both the most commonly prescribed and the least expensive drugs in each class. The inclusion criteria for clinical trials were that they be randomized, controlled trials of drug therapy of uncomplicated mild-to-moderate hypertension with stroke, MI, or death as endpoints. The wholesale drug costs and the total direct outpatient treatment costs to prevent a stroke, MI or death among middle-aged and elderly hypertensives were our outcome measures. The estimated wholesale drug acquisition cost to prevent one major event (MI or stroke or death) ranged from $4730 to $346,236 among middle-aged patients, and from $1595 to $116,754 in the elderly; generic diuretic or β-blocker therapy was more economical than treatment with an ACEI, α-blocker, or CCB. The associated 5-year NNT was 86 for middle-aged patients and 29 for elderly patients. Diuretic therapy remained more cost-effective even under the unlikely assumption that the newer drugs were 50% more effective than diuretics at preventing these major events. The costs associated with potassium supplementation did not eliminate the advantage of diuretics. Treatment costs to prevent major hypertensive complications are much lower with diuretics and β-blockers than with ACEI, CCB, or α-blockers, especially in middle-aged patients.

COST-EFFECTIVENESS STUDY IN PEDIATRIC ALLERGIC DISEASE COST MANAGING ASTHMA

Study for cost managing asthma was implemented in order to recognize cost-effectiveness in treatment for pediatric allergic disease. One month-treatment cost of asthma outpatient treated at medical office, general hospital and university hospital, the age of 0 to 20, was studied. In the study, total outpatient cost was ¥22, 000 including that, physician's fee was ¥6, 000-¥7, 000 (¥4, 000 decreased at hospital), drug fee for treatment was ¥600, prescription drug fee was ¥11, 000, prescription fee was ¥1, 800, laboratory test fee was ¥2, 700. The contents of prescribed drug cost were 30% for DSCG, 28% for anti- allergic agents, 24% for theophyllines, 7% for oral β2 stimulants, 4% for BDP, 2% for inhalant β2 and 5% for others. For prescription drug fee, the difference by institution or the age of a patient was not observed, 2-3 times-difference by a severity of asthma was observed. A major point to consider a decrease in cost managing asthma is that, whether or not strong antiinflammatory inhalant steroid would be applied to mild asthma group treatment, and a consideration for long-time adverse effect and drug dependence, should be judged.

The relationship of social environment, social networks, and health outcomes in the Seattle Longitudinal Study: two analytical approaches.

This study examined the relation of social networks and perceived social environment to health outcomes and cost utilization over a 1-year period in a community sample of 387 (173 males, 214 females). Two analytical strategies, a variable-oriented approach and a subject-oriented approach, were used to complement each other: structural equation modeling assessed the direct relationship between social relationships and health, while cluster analysis examined how social relationship patterns were related to health outcomes. Lower levels of perceived social environment were associated with an increased number of hospital visits. For unmarried individuals, increased age was associated with greater medical usage and estimated total health care cost, while low perceived social environment was related to a greater number of doctor visits. Among married individuals, women had more frequent doctor visits, medication usage, estimated outpatient costs, and primary care visits. Married individuals with low levels of social networks had increased total health care costs, outpatient costs, and primary care visits. Cluster analysis was used to group individuals by characteristics of perceived social environment and social networks. Members of the cluster groups with greater health problems were more likely to be isolated, had the least social contact, and had lower levels of education and income. Including subject-oriented approaches is useful in complementing more popular regression methods for data analysis.

Cost differences among women's primary care physicians.

A secondary analysis of data from the 1987 National Medical Expenditure Survey revealed that women with distinct demographic and socio-economic characteristics identify different physician specialty groups as their usual source of care. The use of certain physician groups for primary care resulted in higher rates of use and expenditures, particularly for younger women. Identifying an internist, rather than a family/general practitioner or an obstetrician/gynecologist, as a usual source of care placed one at higher odds of making more visits and incurring higher total outpatient costs.

A chronic disease score with empirically derived weights.

Different types of medication prescribed during a 6-month period for the treatment and management of chronic conditions were utilized in the refinement and validation of a chronic disease score. Prescription data, in addition to age and sex, were utilized to develop a chronic disease score based on empirically derived weights for each of three outcomes: total cost, outpatient cost, and primary care visits. The ability of the revised chronic disease score to predict health care utilization, costs, hospitalization, and mortality was compared to an earlier version of the chronic disease score (original) that was derived through clinical judgments of disease severity. The predictive validity of the chronic disease score is also compared to ambulatory care groups, which utilize outpatient diagnoses to form mutually exclusive diagnostic categories. Models based on a concurrent 6-month period and a 6-month prospective period (ie, the 6-month period after the chronic disease score or ambulatory care group derivation period) were estimated using a random one half sample of 250,000 managed-care enrollees aged 18 and older. The remaining one half of the enrollee population was used as a validation sample. The revised chronic disease score showed improved estimation and prediction over the original chronic disease score. The difference in variance explained prospectively by the revised chronic disease score versus the ambulatory care groups, conversely, was small. The revised chronic disease score was a better predictor of mortality than the ambulatory care groups. The combination of revised chronic disease score and ambulatory care groups showed only marginally greater predictive power than either one alone. These results suggest that the revised chronic disease score and ambulatory care groups with empirically derived weights provide improved prediction of health care utilization and costs, as well as hospitalization and mortality, over age and sex alone. We recommend the revised chronic disease score with total cost weights for general use as a severity measure because of its relative advantage in predicting mortality compared to the outpatient cost and primary care visit weights.