-
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: To understand rates of procedure failure among patients undergoing revascularization for peripheral arterial disease (PAD) in clinical practice. MATERIALS AND METHODS: This retrospective analysis of patients with PAD who underwent a PAD-related procedure used claims and electronic medical record data from 2005 to 2009. Procedures were grouped by type (endovascular [ie, angioplasty with/without stent, atherectomy] or surgical [ie, bypass surgery, endarterectomy, thrombectomy]) and site (ie, iliac, infrainguinal). The study assessed antiplatelet and anticoagulant agent use; procedure failure, defined as a subsequent procedure or amputation; and predictors of time to procedure failure. RESULTS: A sample of 248 patients with PAD who underwent a PAD-related procedure was identified. The population was 59% male, had a mean age of 73 years, and had a mean follow-up of 23 months. Endovascular procedures alone were performed in 37% of patients, with the remainder receiving surgery only or surgery with an endovascular procedure, and 79% of patients had an infrainguinal intervention. Antiplatelet and anticoagulant use rates after the procedure were 90% and 25%, respectively. After their initial procedure, 20% of patients required a second procedure or amputation, with an average failure time of 228 days. Patients treated with infrainguinal procedures had a significantly higher failure rate versus those treated with iliac procedures (23% vs 8%; P = .011). In multivariate analysis, patients without anticoagulant use before the procedure were at significantly lower failure risk (P = .022). CONCLUSIONS: Repeated intervention and/or major amputation after revascularization of PAD was common. Further investigation of the factors associated with procedure failure is warranted.
Journal of vascular and interventional radiology: JVIR 01/2013; · 1.81 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Cancer patients, especially those with lung cancer and undergoing chemotherapy, have an elevated risk for venous thromboembolism (VTE). This study assessed incidence, timing, and risk factors for VTE (specifically receipt of chemotherapy), along with the association between VTE and survival among lung cancer patients receiving chemotherapy. Using Florida Medicaid administrative claims data (2000-2008), patients with any diagnosis of primary lung cancer were selected. Patients with recent prior VTE and those enrolled in Medicare or an HMO were excluded. Crude rates of VTE per 100 person years were estimated, and Cox proportional hazards models were developed to assess risk factors for VTE in the lung cancer population, and the association between VTE and survival among patients undergoing chemotherapy. Of 15,749 lung cancer patients, 7,052 (2,242 receiving chemotherapy and 4,810 not receiving chemotherapy) met cohort selection criteria. The incidence of VTE was 10.8 per 100 person-years (PYs) in the chemotherapy cohort and 6.8 per 100 PYs in the non-chemotherapy cohort. Among patients on chemotherapy developing VTE, median time to occurrence was 109 days, with 61 and 82 % of patients experiencing an event within six and 12 months, respectively. In multivariate analyses, the adjusted risk of VTE was 30 % higher among patients undergoing chemotherapy. Comorbidity and the presence of a central venous catheter also were significantly associated with a greater risk of developing VTE. Moreover, patients in the chemotherapy cohort who developed VTE had a significantly faster time-to-death (adjusted hazard ratio [HR] = 1.97; 95 % CI 1.69-2.29).VTE was common among lung cancer patients, especially among patients receiving chemotherapy, with the majority of VTE events occurring within 6 months of initiation of chemotherapy. The presence of a VTE event was significantly associated with an increased risk of mortality.
Journal of Thrombosis and Thrombolysis 05/2012; 34(4):446-56. · 1.48 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Treatment guidelines for bipolar disorder (BD) recommend the tapering of antidepressants (ADs) for patients with a recent acute manic or mixed episode. This study assessed rates of AD use and the association between such use and BD-related re-hospitalizations among patients with BD.
Using the IMS LifeLink® Health Plan Claims Database from 1/1/2004 to 6/30/2007, we identified adults 18+ years of age with an acute psychiatric event ("index event"), defined as a hospitalization, emergency room visit, or physician visit, with a prescription for a new BD medication with a primary diagnosis of BD I mania (ICD-9-CM: 296.0x, 296.4x) or BD I mixed (ICD-9-CM: 296.6x). All patients were required to be eligible for the 12 months before index and during the 12-month post-index period, and have a BD-related hospitalization (any diagnosis of any BD subgroup) in the pre-index period. Patients with schizophrenia at any time during the study period were excluded. Study measures included: rates of AD use (minimum of 30 days of available AD therapy within 120 days after the index event) and the association of such use with post-index BD-related hospitalizations.
2126 patients met study criteria (mean age 44 years; 57% female; 53% BD I mania). 32% of all patients had AD use in the post-index period. Compared to BD I patients without AD use in the post-index period, those with AD use had 1.43 to 1.50 times the odds of being re-hospitalized for BD in the follow-up period. Other significant positive predictors included being female and presence of substance abuse.
Administrative claims data do not provide information on symptoms, which may influence continuation of antidepressants.
In this administrative claims database, nearly one-third of patients with BD I manic or mixed subgroups had AD use following an acute event. The positive association observed between AD use and re-hospitalization needs to be confirmed in clinical studies.
Journal of affective disorders 02/2012; 138(3):425-32. · 3.76 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We assessed the burden of hepatocellular carcinoma (HCC), in terms of mortality and medical care costs, based on analysis of the Surveillance, Epidemiology and End Results (SEER)-Medicare database.
We analyzed data from the SEER-Medicare database on patients 66 years or older who were diagnosed with primary HCC from 1991 to 2007, entitled for Medicare Parts A and B, and not enrolled in health maintenance organizations (n = 5712). Controls were individuals without HCC, identified from a 5% sample of Medicare beneficiaries residing in SEER areas; they were matched 1:1 with individuals with HCC (cases) for age, sex, race, and geographic region (average age, 75 y; 34.7% female). Kaplan-Meier analysis was used to estimate survival distributions. Costs were reported in 2009 dollars; per-patient-per-month (PPPM) costs were compared between cases and controls using the Wilcoxon rank sum test.
The largest proportion of cases had localized disease (38.2%), followed by regional (24.0%), unstaged (20.4%), and distant (17.3%) disease. The median survival times were 5 months for cases and 60 months for controls; they were 3 months for patients with distant disease, 4 months for patients with regional disease, and 9 months for those with localized disease. The mean PPPM costs were $7863 for cases and $1243 for controls (P < .001). These costs were primarily driven by inpatient (mean, $5439 vs $682 without HCC; P < .001) and hospice (mean $554 vs $42 without HCC; P < .001) care. Mean PPPM costs by stage were $7265 for localized disease, $8072 for regional disease, and $9585 for distant disease (P < .001 for trend).
Based on analysis of the SEER-Medicare database, costs for patients with HCC are approximately 6- to 8-fold higher than for those without this cancer. Patients with distant HCC had the greatest costs. These findings highlight that HCC is a substantial medical cost burden for elderly patients.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 12/2011; 10(5):547-54. · 5.64 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients with a solid organ transplant (SOTs) and hematopoietic stem cell or bone marrow transplants (HSC/BMTs) are at risk of contracting invasive fungal infections (IFIs). Data on the economic burden of IFIs in the United States are sparse.
We conducted a retrospective matched cohort study using the 2004-2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. The IFI cohort included patients with ICD-9-CM codes indicating a transplant procedure and an IFI. Matched controls (transplant recipients without an IFI) were chosen based on age (10 year categories), sex, region, hospital type, year, and transplant type. Mortality, length of stay, and costs were reported overall, by transplant type, and by type of mycosis.
Nine thousand eight hundred ninety-six patients underwent SOT, and 4661 underwent HSC/BMT. Of these, 80 (0.8%) SOT and 111 (2.4%) HSC/BMT patients had an IFI. Mean age was 41.8 years (SOT) and 37.8 years (HSC/BMT). Aspergillosis was the most common infection. Patients with an IFI had a 5-fold increase in mortality, an additional 19.2 hospital days, and $55,400 in excess costs compared with patients without an IFI. Excess mortality, length of stay, and costs varied by type of transplant and mycosis.
The clinical and economic burden of IFIs in transplant recipients may be high.
American journal of infection control 10/2010; 39(4):e15-20. · 3.01 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Diabetes mellitus requires continuous medical care and patient self-management in order to prevent short-term complications and decrease the risk of long-term complications, which can result in substantial increases in the total economic burden of the disease. Findings from randomized clinical trials have shown that improved glycemic control may reduce the risk of long-term complications as long as a target for hemoglobin A1c is not set below 7% for intensive glycemic control. However, limited data from clinical practice are available regarding the relationship between glycemic control and medical costs associated with diabetes care.
To assess the potential relationships between glycemic levels, diabetes-related hospitalizations, and hospital costs among adult patients with either type 1 or type 2 diabetes mellitus who were assigned to a primary care provider (PCP) in a clinic that was affiliated with a managed care organization (MCO).
A retrospective cohort analysis was conducted using data from approximately 200,000 members of the Fallon Clinic Health Plan who were assigned to a clinic PCP at any time during a 5-year study period beginning January 1, 2002, and ending December 31, 2006. Patients aged 30 years or older with at least 2 medical claims with any listed diagnosis of diabetes mellitus (ICD-9-CM code 250.xx) during the study period and 2 or more A1c values within 1 year of each other during the study period (mean 7.6 tests over 39 months; median=6.8), were identified and stratified into 1 of 5 groups defined by 1% increments of A1c, based on their mean A1c values during the entire study period. A1c data were available only for tests ordered by a clinic provider; tests ordered by other specialists in the MCO's network were absent from the database. The study follow-up period started with each patient's first A1c test (index date) and continued until plan disenrollment, death, or December 31, 2006, whichever was earlier (end date), regardless of when the diagnosis of diabetes mellitus was made. Study measures included the proportion of patients with 1 or more diabetes-related hospitalizations, number of diabetes-related inpatient stays, and the associated estimated hospitalization costs over the follow-up period. Diabetes-related hospitalizations were identified based on a diagnosis, in any of 10 diagnosis fields, for 1 of 16 selected complications of diabetes identified by the authors. Hospital costs were estimated using discharge data (diagnoses and costs calculated from cost-to-charge ratios) contained in the 2004 Healthcare Cost and Utilization Project (HCUP) database and inflated to 2007 dollars using the medical care component of the Consumer Price Index. Multivariate models controlled for age, sex, number of A1c tests, diagnosis of cancer, and follow-up time. A multivariate logistic regression analysis was conducted with the occurrence of at least 1 diabetes-related hospital admission as the dependent variable. In the logistic regression analysis, follow-up time was defined as time from the index date to the date of the first diabetes-related hospitalization, plan disenrollment, death, or the study end date, whichever occurred first. A generalized linear model with a Poisson distribution and a log link was employed to estimate the rate of hospital admissions. In the Poisson regression analysis, follow-up time was defined as duration of the entire study follow-up period and was an offset variable. Costs were estimated using a 2-part model: first, we calculated the probability of having a hospitalization, as determined by the logistic regression above; second, a generalized linear model with a negative binomial distribution and a log link was used to predict the mean cost of diabetes-related hospitalizations only for patients with an inpatient stay, with the duration of the entire study follow-up period as an offset variable. We calculated the mean per patient cost of diabetes-related hospitalizations by multiplying the probability of having a hospitalization (as determined by the first part of the model) by the mean costs for patients who had such admissions (as determined by the second part of the model).
9,887 patients met study selection criteria. Mean A1c level was < 7% for 5,649 (57.1%) patients, 7% to < 8% for 2,747 (27.8%), 8% to < 9% for 1,002 (10.1%), 9% to < 10% for 312 (3.2%), and 10% or more for 177 (1.8%). Over a mean (median) 40 (40) months of follow-up (interquartile range = 30-50 months), 28.7% (n = 2,838) of patients had 1 or more diabetes- related hospital admissions. In the logistic regression analysis, odds of having at least 1 diabetes-related hospital stay did not significantly differ for patients with mean A1c of < 7% compared with patients in most higher mean A1c categories (7% to < 8%, 8% to < 9%, or 9% to < 10%); however, odds of having a diabetes-related hospitalization were significantly higher for patients with mean A1c of 10% or more compared with patients with mean A1c of < 7% (odds ratio = 2.13, 95% confidence interval = 1.36-3.33). In the negative binomial regression analysis of those with at least 1 hospital admission, estimated costs per hospitalized patient increased by mean A1c level. In the Poisson regression analysis, the rate of diabetes-related hospitalizations significantly increased by A1c level (13 per 100 patient-years for patients with mean A1c of < 7% vs. 30 per 100 patient-years for mean A1c of 10% or more when covariates were held at mean levels, P<0.001). In the 2-part model results, adjusted mean estimated costs of diabetes-related hospitalizations per study patient were $2,792 among those with mean A1c of < 7% and $6,759 among those with mean A1c of 10% or more.
In this managed-care plan, the odds of having at least 1 diabetes-related hospitalization were not significantly associated with higher mean A1c except for patients with mean A1c of at least 10%. However, higher mean A1c levels were associated with significantly higher estimated hospitalization costs among those with at least 1 hospitalization and with higher rates of diabetes-related hospital utilization per 100 patient-years.
Journal of managed care pharmacy: JMCP 05/2010; 16(4):264-75. · 2.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The mortality, length of hospitalization, and costs associated with invasive fungal infections (IFIs) in hospitalized patients were studied.
This retrospective database study used data from the 2004 Healthcare Cost and Utilization Project Nationwide In-patient Sample. Patients were selected for inclusion based on diagnostic codes corresponding to an IFI. A control group was matched to the IFI group based on high-risk conditions (i.e., cancer, infection with human immunodeficiency virus, chronic obstructive pulmonary disease, diabetes mellitus, and solid-organ, hematopoietic stem cell, or bone marrow transplant), age, sex, and hospital region and teaching status. Excess mortality, length of hospital stay, and costs were estimated as the differences between the IFI and control groups.
A total of 11,881 patients were identified with a discharge diagnosis of an IFI who could be matched to a control. Frequent infections included candidiasis (40.2%), other mycoses (36.3%), and aspergillosis (16.4%). Patients with IFIs had a significantly higher mortality rate (15% versus 5%), mean +/- S.E. length of stay (18.7 +/- 0.4 days versus 7.3 +/- 0.1 days), and mean +/- S.E. costs ($44,726 +/- $1,255 versus $15,445 +/- $404) (p < 0.001 for all comparisons) than did patients without IFIs. The burden of IFIs varied by high-risk condition (highest for transplant recipients and patients with cancer) and type of infection (highest for candidiasis, zygomycosis, and aspergillosis).
Examination of a large database showed that, compared with high-risk patients without IFIs, those with IFIs had higher mortality, a longer hospital stay, and higher costs associated with their hospitalization.
American journal of health-system pharmacy: AJHP: official journal of the American Society of Health-System Pharmacists 10/2009; 66(19):1711-7. · 2.10 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Staphylococcus aureus (SA) is a common bacterial pathogen in skin and skin structure infections (SSSIs). Limited data exist on hospital treatment patterns and costs for SA-SSSIs.
This retrospective analysis examined the lengths of stay, treatment patterns, and costs of hospitalized patients with an SA-SSSI diagnosis using a nationally representative inpatient database. Patients were selected if they had an ICD-9-CM diagnosis of an SSSI with SA noted between January 2005 and June 2006, received a study antibiotic (ie, intravenous [IV] vancomycin, IV or oral linezolid, and IV daptomycin), and were not in the intensive care unit before receiving a study antibiotic. Generalized linear models assessed predictors of length of stay and costs. Costs are expressed in 2005 US dollars.
Thirteen thousand four hundred thirty-three patients met the selection criteria and mean (+/-SD) age was 48.2 (+/-18.3) years. Forty percent of patients received a nonstudy antibiotic before receiving their first study antibiotic. Ninety-five percent were prescribed vancomycin as their first study antibiotic. Study antibiotics were administered for an average of 4.3 days, and 8% of patients switched study antibiotics. Nineteen percent of patients receiving IV linezolid stepped down to oral linezolid. Mean (+/-SD) lengths of hospital stay and costs were 6.1 (+/-6.0) days and $6830 (+/-$7100). In-hospital mortality, switching antibiotics, and diagnoses of selected complications or comorbidities were associated with increased lengths of stay and costs. Younger age, location outside the Northeast, and use of oral linezolid were associated with lower lengths of stay and costs.
The costs of treating inpatient SA-SSSIs are substantial and vary by patient demographics and treatment characteristics.
American journal of infection control 09/2009; 38(1):44-9. · 3.01 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Unrecognized bipolar disorder in patients presenting with a major depressive episode may lead to delayed diagnosis, inappropriate treatment, and excessive costs. This study models the cost effectiveness of screening for bipolar disorder among adults presenting for the first time with symptoms of major depressive disorder.
A decision-analysis model was used to evaluate the outcomes and cost over 5 years of screening versus not screening for bipolar disorder. Screening was defined as a 1-time administration of the Mood Disorder Questionnaire at the initial visit followed by referral to a psychiatrist for patients screening positive for bipolar disorder. Health states included correctly diagnosed bipolar disorder, unrecognized bipolar disorder, and correctly diagnosed major depressive episodes. Model outcomes included rates of correct diagnosis of bipolar disorder and discounted costs (2006 US dollars) of screening and treating major depressive episodes. Literature was the primary source of data and was collected from September 2007 through March 2009.
According to the model, 1,000 adults in a health plan with 1 million adult members annually present with symptoms of major depressive disorder. An additional 38 patients were correctly diagnosed with depression (unipolar or a major depressive episode) or bipolar disorder (440 with screening vs 402 without screening) through a 1-time screening for bipolar disorder. Estimated 5-year discounted costs per patient were $36,044 without screening and $34,107 with screening (savings of $1,937). Accordingly, total 5-year budgetary savings were estimated at $1.94 million. Results were most sensitive to difference in treatment costs for patients with recognized versus unrecognized bipolar disorder.
A 1-time screening program for bipolar disorder, when patients first present with a major depressive episode, can reduce health care costs to managed-care plans.
The Journal of Clinical Psychiatry 09/2009; 70(9):1230-6. · 5.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the incidence and costs of complications due to radiotherapy alone vs platinum-based chemoradiotherapy among patients diagnosed as having advanced squamous cell carcinoma of the head and neck (ASCCHN) from a payer perspective.
Retrospective cohort study.
Data from the PharMetrics Patient-Centric Database from June 2000 through June 2006.
The study included patients with ASCCHN and an indication of a secondary malignant neoplasm (both identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes), 124 of whom were treated with radiotherapy alone and 77 of whom were treated with chemoradiotherapy (including 53 with cisplatin plus radiotherapy, 26 with carboplatin plus radiotherapy, and 2 with cisplatin and carboplatin plus radiotherapy). The patients were assigned to 1 of 2 cohorts based on treatment type-radiotherapy only and platinum-based chemoradiotherapy-and were followed up for 6 months.
Incidence and costs of treatment-related complications associated with chemotherapy in ASCCHN.
We found significantly (P < .001) higher rates of treatment-related complications among patients receiving chemoradiotherapy (86%) than among patients receiving only radiotherapy (51%). The mean per-patient costs associated with treatment-related complications were approximately $10 000 higher among patients who received chemoradiotherapy than among those treated with radiotherapy alone (P < .001). These costs represented 17% of the total costs during follow-up for patients who received chemoradiotherapy and 11% of costs for those who received radiotherapy. The most expensive complications were dehydration and/or electrolyte imbalance and oral complications.
Our study results suggest that the attributable incidence and costs of treatment-related complications associated with chemotherapy in ASCCHN are substantial. The emergence of safer treatments may have the advantage of alleviating this cost burden.
Archives of otolaryngology--head & neck surgery 07/2009; 135(6):582-8. · 1.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Reducing operating room (OR) time is of interest to hospital administrators because of high costs of OR utilization. Neuromuscular blocking agents (NMBAs) induce muscle relaxation during surgery. Several acetylcholinesterase inhibitors are used to reverse neuromuscular blockade to shorten recovery time. This study explored the relationship between elapsed OR time and the use of specific NMBAs and reversal agents among patients undergoing selected surgeries based on data from two large hospitals. Specifically, this study sought to test the hypothesis that the application of reversal agents in surgeries using a neuromuscular block would be associated with a decrease in elapsed OR time.
This retrospective cohort study used clinical data from two large hospitals. The authors selected seven types of surgical cases involving thoracic, cardiac, vascular, abdominal, peripheral, urological, and neurological systems. Eligible cases were elective surgeries performed under general anesthesia and using one or more NMBAs (including rocuronium, vecuronium, cisatracurium, and/or pancuronium). Multivariate linear regressions were conducted to examine the relationships among neuromuscular blockade, reversal agent use (including neostigmine, pyridostigmine, and edrophonium), and elapsed OR time by controlling for age, gender, and patient comorbidities.
A total of 9670 surgeries were included in this analysis. The mean elapsed OR time across all surgeries was 227 min, and vecuronium was the most commonly used NMBA. Approximately 67% of all surgeries used a reversal agent. After controlling for confounding factors, use of a reversal agent was shown to be associated with the reduction of elapsed OR time in six of seven types of surgery. The magnitude of this effect ranged from 12 to 46 min of OR time saved. The exception was thoracic surgeries, for which use of a reversal agent was shown to be associated with longer OR time (approximately 26 min). Multivariate regression analyses revealed that the type of NMBA used was also a significant predictor of elapsed time for all surgeries (except cardiac).
This analysis has shown that use of selected neuromuscular blockade reversal agents may lead to more efficient OR resource use.
Current Medical Research and Opinion 05/2009; 25(4):943-50. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The incidence of skin and skin structure infections (SSSIs) due to Staphylococcus aureus (SA) is increasing. The objective of this study was to assess the costs of a treatment episode for SA-SSSIs.
This retrospective analysis used a managed-care claims database to assess the duration and costs of incident SA-SSSI episodes treated with selected antibiotics (i.v. vancomycin, oral linezolid, and daptomycin, termed 'study antibiotics'). Patients were included if they had an ICD-9-CM diagnosis of an SSSI and SA between January 1, 2002 and December 31, 2005. Treatment episodes began on the date of the first antibiotic and ended when the patient had fourteen consecutive days without a study antibiotic or SSSI hospitalization. Costs, represented by health plan payments for SSSIs and overall, were updated to 2005 US dollars. A generalized linear model (GLM) assessed predictors of costs.
A total of 1997 patients met the selection criteria. Mean (+/- SD) age was 46.3 (+/- 12.6) years and 55.9% of patients were male. Average episode length was 24 days, and over 95% of patients received i.v. vancomycin or oral linezolid as their initial study antibiotic. Patients remained on study antibiotics for an average of 16.4 days, and only 5% of patients were switched to another study antibiotic. Mean (+/- SD) overall episode costs were $8865 (+/- $20,003), primarily composed of inpatient and outpatient medical services. Treatment failure (i.e., study antibiotic switching or hospitalization), younger age, a diagnosis of bacteremia, osteomyelitis, or multiple complications during the episode, treatment with daptomycin, and greater Charlson co-morbidity score were significant positive predictors of overall costs. Alternatively, treatment with oral linezolid and hospitalization before the start of the outpatient treatment episode were significant negative predictors of overall costs. Mean (+/- SD) SSSI-related costs were $4551 (+/- $11,058).
Medical charts and laboratory test results were not available to confirm SSSI and SA diagnoses, and no information was available regarding antibiotics received in the inpatient setting.
The costs of treating SA-SSSIs are substantial and vary by failure rates, co-morbidities, and type of antibiotic therapy.
Current Medical Research and Opinion 09/2008; 24(10):2821-8. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Acute coronary syndromes (ACS) are life-threatening disorders requiring intensive medical management or invasive cardiovascular procedures. Limited data exist on the costs and resource utilization associated with ACS.
This retrospective single-cohort study analyzed administrative claims data from employer-sponsored plans for patients with an ACS hospitalization in 2001-2002. A 1-year follow-up period was used, and patients who were under age 35 or had an ACS diagnosis in the 12 months before the hospitalization were excluded. Costs were reported in 2005 US dollars.
We identified 16,321 patients hospitalized for ACS during the study period. Mean (+/- SD) age was 55.6 (+/- 6.7) years, 66.7% were male, and 46.3% underwent a revascularization procedure during their initial hospitalization. Mean length of stay for the initial hospitalization was 4.6 days (median: 3.0; IQR: 2.0-5.0), and per-patient expenditures averaged $22,921 (median: $13,960; IQR: $6839-28 588). During the follow-up period, 21% of patients were rehospitalized for ischemic heart disease (IHD), and the cost of rehospitalization averaged $28,637. Additionally, in the year following the inpatient admission, 50% of patients were prescribed antiplatelet or anticoagulant medications, and 90% of patients were prescribed lipid-lowering, antihypertensive, or antiarrhythmic medications. IHD-related expenditures after the initial inpatient stay averaged $9425 (median: $2800; IQR: $899-7577); 61% of these costs were due to rehospitalization. Total first-year costs averaged $32,345 (median: $21,653; IQR: $10,642-41,106).
Diagnoses could not be verified through medical charts. Payments for Medicare patients were not assessed given our focus on the working-age population.
In this employer-sponsored health plan population, the costs of inpatient and outpatient IHD-related care were high. Future studies should evaluate the impact of improved patient management on post-discharge costs.
Current Medical Research and Opinion 03/2008; 24(2):461-8. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A previously published decision-analytic model assessing the clinical and economic consequences of topiramate versus no preventive treatment in migraineurs was updated with new published literature and unpublished clinical trial data. The model captured baseline migraine days, treatment discontinuation, treatment response (i.e., > or = 75%, 50%-74%, and < 50% reduction in migraine frequency), hours of disability, cost of preventive therapy, cost of acute treatment (pharmacy and medical service), and wages. Topiramate was associated with 29 fewer migraine-days and 78 fewer hours of disability per year, compared with no preventive treatment. The incremental cost per migraine-day averted for topiramate versus no preventive treatment was dollar 29 when only direct medical costs were considered and dollar 2 when total costs were included. Model results were sensitive to baseline migraine-days, response probability, and probability of an attack being treated with a triptan. Topiramate may be a cost-effective treatment for the prevention of migraine.
Managed care interface 12/2006; 19(12):31-8.
-
[show abstract]
[hide abstract]
ABSTRACT: State Medicaid programs provide insurance coverage to over 40 million Americans. However, estimates of the annual cost of chronic obstructive pulmonary disease (COPD) from the Medicaid perspective are lacking.
This retrospective cohort study used Medicaid administrative claims data from California and Florida to estimate COPD expenditures using two alternative methods: (1) excess costs (comparing a COPD cohort to a matched comparison cohort); and (2) attributable costs (COPD-related expenditures within a COPD cohort, inclusive of respiratory medications). The COPD cohort in each state included Medicaid recipients not dually eligible for Medicare who were 40+ years of age with at least one medical claim for COPD during 2001. The comparison cohort consisted of patients with medical claims during 2001 for conditions other than chronic respiratory disease, matched by age, sex, and race to the COPD cohort.
A total of 6,738 Medicaid recipients in California and 18,017 in Florida were included in the COPD cohort, with mean ages of 56 and 60 years, respectively. Comorbidities, especially congestive heart failure and vascular disease, were more common in the COPD cohort than among matched controls. The mean excess cost of COPD per-patient was estimated to be approximately 6,500 US dollars in California Medicaid and 5,200 US dollars in Florida Medicaid. Mean attributable costs of COPD were similar in the two Medicaid programs (approximately 2,200 US dollars and 2,300 US dollars per patient, respectively).
COPD places a substantial financial burden on State Medicaid programs. These findings may be of interest to clinicians and policy-makers involved in preventing or managing this chronic disease.
Respiratory Medicine 07/2006; 100(6):996-1005. · 2.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Outcomes of anticoagulation have been assessed in commercially insured populations, but similar data do not exist for Medicaid populations.
To assess the association between warfarin exposure and rates of thromboembolic and bleeding events among patients with nonvalvular atrial fibrillation (NVAF) enrolled in California Medicaid.
Using a retrospective cohort design based on administrative claims data, we selected Medicaid enrollees aged 50 years and older based on their first claim with a diagnosis of AF between January 1, 1998, and March 31, 2002. Patients were excluded if they had selected contraindications to warfarin, claims for valve replacement procedures, or evidence that AF resulted from transient or reversible causes. Pharmacy claims and prothrombin time tests were used to define subsequent periods of warfarin use (exposure) and nonuse (nonexposure) by all patients. The relative rates of hospitalization for thromboembolic and bleeding events associated with periods of warfarin exposure versus nonexposure were estimated.
The 4355 study patients had a mean age of 74 years, and 65% were female. Fifty-nine percent filled any prescriptions for warfarin following AF diagnosis. Across all patients, warfarin exposure occurred during 37% of days after diagnosis. Thromboembolic events were 27% less frequent during periods of warfarin exposure relative to periods of non-exposure (p < 0.01). Major bleeding events were not significantly more common during periods of warfarin exposure (p = 0.55).
In this Medicaid population with NVAF, warfarin use was low and was associated with a relatively modest reduction in thromboembolic events, with no increase in major bleeding risk.
Annals of Pharmacotherapy 06/2006; 40(6):1024-9. · 2.13 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients whose migraines are frequent, cause disruptions of daily routines, or are unresponsive to acute treatment are primary candidates for preventive migraine therapy. This cost-effectiveness model assesses the clinical and economic impact of topiramate (TPM) therapy versus no preventive treatment for migraine headache in the United States.
Despite significant progress in treatment options, the economic burden of migraine to patients, employers, health systems, and society is substantial. Treatment strategies for migraine are directed toward managing acute episodes. However, preventive therapy should be used for patients with frequent migraine attacks (>2 per month) or those experiencing attacks that disrupt daily routines.
Data for the model were obtained from the published literature and pooled results of two randomized, double-blinded, placebo-controlled trials of TPM in migraine prevention. Model inputs included baseline migraine frequency (the base case assumed 6 per month, consistent with the average rate in the TPM trials), treatment discontinuation (including discontinuation due to adverse events), treatment response (ie, > or = 75%, 50% to 75%, and <50% reduction in migraine frequency), cost of preventive therapy (TPM plus physician visits for medication titration), cost of acute treatment per attack (including pharmacy and medical service costs), hours of disability per attack, hourly wage, and quality-of-life (utility) weights. Model outcomes included the number of migraines averted, disability hours, total cost of acute and preventive treatment, and lost wages. Results were expressed as cost per migraine averted and cost per quality-adjusted life years (QALY). All costs were stated as 2002 U.S. dollars. We also conducted sensitivity analyses to assess the robustness of model findings with respect to variation in key parameters.
We estimated that the use of TPM would prevent 1.85 migraines per patient and almost 5 hours of disability per month versus no preventive treatment. Resulting savings in cost of acute treatment (dollar 27) and work loss (dollar 51) offset 68% of the expected monthly cost of TPM (dollar 113). The incremental cost per migraine averted was dollar 19, while the incremental cost per QALY was estimated to be dollar 10,888 (dollar 26,191 when indirect costs were excluded from the analysis). Model results were sensitive to baseline migraine rate and gain in health utility from migraine prevention.
Economic savings associated with reduced migraine frequency offset approximately two thirds of the cost of preventive TPM therapy. The cost-effectiveness of TPM depends on utility gains associated with a reduced frequency of migraine headaches, which is the subject of ongoing research. However, results from our model suggest that the use of TPM in prevention of migraine may offer reasonable value for money relative to many well-accepted medical interventions.
Headache The Journal of Head and Face Pain 09/2005; 45(8):1012-22. · 2.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Warfarin is recommended for prevention of stroke in patients with atrial fibrillation who are at moderate or high risk, but requires intensive management to achieve safe and optimal anticoagulation control. Anticoagulation clinics are often used to administer warfarin therapy more effectively.
To collect data from multiple sites and assess the quality and costs associated with anticoagulation clinic services.
A random sample of 600 adults with chronic nonvalvular atrial fibrillation (CNVAF) receiving warfarin was selected from anticoagulation clinics affiliated with 3 health plans. Patients were identified between 1996 and 1998 and followed for up to one year. We assessed the proportion of time that international normalized ratio (INR) values were within the recommended range (2.0-3.0) and the costs of anticoagulation clinic care.
Patients had an average of 18 clinic contacts over a mean duration of follow-up of 10.5 months. On average, patients were within the recommended INR range 62% of this time, with 25% of days below range and 13% above range. The mean per-patient cost of warfarin monitoring over the follow-up period averaged $261 at site A, $305 at site B, and $205 at site C (in 2003 US$). Mean costs for patients treated for one full year were $288, $339, and $216, respectively.
In 3 geographically diverse health plans, anticoagulation clinics provided a generally higher quality of control than previously reported in other observational studies. This study highlights the costs of obtaining this level of control.
Annals of Pharmacotherapy 04/2005; 39(3):446-51. · 2.13 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Rates of medication adherence over a one-year period were assessed among outpatients with schizophrenia who initiated therapy with conventional or atypical antipsychotic agents.
Data were drawn from paid medical and pharmacy claims for a random sample of 10 percent of all California Medicaid ("Medi-Cal") recipients. Outpatients with schizophrenia who were aged 18 years or older and who initiated monotherapy with a conventional or atypical antipsychotic medication in the last quarter of 1997 were identified. The percentages of patients who discontinued antipsychotic therapy or who had a switch in medications over a one-year period were determined. The use of selected concomitant medications was also assessed. Data were analyzed by means of chi square tests and multivariate statistics that adjusted for demographic and clinical differences between medication groups.
A total of 298 patients who initiated therapy with a conventional (N=93) or atypical (N=205) antipsychotic medication were identified. The groups were similar in mean age (about 42 years) and gender distribution (about 54 percent were male). Compared with patients who received conventional antipsychotics, those receiving atypical antipsychotics were significantly less likely to have a switch in medication and to use concomitant anticholinergic and anxiolytic medications. In each group, antipsychotic medication was available for about 60 percent of days over one year of follow-up.
Compared with the use of conventional antipsychotics, the use of atypical antipsychotic medications was associated with significantly less treatment switching and less use of concomitant medications. However, undertreatment, evidenced by a lack of prescription refills, occurred among patients taking both medication classes, which highlights the need for further research on nonadherence.
Psychiatric Services 06/2003; 54(5):719-23. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To calculate the excess mortality, length of stay, and costs attributable to serious fungal infections in hospitalized elderly patients with selected cancers. Methods: This study involved a retrospective cohort analysis using linked data from the Surveillance, Epidemiology and End Results Program of the National Cancer Institute (SEER) and Medicare claims data. Study cohorts included patients aged 65 years and older who newly received a diagnosis of a selected cancer (acute myeloid leukemia [AML] or squamous cell carcinoma of the head and neck [SCCHN]) in a SEER registry between 1991 and 1996 and who had a subsequent diagnosis of a serious fungal infection during an inpatient hospitalization, and hospitalized controls without a fungal infection matched 1:1 by age, geographic region, receipt of recent chemotherapy, concomitant bacterial infection, timing of the index hospitalization, and cancer stage at diagnosis (for SCCHN patients only).
Eighty AML patients and 52 SCCHN patients experienced a serious fungal infection involving hospitalization. Relative to matched controls, SCCHN patients with fungal infections had significantly higher all-cause mortality (40% vs. 14%, P = 0.002), while mortality rates did not differ between AML cohorts. Patients with fungal infections had significantly longer index hospitalizations regardless of cancer type (mean: 30 days vs. 19 days for AML patients; 20 days vs. 9 days for SCCHN patients), and correspondingly higher Medicare payments (mean +/- SD: 34,268 dollars +/- 31,811 dollars vs. 21,416 dollars +/- 22,449 dollars among AML patients, P < 0.0001; 25,942 dollars +/- 29,122 dollars vs. 10,131 dollars +/- 10,686 dollars among SCCHN patients, P < 0.0001).
Efforts to prevent these infections and/or initiate early treatment may yield both clinical and economic benefits.
Value in Health 8(2):140-8. · 2.19 Impact Factor
