Years Of Claims Data Research Articles

Reoperation Rates and Disease Costs for Primary Open-Angle Glaucoma Patients in the United States Treated with Incisional Glaucoma Surgery

To evaluate the claims-based 5-year economic and reintervention burden for patients with primary open-angle glaucoma (POAG) after incisional glaucoma surgery in the United States. Retrospective Medicare claims analysis. One thousand nine hundred forty-five Medicare fee-for-service patients with POAG treated with trabeculectomy, tube shunt, or EX-PRESS shunt procedures from 2010 through2011. Patients with POAG treated with incisional glaucoma surgery (trabeculectomy, tube shunt, or EX-PRESS shunt) from 2010 through 2011 were identified in the Medicare 5% Standard Analytical Files. Ten years of claims data for each patient (2005-2016) were evaluated for prior incisional surgeries and downstream procedures in the treated eye within 5 years of index. Patients' characteristics, downstream procedures, and POAG-related costs were evaluated. Proportions of patients with downstream procedures in the index eye indicating failure of the index surgery, glaucoma reoperations, nonfailure complications, interventions, or cataract surgery were assessed over 5 years of follow-up. Cumulative rates of index surgery failure and glaucoma reoperations over 5 years after incisional glaucoma surgery. Of 1945 patients, 223 underwent EX-PRESS shunt, 551 underwent tube shunt, and 1171 underwent trabeculectomy at index. Rates of failure, glaucoma reoperations, or nonfailure complications rose over 5 years after index for all patient subgroups. At 1 year, 15.1% of EX-PRESS shunt patients, 11.6% of tube shunt patients, and 8.8% of trabeculectomy patients had experienced failure based on postindex procedures. By 5 years follow-up, these rates were 31.5% of EX-PRESS shunt patients, 27.1% of tube shunt patients, and 23.5% of trabeculectomy patients. Five-year rates of glaucoma reoperations were 18.3%, 14.0%, and 15.1%, respectively. Among tube shunt and trabeculectomy patients with prior incisional surgery, the 5-year failure rates were 32.5% and 32.6%, and reoperations rates were 12.0% and 26.1%, respectively. More than one-fourth of patients with POAG treated with incisional surgery underwent additional procedures to address index surgery failure within 5 years. Of these, more than half underwent additional incisional glaucoma surgery. These outcomes from clinical practice settings demonstrate that patients with POAG who require incisional surgery continue to need additional safe and effective surgical treatment options to manage their glaucoma.

Increased Risk for New-Onset Psychiatric Adverse Events in Patients With Newly Diagnosed Primary Restless Legs Syndrome Who Initiate Treatment With Dopamine Agonists: A Large-Scale Retrospective Claims Matched-Cohort Analysis.

Published literature documents increased risk for psychiatric adverse events (P-AEs) following dopamine agonist (DA) initiation for treatment of primary restless legs syndrome (RLS). We examined the association between DA initiation and subsequent new-onset P-AEs among patients with a new diagnosis of RLS who had no history of psychiatric disorder or DA use. Selected were adults (age 18 years or older) enrolled through United States employer-sponsored plans and Medicare Advantage from 7/1/2008-12/31/2014, with ≥ 2 years of claims data preceding their first RLS diagnosis ("preindex period"). Excluded were those with psychiatric diagnoses (International Classification of Diseases, Ninth Revision [ICD-9] 290-319) or DA use during the preindex period, and those with possible secondary RLS. Patients who initiated (DA+) versus did not initiate (DA-) DAs were matched 1:1 on age at index RLS diagnosis, sex, geographic region, and employment status, and preindex period comorbid illness burden and number of non-DA drug fills. Using a validated ICD-9-based severity-of-illness psychiatric disorder classification system, we compared likelihoods of new-onset P-AEs between matched pairs during parallel follow-up periods. Identified were 889 matched pairs. Compared with their DA- counterparts, DA+ patients were nearly two times more likely to experience development of any P-AE (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.31-2.24, P < .0001); and similarly more likely to experience the development of a severe (OR 1.68, 95% CI 1.03-2.86, P = .04), moderately severe (OR 1.63, 95% CI 1.17-2.29, P = .004), or mild (OR 1.72, 95% CI 1.12-2.65, P = .01) P-AE. Compared to DA- matched control patients, patients in whom RLS was newly diagnosed and who initiated de novo DAs demonstrated significantly increased risk for subsequent development of P-AEs of any severity. Hankin C, Lee D, Garcia-Borreguero D, Wang Z. Increased risk for new-onset psychiatric adverse events in patients with newly diagnosed primary restless legs syndrome who initiate treatment with dopamine agonists: a large-scale retrospective claims matched-cohort analysis. J Clin Sleep Med. 2019;15(9): 1225-1232.

Impact of Financial Incentives on Service Use, Spending, and Health in Medicaid

The Centers for Medicare and Medicaid Services provided grants to Medicaid programs through the Medicaid Incentives for Prevention of Chronic Diseases program to test whether financial incentives changed the use of healthcare services, Medicaid spending, and health outcomes. Six states implemented programs related to diabetes prevention, weight management, diabetes management, and hypertension management. The purpose of this study is to examine whether receipt of financial incentives increased use of services incentivized by the program; reduced expenditures, inpatient admissions, emergency department visits; and improved health outcomes. State data on program participation and incentives (between 2011 and 2015) and 2 years of Medicaid claims data pre-Medicaid Incentives for Prevention of Chronic Diseases enrollment and >2 years of claims data after enrollment were analyzed using covariate-adjusted regression analyses. Negative binomial, logistic, and linear regressions were used, depending on the outcome variable of interest (services, inpatient admissions and emergency department visits, and total expenditures). Analyses were conducted in 2015 and 2016. Incentive recipients attended, on average, one to two more diabetes prevention classes than control participants, but incentives did not significantly improve uptake of other types of services, such as meetings with a health coach or doctor, gym visits, or attendance at Weight Watchers meetings. Modest improvements in health outcomes, such as weight loss, were observed, yet there were very few significant changes in inpatient admissions, emergency department visits, and Medicaid expenditures. Financial incentives are useful for engaging Medicaid enrollees in disease prevention programs, but program engagement may not necessarily lead to changing patterns of healthcare utilization and expenditures in the short run.

DU1 - Early Initiation of Long-Acting Injectable Antipsychotic Treatment is Associated with Lower Healthcare Resource Use and Costs in Patients with Schizophrenia

To determine if early initiation of long-acting injectable (LAI) antipsychotic treatment is associated with lower healthcare resource use and cost in patients with schizophrenia. This retrospective cohort analysis used 9.5 years of claims data (1/1/2007–6/30/2016) from Truven Health MarketScan® Commercial, Medicaid, and Medicare Supplemental databases. In patients ≥18 years with a new episode of schizophrenia, two mutually exclusive cohorts were identified based on time from date of first schizophrenia diagnosis (the new episode) to first date of starting a LAI (index date): ≤1 year (early initiators) and >1 year (late initiators). Patients were required to have continuous enrollment between the new episode of schizophrenia and LAI initiation and for ≥1 year before (baseline) and after (follow-up) index date. Logistic and general linear regression models were performed to estimate the adjusted hospitalization rate and healthcare costs, controlling patient demographic and clinical characteristics, insurance type, baseline all-cause hospitalizations and emergency department visits, and baseline psychiatric medication use (including oral antipsychotic use). 31% (n=1,388) initiated treatment early and 68% (n=2,978) initiated later. In risk-adjusted models, all-cause hospitalization rates were 22.1% (95%CI, 19.8%-24.5%) in early initiators and 26.9% (95%CI 25.2%-28.7%) in late initiators (p<0.001). 14.0% (95%CI, 12.2%-16.0%) of early initiators had a psychiatric hospitalization compared with 19.2% (95%CI 17.7%-20.8%) of late initiators (p<0.001). Adjusted psychiatric healthcare costs were significantly lower in early initiators compared with late initiators [mean (95%CI) $21,337 (20,135-22,539) vs. $24,228 (23,419-25,038)] (p<0.001). Adjusted all-cause healthcare costs were lower in early initiators compared with late initiators [mean (95%CI) $34,661 (32,531-36,791) vs. $36,342 (34,907-37,777)], but the difference was not statistically significant (p=0.21). Schizophrenia patients who initiated a LAI early had lower hospitalization rates and healthcare costs compared with late LAI initiators.

PC-FACS

PC-FACS

Risk of hospitalization and healthcare cost associated with Diabetes Complication Severity Index in Taiwan's National Health Insurance Research Database

ObjectiveThe aim of this study is to test the validity of adapted Diabetes Complication Severity Index (aDCSI) in predicting the risk of hospitalization and healthcare cost in type 2 diabetic patients using a nationally-representative claims database. Study designRetrospective cohort study used 4years of claims data from Taiwan's National Health Insurance Research Database (NHIRD). MethodsType 2 diabetic patients who had 4-years of enrollment were identified as study subjects (N=136,372). The aDCSI score (sum of diabetic complication with severity levels, range 0–13) and complication count (sum of diabetic complications, range 0–7) were generated using diagnostic codes for each patient. Poisson model and linear regression model were conducted to predict risk of hospitalization and healthcare costs associated with aDCSI score and count of diabetic complications. ResultsThe aDCSI score (risk ratio 1.51 to 10.32 categorically, and 1.41 linearly) and count of diabetic complications (risk ratio 1.56 to 12.20 categorically, and 1.66 linearly) were significantly positively associated with risk of hospitalization. A one-point increase in the aDCSI score was positively associated with increased healthcare costs. ConclusionsThe performance of aDCSI in predicting risk of hospitalization and healthcare cost in the nationally-representative claims database is similar to those reported in the original study. It may serve as an efficient tool for stratifying type 2 diabetic patients for disease management programs and population-based studies.

The Burden of Narcolepsy Disease (BOND) study: health-care utilization and cost findings

ObjectivesThe aim of this study was to characterize health-care utilization, costs, and productivity in a large population of patients diagnosed with narcolepsy in the United States. MethodsThis retrospective, observational study using data from the Truven Health Analytics MarketScan® Research Databases assessed 5years of claims data (2006–2010) to compare health-care utilization patterns, productivity, and associated costs among narcolepsy patients (identified by International Classification of Diseases, Ninth Revision (ICD9) narcolepsy diagnosis codes) versus matched controls. A total of 9312 narcolepsy patients (>18years of age, continuously insured between 2006 and 2010) and 46,559 matched controls were identified. ResultsCompared with controls, narcolepsy subjects had approximately twofold higher annual rates of inpatient admissions (0.15 vs. 0.08), emergency department (ED) visits w/o admission (0.34 vs. 0.17), hospital outpatient (OP) visits (2.8 vs. 1.4), other OP services (7.0 vs. 3.2), and physician visits (11.1 vs. 5.6; all p<0.0001). The rate of total annual drug transactions was doubled in narcolepsy versus controls (26.4 vs. 13.3; p<0.0001), including a 337% and 72% higher usage rate of narcolepsy drugs and non-narcolepsy drugs, respectively (both p<0.0001). Mean yearly costs were significantly higher in narcolepsy compared with controls for medical services ($8346 vs. $4147; p<0.0001) and drugs ($3356 vs. $1114; p<0.0001). ConclusionsNarcolepsy was found to be associated with substantial personal and economic burdens, as indicated by significantly higher rates of health-care utilization and medical costs in this large US group of narcolepsy patients.

Common community‐acquired infections and subsequent risk of multiple myeloma: A population‐based study

The role of bacteria and viruses as aetiological agents in the pathogenesis of cancer has been well established for several sites, including a number of haematological malignancies. Less clear is the impact of such exposures on the subsequent development of multiple myeloma (MM). Using the population-based U.S. Surveillance Epidemiology and End Results-Medicare dataset, 15,318 elderly MM and 200,000 controls were identified to investigate the impact of 14 common community-acquired infections and risk of MM. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were adjusted for sex, age and calendar year of selection. The 13-month period prior to diagnosis/selection was excluded. Risk of MM was increased by 5-39% following Medicare claims for eight of the investigated infections. Positive associations were observed for several infections including bronchitis (adjusted OR 1.14, 95% CI 1.09-1.18), sinusitis (OR 1.15, 95% CI 1.10-1.20) pneumonia (OR 1.27, 95% CI 1.21-1.33), herpes zoster (OR 1.39, 95% CI 1.29-1.49) and cystitis (OR 1.09, 95% CI 1.05-1.14). Each of these infections remained significantly elevated following the exclusion of more than 6 years of claims data. Exposure to infectious antigens may therefore play a role in the development of MM. Alternatively, the observed associations may be a manifestation of an underlying immune disturbance present several years prior to MM diagnosis and thereby part of the natural history of disease progression.

Trends in the use of postprostatectomy therapies for patients with prostate cancer: A Surveillance, Epidemiology, and End Results Medicare analysis

For patients with adverse pathologic factors (positive surgical margins, extracapsular extension, or seminal vesicle invasion) on prostatectomy pathology, the use and timing of postsurgical treatments are controversial. The goal of the current study was to examine patterns of care in patients with a pathologic indication for postprostatectomy radiotherapy (RT) using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. A total of 3460 men treated with radical prostatectomy for localized prostate cancer between 2000 and 2006 with at least 1 adverse pathologic factor and at least 3 years of claims data after surgery were included. Medicare claims through December 31, 2009 were examined. Rates of postprostatectomy hormonal therapy, RT, or both were examined. Logistic regression analysis examined potential factors associated with the receipt and timing of RT. Within 3 years after surgery, 1076 patients (31%) received some form of further therapy, including 850 (25%) who received RT. Receipt of RT was < 35% in all subgroups including every year of study. Fewer than one-half of patients who received RT (43%) did so within 6 months of surgery. On multivariate analysis, pathologic T classification and tumor grade were associated with receipt of RT within 6 months or 3 years of surgery, as were younger age, geographic region, and population density. Rates of postprostatectomy RT remain low and the timing of RT has not appreciably changed since the publication of the randomized trials supporting the use of adjuvant RT. The use of hormone therapy is almost as common as RT, despite a relative lack of evidence supporting its use in this setting.

Trends in the treatment changes and medication persistence of chronic myeloid leukemia in Taiwan from 1997 to 2007: a longitudinal population database analysis.

BackgroundFew studies have examined the longitudinal changes in the patterns, selection, and utilization of treatments for chronic myeloid leukemia (CML) in routine clinical practice since the introduction of imatinib. Therefore, we investigated the trends in CML therapy, including changes, patterns, and persistence to imatinib therapy among patients with newly diagnosed CML.MethodsWe conducted a cross-sectional and longitudinal analysis of 11 years of claims data for patients with newly diagnosed CML included in the Taiwan National Health Insurance program. Pharmacy and diagnosis claims for newly diagnosed CML recorded between 1997 and 2007 year were extracted from the database. Annual overall use, new use of CML therapy, and persistence to imatinib therapy were estimated. The Anatomical Therapeutic Chemical codes for CML therapy [i.e., imatinib and conventional therapy: busulfan, hydroxyurea, interferon-α (IFNα), and cytarabine], and the process code for hematopoietic stem cell transplantation were used to categorize treatment patterns. Associations with patients characteristics were analyzed by multivariate logistic regression.ResultsOverall, the proportion of patients with newly diagnosed CML to all patients with CML increased by approximately 4-fold between 1998 and 2007. There were steady increases in the proportions of all treated patients and those starting therapy from 2003 to 2007. Fewer comorbid conditions and lower severity of CML were associated with treatment initiation. Medication persistence varied according to treatment duration, as 38.7% patients continued imatinib for ≥ 18 months without interruption but only 7.7% continued imatinib for ≥ 5 years. Factors associated with persistence to imatinib therapy were removal of the need for prior authorization for imatinib, and prior use of hydroxyurea and IFNα, whereas having undergone hematopoietic stem cell transplantation led to reduced likelihood of persistence to imatinib therapy.ConclusionTreatment decisions for patients with CML changed over time in routine clinical practice. Our findings suggest that clinicians are increasingly adopting the recommendations of international treatment guidelines for CML. However, persistence to imatinib therapy is still substantially below the recommended level based on current evidence for its efficacy. Our study also highlights the need to improve treatment persistence and effectiveness of imatinib over the long term.

Anti-inflammatory Medication Adherence and Cost and Utilization of Asthma Care in a Commercially Insured Population

Objective. The authors hypothesized that adherence to anti-inflammatory treatment could reduce overall cost of asthma care, as higher spending on drugs would be offset by reductions in hospital and emergency care. Methods. A retrospective observational study using 2 years of claims data for 41,234 commercially insured asthmatics on monotherapy with either leukotriene inhibitors (LI) or inhaled corticosteriods (ICS). Patients were grouped into adherence quartiles based on the percentage of days per year they had prescriptions filled (medication possession ratio). The relationship between adherence and four outcomes was examined: () emergency department (ED) visits, () hospitalizations, () nondrug net payments for asthma care, () total net payments for asthma care (including drug costs). Multivariate and logistic regression models adjusting for demographics, comorbidities, and measures of past asthma utilization were used. Results. Adherence rates were low with a median medication possession ratio of 39% for LI and 15% for ICS. Both ED and hospital use was negatively associated with adherence to LI. Patients in the lowest quartile experienced 80 (95% confidence interval (CI) = 62–102) ED visits and 34 (95% CI = 22–52) admissions per 1000 patient-years compared to 36 (95% CI = 27–49) ED visits and 13 (95% CI = 8–22) admissions in the highest quartile. In contrast, ED visits and hospital admissions did not differ significantly between adherence groups for ICS. Total payments for asthma care increased significantly with higher adherence for both LI and ICS patients. Comparing the lowest and highest adherence quartile, payments per person per month increased significantly from $65.11 (95% CI = $57.02–$73.20) to $147.46 (95% CI = $139.48–$155.44) for patients on LI and from $38.71 (95% CI = $29.52–$47.90) to 93.13 (95% CI = $83.70–$102.56) for patients on ICS. The only subgroup, for which overall asthma payments did not increase with better adherence, were patients with past ED visit or hospital admission on LI. Conclusions. In this observational study, treatment with LI, but not with ICS, appears to improve disease control, as evidenced by the reduction in the incidence of ED visits and hospitalizations in patients on LI. Savings generated by this reduction in high-cost events don't offset the increased payments for drugs in more adherence patients, except for selected high-risk patients.

Health Supervision Visits among SSI-Eligible Children in the D.C. Medicaid Program: A Comparison of Enrollees in Fee-for-Service and Partially Capitated Managed Care

Managed care plans that involve some form of capitation may have adverse effects on children with special health care needs because the financial incentives to control costs may result in under-treatment and restrict access to expensive services and specialty providers. Proponents highlight the advantages of a managed care model, including case management and coordination of services. In light of this debate, only a few state Medicaid programs have implemented a managed care option for children with special health care needs. This study evaluates the effects of plan choice (partially capitated managed care versus fee-for-service) on whether children with disabilities eligible for Supplemental Security Income (SSI) and enrolled in the District of Columbia's Medicaid program are in compliance with the guidelines for health supervision visits established by the American Academy of Pediatrics (AAP). Our findings, based on five years of claims data, show that SSI-eligible children with disabilities enrolled in a partially capitated managed care plan are significantly more likely to be in compliance with the AAP guidelines for health supervision visits compared to their fee-for-service counterparts. Moreover, we find that selection due to unobservable characteristics does not significantly bias the estimated program effects.

Disease-related and all-cause health care costs of elderly patients with gout.

BACKGROUND: Gout is a common cause of inflammatory arthritis in the United States, and its prevalence has increased in recent decades, especially among older adults. Older adults with gout are of particular interest because they tend to experience higher rates of tophi, an advanced stage of gout, than do younger patients. OBJECTIVE: For older adults with gout to (1) assess health care utilization and costs from a third-party payer perspective; (2) evaluate health care costs related to tophi; and (3) explore the relationship between elevated serum uric acid (UA) level, an indicator of disease control, and health care utilization.

Utilization of Pharmacologic Treatment in Youths with Attention Deficit/Hyperactivity Disorder in Medicaid Database

Little is known about longitudinal changes in drug utilization in attention-deficit/hyperactivity disorder (ADHD). To describe longitudinal trends in ADHD drug utilization and explore demographic differences among youths eligible for a large Southern state Medicaid program. A cross-sectional and longitudinal analysis of 10 years of claims data for all Medicaid beneficiaries younger than 20 years of age with 6 months or more of continuous insurance (N = 2,131,953) was conducted. Annual prevalence, incidence, and persistence in ADHD medication use (stimulants and atomoxetine) were estimated based on pharmacy claims and clinician-reported ADHD diagnosis. ADHD prevalence increased 1.70-fold (95% CI 1.67 to 1.73) from 3.10% (21,904 of 705,573 beneficiaries) in fiscal year 1995-1996 to 5.27% (41,681 of 790,338) in 2003-2004, paralleled by a 1.84-fold (95% CI 1.81 to 1.87) increase in drug use to 4.63%. In 2003-2004, 0.89% of youths were diagnosed and newly started on drugs, reflecting a 1.38-fold (95% CI 1.33 to 1.43) increase over 1995-1996. One in five white males between the ages of 10 and 14 years (19.24%; 95% CI 18.81 to 19.67) received ADHD medication in 2003-2004. Males continued to be more likely diagnosed and treated than females (prevalence ratio [PR] in 2003-2004 = 2.96; 95% CI 2.90 to 3.03 vs 3.82; 95% CI 3.69 to 3.96 in 1995-1996), as were whites when compared with Hispanics (PR in 2003-2004 = 2.65; 95% CI 2.57 to 2.73 vs 3.78; 95% CI 3.57 to 3.99 in 1995-1996) and blacks (PR in 2003-2004 = 1.81; 95% CI 1.76 to 1.85 vs 2.00; 95% CI 1.93 to 2.07 in 1995-1996). The most common starting age throughout the study period was 5-9 years, with 2.45% (95% CI 2.37 to 2.52) new ADHD drug users in 2003-2004, but largest increases in prevalence were observed in adolescents 15-19 years of age, with 2.47% (95% CI 2.38 to 2.55) in 2003-2004 compared with 0.45% (95% CI 0.41 to 0.49) in 1995-1996. Medication persistence varied, with only 49.9% (95% CI 49.4 to 50.5) of new users receiving drugs after 1 year, with yet another 17.2% (95% CI 16.4 to 18.0) continuing for 5 years or more. ADHD drug utilization continues to increase due to steady increases in diagnosis and chronic use of the drugs over several years. While racial, ethnic, and sex differences persist, the age distribution of drug users has shifted toward older children. These findings emphasize the need for studies that analyze determinants of treatment as well as outcomes, both benefits and risks, associated with long-term medication use.

Cost Shifting Under Managed Behavioral Health Care

The study examined whether a managed behavioral health care organization (MBHO) shifted treatment costs. Four years of claims data (1991-1995) from an insurer that introduced an MBHO in 1992 to control treatment costs were analyzed. Although the MBHO was not at direct financial risk for specialty mental health treatment, it faced incentives related to reputation and contract renewal to shift costs to primary care treatment or prescription drugs. It was hypothesized that if cost shifting occurred, an increase would be noted in the use of psychotropic medications without concurrent use of specialty mental health treatment. Simple t tests and a generalized estimating equations probit specification were used to test this hypothesis. Separate tests were performed for use of any psychotropic medication, any newer antidepressant, and any stimulant in a large employer group that simultaneously implemented parity coverage (75,360 enrollees) and a group of smaller employers that did not (9,228 enrollees). The use of any psychotropic medication rose 64% in relative terms (p<.001) over the four-year period among enrollees of the large employer group and by 87% in the smaller groups (p<.001). In general, there were downward secular trends in the use of psychotropic medications without specialty care. Introduction of the MBHO was not significantly associated with the use of psychotropic medication alone. For newer antidepressants, introduction of the MBHO was associated in the large group with a 2.4 (p=.003) absolute percentage point decrease in medication use alone. No evidence was found to suggest that the MBHO shifted treatment costs.

Retrospective, Nested, Case-Control Study of the Association between Transfusion Frequency and Potential Complications of Iron Overload in Patients with Myelodysplastic Syndrome and Other Acquired Hematopoietic Disorders.

Background Patients with myelodysplastic syndrome (MDS) and other acquired hematopoietic disorders frequently require chronic transfusion therapy. Although red cell transfusions are known to cause iron overload, data on the risk of iron-related complications in these patients are limited.Methods We conducted a retrospective, case-control study of the association between complications of iron overload and exposure to transfusions among patients in a large US health-insurance claims database with a diagnosis of MDS and other hematopoietic disorders (ICD-9-CM 238.7: neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues) between 1997 and 2004. Patients with <1 year of claims data prior to this diagnosis (“diagnosis date”), <40 years of age as of diagnosis date, with potential complications of iron overload prior to the diagnosis date, or with diagnoses of thalassemia (ICD-9-CM 282.4) or sickle cell disease (ICD-9-CM 282.6), or were excluded. Complications included: cardiomyopathy/heart failure (ICD-9-CM 425, 428), conduction/rhythm disorders (ICD-9-CM 426, 427), diabetes (ICD-9-CM 250 or antidiabetes medication), and liver disease (ICD-9-CM 571, 572.2, 572.3, 572.8 573.0, 573.8, 573.9, 789.1, 789.5, v427). Cases were defined as subjects with complications of iron overload after the diagnosis date and were compared with a corresponding number of controls (patients without complications) with respect to receipt of transfusions, controlling for other demographic and clinical characteristics (e.g., age, sex, region, plan type, comorbidities, medical care utilization and expenditures), using multivariate conditional logistic regression.Results A total of 7113 patients met inclusion criteria. From these, we identified 511 patients with one or more complications after the diagnosis date and a corresponding number of controls. Patients with complications were older (mean age 60 vs 56 years, p<.0001) and had more comorbidities (mean Charlson index 2.8 vs 1.4, p<.0001) than those without complications. Mean (max) follow-up was 6.8 (46.0) months. Among those with complications, 22% received one or more transfusion post-diagnosis, compared with 5% of those without complications.Few patients in either group (<1%) received deferoxamine. After controlling for demographic and clinical characteristics using multivariate conditional logistic regression, risk of potential complications of iron overload was significantly associated with receipt of transfusions (Odds ratio [OR]=2.909, p=.0008). Results for specific potential complications were as follows: cardiomyopathy or heart failure (OR 1.616, p=.2955), conduction/rhythm disorders (OR=4.135, p<.0005), diabetes (OR=5.063, p=.0025), and liver disease (OR=3.325, p=.0008). Risk of complications also was associated with the number of transfusion episodes (unique days on which transfusions were received) (OR=1.096, p=.0483).Conclusions In patients with MDS and other acquired hematopoietic disorders, patients receiving transfusions are at increased risks of potential complications of iron overload. Iron chelation therapy may be appropriate especially for those with a relatively favorable prognosis.

Economic Profiling of Physician Specialists: Use of Outlier Treatment and Episode Attribution Rules

This paper examines the influence of episode attribution methodology and cost outlier methodology on the accuracy of physicians' economic profiles. Four years of claims data from a mixed model HMO were processed using the leading episode grouper software. Episode grouped results then were applied to construct input distributions for a simulation model. For each of four specialties (cardiology, family practice, general surgery, and neurology), we employed sets of 18 simulations to investigate the effects of three alternative episode attribution methodologies and six alternative cost outlier methodologies on sensitivity, specificity, and positive predictive error in classifying cost-efficient and cost-inefficient physicians. For identification of cost-efficient physicians, the most accurate profiling results were obtained when Winsorizing outliers at 2% and 98% of episode-type cost distributions, and attributing responsibility for episode costs to physicians who accounted for at least 30% of associated professional and prescribing fees. No consistent combination of outlier methodology and episode attribution rule was found to be superior for identifying cost-inefficient physicians.

Community Pharmacy–Based Pharmaceutical Care for Asthma Patients

Despite significant progress in asthma drug therapy in recent years, there has been no major change in asthma morbidity and mortality. It is still important to determine whether pharmaceutical care (PC) influences health outcomes. To evaluate the effectiveness of PC with regard to clinical, humanistic, and economic outcomes in adults with asthma. An intervention study was conducted over 12 months. At baseline, 39 community/retail pharmacies, 84 primary care physicians (general practitioners, internal specialists, chest physicians), and 183 patients (aged 18-65 y) diagnosed with asthma were included. To evaluate economic outcomes, 2 German statutory health insurance funds provided 2 years of claims data for their insured patients (n = 55). A 1:10 matching was carried out to compare the data of this intervention subgroup with those of a control group (n = 550). Significant improvements were found for all humanistic outcomes (eg, asthma-specific quality of life, self-efficacy, knowledge, medication adherence). In addition, asthma severity, self-reported symptoms, peak expiratory flow, and patients' inhalation technique improved. Increases in forced expiratory volume in 1 second and vital capacity were not significant over time. Evaluation of the insurance claims data revealed a shift toward better adherence to evidence-based therapy. The study shows that PC for people with asthma has a positive impact on humanistic and, to some extent, on clinical outcomes. To determine potential economic benefits, future research should focus on patients with more severe asthma.

Economic burden of transfusion dependence in patients with myelodysplastic syndromes

6064 Background: Few studies have examined health economic burden in transfusion-dependent patients with myelodysplastic syndromes (MDS). Two-thirds of MDS patients are estimated to have anemia and require red blood cell transfusions, costing approximately $550/unit transfused. This study explored health care costs and utilization in this population. Methods: Administrative claims data from a large US health plan with commercial, Medicare, and Medicaid members were used to identify transfusion-dependent patients from 5/1/00 through 3/31/03 that were ≥ 55 years of age. Transfusion dependence (TD) was defined as ≥ 2 transfusion events in an 8-week period as indicated by procedure and/or revenue codes and service dates for whole or red blood cell transfusions, and a minimum of a third transfusion occurring 3–6 months from the initial transfusion. MDS was identified from medical claims data with an ICD-9-CM diagnosis code (238.7, 284.9, 285.0, 205.20, 208.20) in the 6 months prior to and up to 12 months following the index transfusion date. Patients with evidence of chemotherapy-induced anemia were excluded. Deferoxamine use was identified in all TD patients, regardless of MDS status, and one year of claims data following first administration was captured. Medical costs were defined as transfusion-related if costs occurred on the same day as a transfusion event. Results: A total of 338 transfusion-dependent MDS patients were identified. Average age was 73.6 years. Annualized average total medical and pharmacy costs were $58,457. 82.7% of transfusions occurred in an outpatient setting with an average of 11.03 outpatient transfusions per patient per year. Annualized transfusion-related medical costs in the outpatient setting were $9,270. 49.41% of patients had erythropoietin use and average costs per treated patient were $12,589. For 20 TD patients with deferoxamine use and one year of continuous follow-up, the average duration of therapy was 276.35 days; and average costs per year were $7,437. Conclusions: The economic burden in TD MDS patients is high. Significant opportunity exists to decrease economic burden if transfusion independence can be achieved in this population. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Celgene

Relative Procedure Intensity with Self-Referral and Radiologist Referral: Extremity Radiography

To compare the relative use of bilateral versus unilateral extremity radiographic examinations when patients are referred to radiologists for imaging (radiologist referred) versus when studies are performed in the referring physician's office (self-referred). We reviewed 1 year of claims data for extremity radiographic examinations performed by a referring physician or referred to a radiology facility and claims data for related patient office visits. Data were analyzed for orthopedics, podiatry, and rheumatology, and data were divided by the practice pattern of the referring physician into pure self-referring, pure radiologist-referring, and mixed-referring categories. We compared the percentage of unilateral and bilateral studies and the number of unilateral and bilateral studies per 100 office visits in each setting. Statistical analysis of each comparison was performed with a one-tailed Z test. A total of 13 094 (14%) self-referred studies were bilateral, while 778 (10%) radiologist-referred studies were bilateral (P < .001). The rate of self-referred bilateral examinations was 2.21 times higher per 100 office visits than the rate of radiologist-referred bilateral examinations. Combined bilateral and unilateral use by self-referrers was only 1.86 times higher than use by radiologist-referrers. Orthopedists had no clinically meaningful difference in the percentage of self-referred and radiologist-referred bilateral studies, but they ordered 1.98 times as many studies per 100 visits when they self-referred studies. Self-referring podiatrists and rheumatologists ordered bilateral studies up to 3.25 times more frequently than did their radiologist-referring colleagues. Mixed-referring podiatrists had 2.70-times increased use of bilateral examinations when performing imaging in their offices, whereas mixed-referring rheumatologists had 6.40-times increase in that setting. Orthopedists, podiatrists, and rheumatologists use extremity radiography at a higher rate when they self-refer. Moreover, self-referring podiatrists and rheumatologists order radiographic examinations of increased intensity compared with radiologist-referring physicians.