Out-of-pocket medical spending for care of chronic conditions

Hospital cost and length of stay in idiopathic pulmonary fibrosis

OBJECTIVE

To provide a detailed picture of the economic impact of hospitalization in idiopathic pulmonary fibrosis (IPF) and to identify factors associated with cost and length of stay (LOS).

METHODS

In this retrospective cross-sectional study using the Nationwide Inpatient Sample (NIS), this study included hospitalizations for IPF (ICD-9-CM 516.3) with a principal diagnosis of respiratory disease (ICD-9-CM 460-519) from 2009-2011; lung transplant admissions were excluded. Total inpatient cost, LOS, in-hospital death, and discharge disposition were reported. Linear regression models were used to determine variables predictive of LOS and cost.

RESULTS

From 2009-2011, 22,350 non-transplant IPF patients with a principal diagnosis of respiratory disease were admitted: mean (±SE) age was 70.0 (0.32), and 49.1% were female. While in hospital, 11.4% of patients received mechanical ventilation and 8.9% received non-invasive ventilation. Mean (±SE) LOS was 7.4 (0.15) days overall (p < .001). The mean (±SD) admission cost was $16,042 (±631). Of hospitalized patients, 14.1% died, 20.6% transferred facilities, and 46.4% were routinely discharged. The adjusted LOS (95% CI) for patients with and without mechanical ventilation was 16.1 days (15-17.5) vs. 6.3 (6-6.5); adjusted costs were $48,772 (43,979-53,565) vs. $11,861 (11,292-12,431).

LIMITATIONS

The positive predictive value of the algorithm used to identify IPF is not optimal. The NIS database does not follow patients longitudinally, and claims after admission are not available. Claims do not indicate whether listed diagnoses were present on admission or developed during hospitalization. The exclusion of transplant-related expenditures lead to under-estimation of cost.

CONCLUSION

Using a nationally-representative database, we found IPF respiratory-related hospitalizations represent a significant economic burden with ∼7,000 non-transplant IPF admissions per year, at a mean cost of $16,000 per admission. Mechanical ventilation is associated with statistically significant increases in LOS and cost. Therapeutic advances that reduce rates and costs of IPF hospitalizations are needed.

Challenges around Access to and Cost of Life-Saving Medications after Allogeneic Hematopoietic Cell Transplantation for Medicare Patients

Hematopoietic cell transplantation (HCT) is an expensive, medically complicated, and potentially life-threatening therapy for multiple hematologic and nonhematologic disorders with a prolonged trajectory of recovery. Similar to financial issues in other cancer treatments, adverse financial consequences of HCT are emerging as an important issue and may be associated with poor quality of life and increased distress in HCT survivors. Prescription medicine coverage for HCT for Medicare and some Medicaid beneficiaries, especially in the long-term, remains suboptimal because of inadequate payer formularies or prohibitive copays. With an increasing number of older patients undergoing HCT and improvement in the overall survival after HCT, the problem of financial burden faced by Medicare beneficiaries with fixed incomes is going to worsen. In this article, we describe the typical financial burden borne by HCT recipients based on estimated copayment amounts attached to the categories of key medications as elucidated through 2 case studies. We also suggest some possible solutions for consideration to help these patients and families get through the HCT by minimizing the financial burden from essential medications needed during the post-HCT period.

Sex differences in healthcare expenditures among adults with diabetes: evidence from the medical expenditure panel survey, 2002-2011

BACKGROUND

The evidence assessing differences in medical costs between men and women with diabetes living in the United States is sparse; however, evidence suggests women generally have higher healthcare expenditures compared to men. Since little is known about these differences, the aim of this study was to assess differences in out-of-pocket (OOP) and total healthcare expenditures among adults with diabetes.

METHODS

Data were used from 20,442 adults (≥18 years of age) with diabetes from the 2002-2011 Medical Expenditure Panel Survey. Dependent variables were OOP and total direct expenditures for multiple health services (prescription, office-based, inpatient, outpatient, emergency, dental, home healthcare, and other services). The independent variable was sex. Covariates included sociodemographic characteristics, comorbid conditions, and time. Sample demographics were summarized. Mean OOP and total direct expenditures for health services by sex status were analyzed. Regression models were performed to assess incremental costs of healthcare expenditures by sex among adults with diabetes.

RESULTS

Fifty-six percent of the sample was composed of women. Unadjusted mean OOP costs were higher for women for prescriptions ($1177; 95% CI $1117-$1237 vs. $959; 95% CI $918-$1000; p < 0.001) compared to men. Unadjusted mean total direct expenditures were also higher for women for prescriptions ($3797; 95% CI $3660-$3934 vs. $3334; 95% CI $3208-$3460; p < 0.001) and home healthcare ($752; 95% CI $646-$858 vs. $397; 95% CI $332-$462; p < 0.001). When adjusting for covariates, higher OOP and total direct costs persisted for women for prescription services (OOP: $156; 95% CI $87-$225; p < 0.001 and total: $184; 95% CI $50-$318; p = 0.007). Women also paid > $50 OOP for office-based visits (p < 0.001) and > $55 total expenditures for home healthcare (p = 0.041) compared to men after adjustments.

CONCLUSIONS

Our findings show women with diabetes have higher OOP and total direct expenditures compared to men. Additional research is needed to investigate this disparity between men and women and to understand the associated drivers and clinical implications. Policy recommendations are warranted to minimize the higher burden of costs for women with diabetes.

Considerations When Using Predictive Equations to Estimate Energy Needs Among Older, Hospitalized Patients: A Narrative Review

The aim of this narrative review was to summarize the accuracy of predictive equations used to estimate energy expenditure in older, hospitalized adults. More than 50% of patients admitted to intensive care units are older adults. Currently accepted prediction equations used to determine energy intake in the older, hospitalized patient were not specifically developed for the aging population. Rates of multimorbidity, polypharmacy and malnutrition, conditions that influence energy expenditure, are higher in older adults compared to younger adults. For these reasons, current equations may not accurately assess energy needs in this population. As the evidence demonstrating the importance of nutritional supplementation in older, hospitalized adults grows, more accurate energy assessment methods that account for age-related conditions are needed to predict nutritional requirements.

Multimorbidity: constellations of conditions across subgroups of midlife and older individuals, and related Medicare expenditures

INTRODUCTION

The Department of Health and Human Services' 2010 Strategic Framework on Multiple Chronic Conditions called for the identification of common constellations of conditions in older adults.

OBJECTIVES

To analyze patterns of conditions constituting multimorbidity (CCMM) and expenditures in a US representative sample of midlife and older adults (50-64 and ≥65 years of age, respectively).

DESIGN

A cross-sectional study of the 2010 Health and Retirement Study (HRS; n=17,912). The following measures were used: (1) count and combinations of CCMM, including (i) chronic conditions (hypertension, arthritis, heart disease, lung disease, stroke, diabetes, cancer, and psychiatric conditions), (ii) functional limitations (upper body limitations, lower body limitations, strength limitations, limitations in activities of daily living, and limitations in instrumental activities of daily living), and (iii) geriatric syndromes (cognitive impairment, depressive symptoms, incontinence, visual impairment, hearing impairment, severe pain, and dizziness); and (2) annualized 2011 Medicare expenditures for HRS participants who were Medicare fee-for-service beneficiaries (n=5,677). Medicaid beneficiaries were also identified based on their self-reported insurance status.

RESULTS

No large representations of participants within specific CCMM categories were observed; however, functional limitations and geriatric syndromes were prominently present with higher CCMM counts. Among fee-for-service Medicare beneficiaries aged 50-64 years, 26.7% of the participants presented with ≥10 CCMM, but incurred 48% of the expenditure. In those aged ≥65 years, these percentages were 16.9% and 34.4%, respectively.

CONCLUSION

Functional limitations and geriatric syndromes considerably add to the MM burden in midlife and older adults. This burden is much higher than previously reported.

Patients' willingness to pay for their drugs in primary care clinics in an urbanized setting in Malaysia: a guide on drug charges implementation

BACKGROUND

Malaysia is an upper middle income country that provides subsidized healthcare to ensure universal coverage to its citizens. The challenge of escalating health care cost occurs in most countries, including Malaysia due to increase in disease prevalence, which induced an escalation in drug expenditure. In 2009, the Ministry of Health has allocated up to Malaysian Ringgit (MYR) 1.402 billion (approximately USD 390 million) on subsidised drugs. This study was conducted to measure patients' willingness to pay (WTP) for treatment of chronic condition or acute illnesses, in an urbanized population.

METHODS

A cross-sectional study, through face-to-face interview was conducted in an urban state in 2012-2013. Systematic random sampling of 324 patients was selected from a list of patients attending ten public primary cares with Family Medicine Specialist service. Patients were asked using a bidding technique of maximum amount (in MYR) if they are WTP for chronic or acute illnesses.

RESULTS

Patients are mostly young, female, of lower education and lower income. A total of 234 respondents (72.2%) were not willing to pay for drug charges. WTP for drugs either for chronic or acute illness were at low at median of MYR10 per visit (USD 3.8). Bivariate analysis showed that lower numbers of dependent children (≤3), higher personal and household income are associated with WTP. Multivariate analysis showed only number of dependent children (≤3) as significant (p = 0.009; 95% CI 1.27-5.44) predictor to drugs' WTP.

CONCLUSION

The result indicates that primary care patients have low WTP for drugs, either for chronic condition or acute illness. Citizens are comfortable in the comfort zone whereby health services are highly subsidized through universal coverage. Hence, there is a resistance to pay for drugs.

Socioeconomic inequalities in health in the context of multimorbidity: A Korean panel study

Socioeconomic inequalities in health are commonly known to decrease at late age. Yet, it remains unclear whether socioeconomic inequalities in health at late age appear in relation to multimorbidity, particularly in Korea where social support remains unsatisfactory for older people. Using three waves of Korea Health Panel, data of 19,942 observations with repeated measure were constructed to ensure a temporal sequence between three socioeconomic measures (i.e., poverty, employment status, and education) and multimorbidity with a t to t+1 year transition. A multilevel multinomial model was applied to quantify the socioeconomic impact across different age, diseases and disease groups, both separately and in combination. There were associations between socioeconomic position (SEP) and multimorbidity, and increasing trends of socioeconomic inequalities not only with greater number of morbidity but also with age. The latter result was only observed with employment status through mid-to-early old age; i.e., between the 40s (odds ratio (OR) = 2.45, 95% confidence interval (CI):1.08–5.57) and 70s (OR = 3.48, 95%CI: 1.24–9.74). The patterns of socioeconomic inequalities in multimorbidity varied for particular pairs of diseases and were stronger in the disease pairs co-occurring with mental and cardiovascular diseases but weaker in the disease pairs co-occurring with cancer. Accumulation of adversity tended to intensify with increase in number of diseases and older age, though this finding was not consistently supported. The labour market should be encouraged to actively participate in actions to promote healthy aging needs to be complemented by the provision of more generous and universal income support to the elderly in Korea.

Trends and Disparities in Osteoporosis Screening Among Women in the United States, 2008-2014

BACKGROUND

The United States Preventive Services Task Force recommends universal osteoporosis screening among women ages 65+ and targeted screening of younger women, but historically, adherence to these evidence-based recommendations has been suboptimal.

METHODS

To describe contemporary patterns of osteoporosis screening, we conducted a retrospective analysis using the OptumLabs^™ Data Warehouse, a database of de-identified administrative claims, which includes medical and eligibility information for over 100 million Medicare Advantage and commercial enrollees. Study participants included 1,638,454 women ages 50+ with no prior history of osteoporosis diagnosis, osteoporosis drug use, or hip fracture. Osteoporosis screening during the most recent 2-year period of continuous enrollment was assessed via medical claims. Patient sociodemographics, comorbidities, and utilization of other services were also determined using health insurance files.

RESULTS

Overall screening rates were low: 21.1%, 26.5%, and 12.8% among women ages 50-64, 65-79, and 80+ years, respectively. Secular trends differed significantly by age (P <.001). Between 2008 and 2014, utilization among women ages 50-64 years declined 31.4%, changed little among women 65-79, and increased 37.7% among women 80+ years. Even after accounting for socioeconomic status, health status, and health care utilization patterns, non-Hispanic black women were least likely to be screened, whereas non-Hispanic Asian and Hispanic women were most likely to undergo screening. Marked socioeconomic gradients in screening probabilities narrowed substantially over time, decreasing by 44.5%, 71.9%, and 59.7% among women ages 50-64, 65-79 and 80+ years, respectively.

CONCLUSIONS

Despite significant changes in utilization of osteoporosis screening among women ages 50-64 and 80+, in line with national recommendations, tremendous deficiencies among women 65+ remain.

Real world heart failure epidemiology and outcome: A population-based analysis of 88,195 patients

BACKGROUND

Heart failure (HF) is frequent and its prevalence is increasing. We aimed to evaluate the epidemiologic features of HF patients, the 1-year follow-up outcomes and the independent predictors of those outcomes at a population level.

METHODS AND RESULTS

Population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on December 31st, 2012. Patients were divided in 3 groups: patients without a previous HF hospitalization, patients with a remote (>1 year) HF hospitalization and patients with a recent (<1 year) HF admission. We analyzed 1year all-cause and HF hospitalizations, and all-cause mortality. Logistic regression was used to identify the independent predictors of each of those outcomes. A total of 88,195 patients were included. Mean age was 77 years, 55% were women. Comorbidities were frequent. Fourteen percent of patients had never been hospitalized, 71% had a remote HF hospitalization and 15% a recent hospitalization. At 1-year follow-up, all-cause and HF hospitalization were 53% and 8.8%, respectively. One-year all-cause mortality rate was 14%, and was higher in patients with a recent HF hospitalization (24%). The presence of diabetes mellitus, atrial fibrillation or chronic kidney disease was independently associated with all-cause and HF hospitalization and all-cause mortality. Hospital admissions and emergency department visits the previous year were also found to be independently associated with the three study outcomes.

CONCLUSIONS

Outcomes are different depending on the HF population studied. Some comorbidity, an all-cause hospitalization or emergency department visit the previous year were associated with a worse outcome.

Observation Status or Inpatient Admission: Impact of Patient Disposition on Outcomes and Utilization Among Emergency Department Patients With Chest Pain

OBJECTIVES

to compare healthcare utilization including coronary angiography, percutaneous coronary intervention (PCI), rehospitalization, and rate of subsequent acute myocardial infarction (AMI) within 30 days, among patients presenting to the emergency department (ED) with chest pain admitted as short-term inpatient (≤2 days) versus observation (in-ED observation units combined with in-hospital observation).

METHODS

We identified adults diagnosed with acute chest pain in the ED from 2010 to 2014 using administrative claims from privately insured and Medicare Advantage. Patients having AMI during the index visit were excluded. One-to-one propensity-score matching and logistic regression were used. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

RESULTS

A total of 774,017 chest pain visits were included. After matching, healthcare utilization was lower among observation versus short inpatient, with 10.9% versus 24.4% (OR = 0.38, 95% CI = 0.36 to 0.39) undergoing cardiac catheterization and 1.8% versus 7.6% (OR = 0.23, 95% CI = 0.21 to 0.24) having PCI. The incidence of subsequent AMI within the following 30 days was similar in patients admitted as observation versus short inpatient (0.23% vs. 0.21%; OR = 1.09, 95% CI = 0.84 to 1.42).

CONCLUSIONS

There were higher rates of cardiac catheterization and PCI among those admitted as a short inpatient compared to observation, while the incidence of subsequent AMI within 30 days was similar.

Regulator Loss Functions and Hierarchical Modeling for Safety Decision Making

BACKGROUND

Regulators must act to protect the public when evidence indicates safety problems with medical devices. This requires complex tradeoffs among risks and benefits, which conventional safety surveillance methods do not incorporate.

OBJECTIVE

To combine explicit regulator loss functions with statistical evidence on medical device safety signals to improve decision making.

METHODS

In the Hospital Cost and Utilization Project National Inpatient Sample, we select pediatric inpatient admissions and identify adverse medical device events (AMDEs). We fit hierarchical Bayesian models to the annual hospital-level AMDE rates, accounting for patient and hospital characteristics. These models produce expected AMDE rates (a safety target), against which we compare the observed rates in a test year to compute a safety signal. We specify a set of loss functions that quantify the costs and benefits of each action as a function of the safety signal. We integrate the loss functions over the posterior distribution of the safety signal to obtain the posterior (Bayes) risk; the preferred action has the smallest Bayes risk. Using simulation and an analysis of AMDE data, we compare our minimum-risk decisions to a conventional Z score approach for classifying safety signals.

RESULTS

The 2 rules produced different actions for nearly half of hospitals (45%). In the simulation, decisions that minimize Bayes risk outperform Z score-based decisions, even when the loss functions or hierarchical models are misspecified.

LIMITATIONS

Our method is sensitive to the choice of loss functions; eliciting quantitative inputs to the loss functions from regulators is challenging.

CONCLUSIONS

A decision-theoretic approach to acting on safety signals is potentially promising but requires careful specification of loss functions in consultation with subject matter experts.

Prevalence of Chronic Conditions and Multimorbidities in a Geographically Defined Geriatric Population With Diverse Races and Ethnicities

OBJECTIVE

The objective of this study is to examine racial/ethnic differences in prevalence of chronic conditions and multimorbidities in the geriatric population of a state with diverse races/ethnicities.

METHOD

Fifteen chronic conditions and their dyads and triads were investigated using Hawaii Medicare 2012 data. For each condition, a multivariable logistic regression model was used to investigate differences in race/ethnicity, adjusting for subject characteristics.

RESULTS

Of the 84,212 beneficiaries, 27.8% were Whites, 54.6% Asians, and 5.2% Hispanics. Racial/ethnic disparities were prevalent for most conditions. Compared with Whites, Asians, Hispanics, and Others showed significantly higher prevalence rates in hypertension, hyperlipidemia, diabetes, and most dyads or triads of the chronic conditions. However, Whites had higher prevalence rates in arthritis and dementia.

DISCUSSION

Race/ethnicity may need to be considered when making clinical decisions and developing health care programs to reduce health disparities and improve quality of life for older individuals with chronic conditions.

Stratifying Patients with Diabetes into Clinically Relevant Groups by Combination of Chronic Conditions to Identify Gaps in Quality of Care

OBJECTIVE

To find clinically relevant combinations of chronic conditions among patients with diabetes and to examine their relationships with six diabetes quality metrics.

DATA SOURCES/STUDY SETTING

Twenty-nine thousand five hundred and sixty-two adult patients with diabetes seen at eight Midwestern U.S. health systems during 2010-2011.

STUDY DESIGN

We retrospectively evaluated the relationship between six diabetes quality metrics and patients' combinations of chronic conditions. We analyzed 12 conditions that were concordant with diabetes care to define five mutually exclusive combinations of conditions ("classes") based on condition co-occurrence. We used logistic regression to quantify the relationship between condition classes and quality metrics, adjusted for patient demographics and utilization.

DATA COLLECTION

We extracted electronic health record data using a standardized algorithm.

PRINCIPAL FINDINGS

We found the following condition classes: severe cardiac, cardiac, noncardiac vascular, risk factors, and no concordant comorbidities. Adjusted odds ratios and 95 percent confidence intervals for glycemic control were, respectively, 1.95 (1.7-2.2), 1.6 (1.4-1.9), 1.3 (1.2-1.5), and 1.3 (1.2-1.4) compared to the class with no comorbidities. Results showed similar patterns for other metrics.

CONCLUSIONS

Patients had distinct quality metric achievement by condition class, and those in less severe classes were less likely to achieve diabetes metrics.

Explaining Obesity- and Smoking-related Healthcare Costs through Unconditional Quantile Regression

Background: This paper assesses obesity- and smoking-related incremental healthcare costs for the employees and dependents of a large U.S. employer. Objectives: Unlike previous studies, this study evaluates the distributional effects of obesity and smoking on healthcare cost distribution using a recently developed econometric framework: the unconditional quantile regression (UQR). Methods: Results were compared with the traditional conditional quantile regression (CQR), and the generalized linear modeling (GLM) framework that is commonly used for modeling healthcare cost. Results: The study found strong evidence of association of healthcare costs with obesity and smoking. More importantly, the study found that these effects are substantially higher in the upper quantiles of the healthcare cost distribution than in the lower quantiles. The insights on the heterogeneity of impacts of obesity and smoking on healthcare costs would not have been captured by traditional mean-based approaches. The study also found that UQR impact estimates were substantially different from CQR impact estimates in the upper quantiles of the cost distribution. Conclusions: These results suggest the potential role that smoking cessation and weight management programs can play in arresting the growth in healthcare costs. Specifically, given the finding that obesity and smoking have markedly higher impacts on high-cost patients, such programs appear to have significant cost saving potential if targeted toward high-cost patients.

Health care resource use and costs associated with possible side effects of high oral corticosteroid use in asthma: a claims-based analysis

BACKGROUND

The objective of this study was to estimate the prevalence of possible oral corticosteroid (OCS)-related side effects and health care resource use and costs in patients with asthma.

METHODS

This was a cross-sectional, matched-cohort, retrospective study using a commercial claims database. Adults with asthma diagnosis codes and evidence of asthma medication use were studied. Patients with high OCS use (≥30 days of OCS annually) were divided into those who did versus those who did not experience OCS-related possible side effects. Their health care resource use and costs were compared using linear regression or negative binomial regression models, adjusting for age, sex, geographic region, Charlson Comorbidity Index score, and chronic obstructive pulmonary disease status.

RESULTS

After adjustment, high OCS users with possible side effects were more likely to have office visits (23.0 vs 19.6; P<0.001) and hospitalizations (0.44 vs 0.22; P<0.001) than those without possible side effects. Emergency department visits were similar between the groups. High OCS users with possible side effects had higher adjusted total annual mean health care costs ($25,168) than those without such side effects ($21,882; P=0.009).

CONCLUSION

Among high OCS users, patients with possible OCS-related side effects are more likely to use health care services than those without such side effects. Although OCS may help control asthma and manage exacerbations, OCS side effects may result in additional health care resource use and costs, highlighting the need for OCS-sparing asthma therapies.

A Systematic Review of Health Economic Evaluation Studies Using the Patient's Perspective

BACKGROUND

Patient-centered care has become increasingly important and relevant for informed health care decision making.

OBJECTIVE

Our study aimed to perform a systematic review of health economic evaluation studies from the patient's perspective.

METHODS

PubMed, EMBASE, and Cochrane Central databases were searched through May 2014 for cost-effectiveness, cost-utility, and cost-benefit studies using the patient's perspective in their analysis. The reporting quality of the studies was evaluated on the basis of Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

We identified 30 health economic evaluations using the patient's perspective, of which 7 were conducted in the United States, 9 in Europe, and 14 in Asian or other countries. Seventeen of 23 health conditions evaluated were chronic in nature. Among 12 studies that justified the use of the patient's perspective, patient's financial burden associated with medical treatment was the most commonly cited rationale. A total of 29, 17, and 15 studies examined direct medical, direct nonmedical, and indirect costs, respectively. Seventeen studies also included societal, governmental or payer's, and/or provider's perspective(s) in their analyses. Based on Consolidated Health Economic Evaluation Reporting Standards, more than 20% of the reporting items in these studies were either partially satisfied or not satisfied.

CONCLUSIONS

There is a paucity of health economic evaluations conducted from the patient's perspective in the literature. For those studies using the patient's perspective, the true patient costs were not fully explored and study reporting quality was not optimal. With the increasing focus on patient-centered outcomes in health policy research, more frequent use of the patient's perspective in economic studies should be advocated.

Burden of illness, annual healthcare utilization, and costs associated with commercially insured patients with Cushing disease in the United States

OBJECTIVE

To describe the burden of illness, healthcare utilization, and costs associated with Cushing disease (CD), a rare disorder resulting from adrenocorticotropic hormone-secreting pituitary tumors, in commercially insured patients in the U. S.

METHODS

Patients with CD were identified in 2010 in the IMS Health PharMetrics and Truven Health Analytics MarketScan claims databases. Because there is no diagnosis code for CD, patients were identified with a claim for Cushing syndrome and either benign pituitary adenoma or hypophysectomy. We estimated total and CD-related utilization and costs using pharmacy and medical claims.

RESULTS

We identified 685 CD patients (81% female; mean age, 41.7 years; mean Charlson comorbidity index, 1.6; mean number of chronic conditions, 4.2); 30.5% of the patients had diabetes, 22.5% had psychiatric disturbances, 21% had infections, 8.6% had osteoporosis, 8% had cardiovascular disease/stroke, 5.5% had kidney stones, and 0.7% had compression fracture of a vertebra. Patients had a mean of 19.8 office visits per year; 38.4% had inpatient hospitalizations and 34.2% visited the emergency department (ED). Patients had a mean of 3.2 CD-related office visits per year; 26.9% had CD-related hospitalizations, 0.9% had CD-related ED visits, and 36.8% had CD treatments. Mean annual total costs were $34,992 (pharmacy, $3,597; medical costs, $31,395). CD-related costs accounted for $14,310 of total costs (CD treatment costs, $9,353; other CD-related costs, $4,957).

CONCLUSION

CD patients have a high burden of illness. Among CD patients in this study, 30.5% had diabetes, 22.5% had psychiatric disturbances, 21% had infections, 8.6% had osteoporosis, 8% had cardiovascular disease/stroke, and 5.5% had kidney stones. Patients had 19.8 office visits per year, and >34% of patients were hospitalized. Mean total cost of care was approximately $35,000 per year.

Hospital Inpatient Costs for Adults with Multiple Chronic Conditions

This article offers national estimates of the proportions of hospital inpatient cases and cost for adult, nonmaternal patients who have multiple chronic conditions. The authors employ a refined classification of chronic versus acute conditions, collapsed to no more than one condition per distinct category of condition. The number of different chronic conditions provides a simple measure of complexity, differing from measures of severity of illness that pertain to a particular episode of treatment. A multivariate regression finds that the number of chronic conditions is an independent influence on hospital cost per case, controlling for other key determinants. Patients with complex illness (e.g., 3+ or 5+ chronic conditions) have a disproportionately large effect on hospital cost per year. The identification of patients in the hospital with complex illness can help in targeting new covered services in a health plan or in risk adjusting health plan premiums. Current policies and demonstrations for the Medicare program may not be sufficient to address complex illness.

[The influence of excess weight and obesity on health spending in Brazilian households]

The objective of this study was to evaluate the influence of excess weight and obesity on health spending in Brazilian households. Data from the Household Budget Survey 2008-2009 were used to estimate monetary health spending, corresponding to out-of-pocket spending, including purchase of medicines and payment for healthcare services, and to evaluate the nutritional status of the 55,970 household residents. Monthly spending on health and its components were analyzed according to the number of excess weight and obese individuals in households (none, one, two, or three or more individuals). The presence and increasing number of excess weight and obese individuals has resulted in greater spending on health, especially on medicines and health insurance. The results were maintained after adjusting for income, region, area, and presence of elderly and number of residents in the household. Excess weight and obesity had a direct impact on out-of-pocket health spending by Brazilian families.

Chronic Conditions and Self-Reported Health in a Medicare Advantage Plan Population

Self-reported changes in physical and mental health by members are an important dimension by which the quality of a Medicare Advantage (MA) plan is rated by the Centers for Medicare & Medicaid Services. To better target their interventions, MA plans need a better understanding of what observed characteristics-including clinical health conditions-predict self-reported changes in physical and mental health. This study explored how one MA plan's survey of participants' responses regarding changes in physical and mental health is associated with a set of chronic conditions as well as sociodemographic characteristics. Multinomial logistic regressions were used to examine the influence of 9 chronic conditions and age, sex, race, education, dual eligibility status (Medicare/Medicaid eligible), marital and living status, and assistance with survey completion on changes in patient-reported physical and mental health. Six conditions-dementia (P < 0.001), diabetes (P = 0.003), congestive heart failure (P = 0.002), cerebrovascular disease (P = 0.001), coronary artery disease (CAD) (P < 0.001), and rheumatoid arthritis (P < 0.001)-were associated with self-reported worsening of overall physical health. Four conditions-dementia (P < 0.002), diabetes (P = 0.047), CAD (P = 0.001), and decubitus ulcers (P = 0.033)-were associated with self-reported worsening of overall mental health. Females, married respondents, and those needing assistance with survey completion were more likely to report worsening of their mental health. Enrollees older than age 65 actually were less likely to report worsening of overall mental health. Findings provide insight into which members may be more susceptible to reporting that their physical or mental health is worsening.

Multimorbidity in chronic disease: impact on health care resources and costs

Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.

Catalog of 199 register-based definitions of chronic conditions

INTRODUCTION

The aim of the current study was to present and discuss a broad range of register-based definitions of chronic conditions for use in register research, as well as the challenges and pitfalls when defining chronic conditions by the use of registers.

MATERIALS AND METHODS

The definitions were defined based on information from nationwide Danish public healthcare registers. Medical and epidemiological specialists identified and grouped relevant diagnosis codes that covered chronic conditions, using the International Classification System version 10 (ICD-10). Where relevant, prescription and other healthcare data were also used to define the chronic conditions.

RESULTS

We identified 199 chronic conditions and subgroups, which were divided into four groups according to a medical judgment of the expected duration of the conditions, as follows. Category I: Stationary to progressive conditions (maximum register inclusion time of diagnosis since the start of the register in 1994). Category II: Stationary to diminishing conditions (10 years of register inclusion after time of diagnosis). Category III: Diminishing conditions (5 years of register inclusion after time of diagnosis). Category IV: Borderline conditions (2 years of register inclusion time following diagnosis). The conditions were primarily defined using hospital discharge diagnoses; however, for 35 conditions, including common conditions such as diabetes, chronic obstructive lung disease and allergy, more complex definitions were proposed based on record linkage between multiple registers, including registers of prescribed drugs and use of general practitioners' services. CONCLUSIONS THIS STUDY PROVIDED A CATALOG OF REGISTER-BASED DEFINITIONS FOR CHRONIC CONDITIONS FOR USE IN HEALTHCARE PLANNING AND RESEARCH, WHICH IS, TO THE AUTHORS' KNOWLEDGE, THE LARGEST CURRENTLY COMPILED IN A SINGLE STUDY.

Integrating palliative care into primary care for patients with chronic, life-limiting conditions

As longevity increases, individuals with chronic, life-limiting conditions will live longer with disease burden and functional decline. Nurse practitioners can integrate symptom management, early decision-making, and supportive care into the primary care setting to improve quality of life and decrease economic and emotional impact at the end of life.

Relationship between continuity of care and adverse outcomes varies by number of chronic conditions among older adults with diabetes

Background

Continuity of care is a basic tenant of primary care practice. However, the evidence on the importance of continuity of care for older adults with complex conditions is mixed.

Objective

To assess the relationship between measurement of continuity of care, number of chronic conditions, and health outcomes.

Design

We analyzed data from a cohort of 1,600 US older adults with diabetes and ≥1 other chronic condition in a private Medicare health plan from July 2010 to December 2011. Multivariate regression models were used to examine the association of baseline continuity (the first 6 months) and the composite outcome of any emergency room use or inpatient hospitalization occurring in the following 12-month period.

Results

After adjusting for baseline covariates, high known provider continuity (KPC) was associated with an 84% (adjusted odds ratio 0.16; 95% confidence interval 0.09–0.26) reduction in the risk of the composite outcome. High KPC was significantly associated with a lower risk of the composite outcome among individuals with ≥6 conditions. However, the usual provider of care and continuity of care indices were not significantly related with the composite outcome in the overall sample or in those with ≥6 conditions.

Conclusion

The relationship between continuity of care and adverse outcomes depends on the measure of continuity of care employed. High morbidity patients are more likely to benefit from continuity of care interventions as measured by the KPC, which measures the proportion of a patient’s visits that are with the same providers over time.

Corticosteroid-related adverse events in patients with giant cell arteritis: A claims-based analysis

OBJECTIVE

Corticosteroids (CS) are standard treatment for giant cell arteritis (GCA), but concerns persist over toxicities associated with long-term use. In this retrospective study of medical claims data, we estimated risks for adverse events (AEs) in CS-treated GCA patients.

METHODS

Cox regression analyses with CS use as a time-dependent variable were conducted on data from the 2003 to 2012 Truven Health Analytics MarketScan Database. Patients 50 years of age and older who had ≥2 claims of newly diagnosed GCA, ≥1 filled oral CS prescription, and no AEs before GCA diagnosis were included. The primary outcome was presence of a new CS-related AE.

RESULTS

In total, 2497 patients were included. Their mean age was 71.0 years, and 71% were women. Follow-up was 9680 patient-years (PY). CS treatment continued for a mean (SD) of 1.196 (729.2) days; mean (SD) prescribed cumulative CS dose was 6983.3mg (6519.9). The overall AE rate was 0.43 events/PY; the most frequent AEs were cataract and bone disease. For each 1000-mg increase in CS exposure, the hazard ratio (HR) increased by 3% (HR = 1.03; 95% CI: 1.02-1.05; P < 0.001). Additionally, statistically significant individual associations between increased CS exposure and AE risk were observed for bone-related AEs (P < 0.001), cataract (P < 0.001), glaucoma (P = 0.005), pneumonia (P = 0.003), and diabetes mellitus (P < 0.001 in a subset of patients with no previous history of diabetes).

CONCLUSION

CS exposure significantly increased risk for potentially serious AEs, emphasizing a need for new treatment options for GCA patients.

Evaluating Clinical Practice Guidelines Based on Their Association with Return to Work in Administrative Claims Data

OBJECTIVE

To examine the association between non-adherence to clinical practice guidelines (CPGs) and time to return to work (RTW) for patients with workplace injuries.

DATA SOURCES/STUDY SETTING

Secondary analysis of medical billing and disability data for 148,199 for shoulder and back injuries from a workers' compensation insurer.

STUDY DESIGN

Cox proportional hazard regression is used to estimate the association between time to RTW and receipt of guideline-discordant care. We test the robustness of our findings to an omitted confounding variable.

DATA COLLECTION

Collected by the insurer from the time an injury was reported, through recovery or last follow-up.

PRINCIPAL FINDINGS

Receiving guideline-discordant care was associated with slower RTW for only some guidelines. Early receipt of care, and getting less than the recommended amount of care, were correlated with faster RTW. Excessive physical therapy, bracing, and injections were associated with slower RTW.

CONCLUSIONS

There is not a consistent relationship between performance on CPGs and RTW. The association between performance on CPG and RTW is difficult to measure in observational data, because analysts cannot control for omitted variables that affect a patient's treatment and outcomes. CPGs supported by observational studies or randomized trials may have a more certain relationship to health outcomes.

The Influence of Respondent Characteristics on the Validity of Self-Reported Survey Responses

OBJECTIVE

To examine concordance between member self-reports and the organization's administrative claims data for two key health factors: number of chronic conditions, and number of prescription drugs.

DATA

Medicare Advantage plan claims data and member survey data from 2011 to 2012.

DESIGN

Mailed surveys to 15,000 members, enrolled minimum 6 months, drawn from a random sample of primary care physician practices with at least 200 members.

METHODS

Descriptive statistics were generated for extent of concordance. Multivariable logistic regressions were used to analyze the association of selected respondent characteristics with likelihood of concordance.

FINDINGS

Concordance for number of chronic conditions was 58.4 percent, with 27.3 percent under-reporting, 14.2 percent over-reporting. Concordance for number of prescription drugs was 56.6 percent with 38.9 percent under-reporting, 4.5 percent over-reporting. Number of prescriptions and assistance in survey completion were associated with higher likelihood of concordance for chronic conditions. Assistance in survey completion and number of chronic conditions were associated with higher concordance, and age and number of prescriptions were associated with lower concordance, for prescription drugs.

CONCLUSIONS

Self-reported number of chronic conditions and prescription medications are not in high concordance with claims data. Health care researchers and policy makers using patient self-reported data should be aware of these potential biases.

Financial Hardship--an Unwanted Consequence of Cancer Treatment

The substantial economic burden of cancer is increasingly being shifted to patients. Financial burden experienced by patients as a result of medical treatment has an impact on their lifestyle choices, health behaviors, and quality of life. Variation in treatment recommendations based on the patients' economic status or affordability may be against the basic tenet of social justice and is a growing challenge for policy makers. This review summarizes the multifaceted constructs and current trends associated with financial hardship within the context of cancer care and healthcare economics focusing mainly on hematological malignancies but supplemented by nonhematological cancer and general medical literature. We also highlight the patient and physician perspectives about this issue and identify important areas for future research. We discuss the need for more proactive solutions so that patients can achieve good clinical outcomes, without catastrophic financial consequences for themselves and their families.

Multiple chronic conditions and healthcare costs among adults

The prevalence of multiple chronic conditions (MCC) is increasing among individuals of all ages. MCC are associated with poor health outcomes. The presence of MCC has profound healthcare utilization and cost implications for public and private insurance payers, individuals, and families. Investigators have used a variety of definitions for MCC to evaluate costs associated with MCC. The objective of this article is to examine the current literature in estimating excess costs associated with MCC among adults. The discussion highlights some of the theoretical and technical merits of various MCC definitions and models used to estimate the excess costs associated with MCC.

Societal responsibility and moral hazard: How much are we willing to pay for quality-adjusted life?

Health care spending in the United States continues to rise with cancer care consuming a disproportionate amount of that spending. As the US population ages and cancer treatment options become more complex, cost containment strategies have become essential in oncology. Patient-centered decision-making will help to contain costs but requires a well-informed patient who is able to reconcile potential treatment choices with their beliefs and values. J. Surg. Oncol. 2016;114:269-274. © 2016 Wiley Periodicals, Inc.

Morbidity and Mortality of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in United States Adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening disorders. Our study objective was to describe the incidence, costs of care, length of stay, comorbidities, and mortality of SJS and TEN in US adults. The Nationwide Inpatient Sample 2009-2012, containing a 20% sample of all US hospitalizations, was analyzed. We used a validated approach involving International Classification of Disease, 9th edition, Clinical Modification codes to identify SJS, SJS/TEN, and TEN (n = 2,591, n = 502, and n = 564, respectively). The mean estimated incidences of SJS, SJS/TEN, and TEN were 9.2, 1.6, and 1.9 per million adults per year, respectively. SJS/TEN was associated with nonwhite race, particularly Asians (odds ratio = 3.27, 95% confidence interval = 3.02-3.54) and blacks (odds ratio = 2.01, 95% confidence interval = 1.92-2.10). Significantly prolonged length of stay and higher costs of care (SJS: 9.8 ± 0.3 days, $21,437 ± $807; SJS/TEN: 16.5 ± 1.0 days, $58,954 ± $5,238; TEN: 16.2 ± 1.0 days, $53,695 ± $4,037) were observed compared with all other admissions (4.7 ± 0.02 days, $11,281 ± $98). Mean adjusted mortality was 4.8% for SJS, 19.4% for SJS/TEN, and 14.8% for TEN. SJS, SJS/TEN, and TEN pose a substantial health care burden. Predictors of mortality included increasing age, increasing number of chronic conditions, infection (septicemia, pneumonia, tuberculosis), hematological malignancy (non-Hodgkin's lymphoma, leukemia), and renal failure (P ≤ 0.03 for all). Further studies are needed to confirm mortality findings to improve prognostication of SJS/TEN.

Patterns and determinants of out-of-pocket health care expenditure in Sri Lanka: evidence from household surveys

This article examines patterns and determinants of the likelihood and financial burden of encountering out-of-pocket healthcare expenses in Sri Lankan households as, on average, more than 60% of households incur such costs. This percentage varies substantially across household categories in demographic properties, sectors and ability-to-pay. Households comprising more than one elderly person, pre-school children, members with chronic illnesses, and literate household heads are at significant risk of incurring out-of-pocket payments and bearing a higher financial burden. Rural and estate sector households are more likely to bear a higher burden. The marginal effects of household income show that the burden of private healthcare is less sensitive towards changes in household income and that households' burden in private healthcare was regressive in 2006/2007. Hence results imply that low-income households need to be protected. Analysis of supply side factors shows that availability of closer government hospitals, bed numbers and dentists in government hospitals reduce the burden of out-of-pocket expenses. However, more government doctors lead to higher likelihood and burden of incurring such healthcare expenses and create a government-doctor-induced cost. Therefore, the results show a convincing need for the expansion of healthcare infrastructure by government and a policy framework for its doctors that will lessen the financial burden in Sri Lankan households, particularly the poor.

Improving condition severity classification with an efficient active learning based framework

Classification of condition severity can be useful for discriminating among sets of conditions or phenotypes, for example when prioritizing patient care or for other healthcare purposes. Electronic Health Records (EHRs) represent a rich source of labeled information that can be harnessed for severity classification. The labeling of EHRs is expensive and in many cases requires employing professionals with high level of expertise. In this study, we demonstrate the use of Active Learning (AL) techniques to decrease expert labeling efforts. We employ three AL methods and demonstrate their ability to reduce labeling efforts while effectively discriminating condition severity. We incorporate three AL methods into a new framework based on the original CAESAR (Classification Approach for Extracting Severity Automatically from Electronic Health Records) framework to create the Active Learning Enhancement framework (CAESAR-ALE). We applied CAESAR-ALE to a dataset containing 516 conditions of varying severity levels that were manually labeled by seven experts. Our dataset, called the "CAESAR dataset," was created from the medical records of 1.9 million patients treated at Columbia University Medical Center (CUMC). All three AL methods decreased labelers' efforts compared to the learning methods applied by the original CAESER framework in which the classifier was trained on the entire set of conditions; depending on the AL strategy used in the current study, the reduction ranged from 48% to 64% that can result in significant savings, both in time and money. As for the PPV (precision) measure, CAESAR-ALE achieved more than 13% absolute improvement in the predictive capabilities of the framework when classifying conditions as severe. These results demonstrate the potential of AL methods to decrease the labeling efforts of medical experts, while increasing accuracy given the same (or even a smaller) number of acquired conditions. We also demonstrated that the methods included in the CAESAR-ALE framework (Exploitation and Combination_XA) are more robust to the use of human labelers with different levels of professional expertise.

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

BACKGROUND

Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.

OBJECTIVE

Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.

DATA SOURCES

We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.

RESULTS

From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.

CONCLUSIONS/IMPLICATIONS

This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.

Maternal depressive symptoms and healthcare expenditures for publicly insured children with chronic health conditions

This study estimated the prevalence of maternal depressive symptoms and tested associations between maternal depressive symptoms and healthcare utilization and expenditures among United States publicly insured children with chronic health conditions (CCHC). A total of 6,060 publicly insured CCHC from the 2004-2009 Medical Expenditure Panel Surveys were analyzed using negative binomial models to compare healthcare utilization for CCHC of mothers with and without depressive symptoms. Annual healthcare expenditures for both groups were compared using a two-part model with a logistic regression and generalized linear model. The prevalence of depressive symptoms among mothers with CCHC was 19 %. There were no differences in annual healthcare utilization for CCHC of mothers with and without depressive symptoms. Maternal depressive symptoms were associated with greater odds of ED expenditures [odds ratio (OR) 1.26; 95 % CI 1.03-1.54] and lesser odds of dental expenditures (OR 0.81; 95 % CI 0.66-0.98) and total expenditures (OR 0.71; 95 % CI 0.51-0.98). Children of symptomatic mothers had lower predicted outpatient expenditures and higher predicted expenditures for total health, prescription medications, dental care; and office based, inpatient and ED visits. Mothers with CCHC were more likely to report depressive symptoms than were mothers with children without chronic health conditions. There were few differences in annual healthcare utilization and expenditures between CCHC of mothers with and without depressive symptoms. However, having a mother with depressive symptoms was associated with higher ED expenditures and higher predicted healthcare expenditures in a population of children who comprise over three-fourths of the top decile of Medicaid spending.

Incremental healthcare resource utilization and costs in US patients with Cushing's disease compared with diabetes mellitus and population controls

PURPOSE

Resource utilization and costs in Cushing's disease (CD) patients have not been studied extensively. We compared CD patients with diabetes mellitus (DM) patients and population-based controls to characterize differences in utilization and costs.

METHODS

Using 2008-2012 MarketScan® database, we identified three patient groups: (1) CD patients; (2) DM patients; and (3) population-based control patients without CD. DM and control patients were matched to CD patients by age, gender, region, and review year in a 2:1 ratio. Outcomes included annual healthcare resource utilization and costs.

RESULTS

There were 1852 CD patients, 3704 DM patients and 3704 controls. Mean age was 42.9 years; 78.2 % were female. CD patients were hospitalized more frequently (19.3 %) than DM patients (11.0 %, p < .001) or controls (5.6 %, p < .001). CD patients visited the ED more frequently (25.4 %) than DM patients (21.1 %, p < .001) or controls (14.3 %, p < .001). CD patients had more office visits than DM patients (19.1 vs. 10.7, p < .001) or controls (7.1, p < .001). CD patients on average filled more prescriptions than DM patients (51.7 vs. 42.7, p < .001) or controls (20.5, p < .001). Mean total healthcare costs for CD patients were $26,269 versus $12,282 for DM patients (p < .001) and $5869 for controls (p < .001).

CONCLUSIONS

CD patients had significantly higher annual rates of healthcare resource utilization compared to matched DM patients and population controls without CD. CD patient costs were double DM costs and quadruple control costs. This study puts into context the additional burdens of CD over DM, a common, chronic endocrine condition affecting multiple organ systems, and population controls.

The incidence of high medical expenses by health status in seven developed countries

Health care policy seeks to ensure that citizens are protected from the financial risk associated with needing health care. Yet rising health care costs in many countries are leading to a greater reliance on out-of-pocket (OOP) measures. This paper uses 2010 household survey data from seven countries to measure and compare the burden OOP expenses place on individuals. It compares countries based on the extent to which citizens with health problems devote a large share of their income to OOP expenses. The paper finds that in all countries but France, and to a lesser extent Slovenia, citizens with health problems face considerably higher medical costs than do those without. As many as one-quarter of less healthy citizens in the US, Poland, Russia and Israel devote a large share of their income to OOP expenses. The paper also finds a strong cross-national correlation between the degree to which citizens face high OOP expenses, and the disparities in OOP expenses between those with and without health problems. The levels of high OOP spending uncovered, and their inequitable impact on those with health problems in the seven countries, underscore the potential for OOP measures to undermine core objectives of health care systems, including those of equitable financing, equal access, and improved health among the population.

Financial burdens and barriers to care among nonelderly adults: The role of functional limitations and chronic conditions

BACKGROUND

People with functional limitations and chronic conditions account for the greatest resource use within the health care system.

OBJECTIVE

To examine financial burdens and barriers to care among nonelderly adults, focusing on the role of functional limitations and chronic conditions.

METHODS

High financial burden is defined as medical spending exceeding 20 percent of family income. Financial barriers are defined as delaying care/being unable to get care for financial reasons, and reporting that delaying care/going without was a big problem. Data are from the Medical Expenditure Panel Survey (2008-2012).

RESULTS

Functional limitations are associated with increased prevalence of financial burdens. Among single adults, the frequency of high burdens is 20.3% for those with functional limitations, versus 7.8% for those without. Among those with functional limitations, those with 3 or more chronic conditions are twice as likely to have high burdens compared to those without chronic conditions (22.2% versus 11.1%, respectively). Similar patterns occur among persons in multi-person families whose members have functional limitations and chronic conditions. Having functional limitations and chronic conditions is also strongly associated with financial barriers to care: 40.2% among the uninsured, 21.9% among those with public coverage, and 13.6% among those with private group insurance were unable to get care.

CONCLUSIONS

Functional limitations and chronic conditions are associated with increased prevalence of burdens and financial barriers in all insurance categories, with the exception that an association between functional limitations and the prevalence of burdens was not observed for public coverage.

Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis

Background

The burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa.

Methods

Secondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007–2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models.

Results

The prevalence of multimorbidity in the adult population varied from 3∙9% in Ghana to 33∙6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0∙56, 95% CI = 0∙46, 0∙66), a higher likelihood of being hospitalised in India (AOR = 1∙59, 95% CI = 1∙45, 1∙75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88∙3% for outpatient, 55∙9% for inpatient visit in China) in most countries.

Conclusion

Multimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups such as the elderly with multimorbidity.

Exploring the role of multiple chronic conditions in traditional Chinese medicine use and three types of traditional Chinese medicine therapy among adults in Taiwan

INTRODUCTION

Numerous people with chronic conditions like to use traditional Chinese medicine (TCM) treatment, or integrated treatment of TCM and Western medicine (WM). Our study explored the associations between multiple chronic conditions (MCC) and TCM use and the use of specific types of TCM therapy among adults in Taiwan. In addition, we explored the TCM use of adults with seven common types of chronic conditions.

METHODS

In our study, a national representative sample in 2005 was used. The Chronic Condition Indicator and the Clinical Classifications System created by the U.S. Agency for Healthcare Research and Quality were used to define the number of chronic conditions of adults. Logistic regressions adjusted for demographic characteristics were used to analyze the associations. The frequency of TCM use among adults with different numbers of chronic conditions was quantified.

RESULTS

TCM use for adults with ≥5 chronic conditions (odds ratio [OR] 1.86) was higher than TCM use for adults with 2-4 chronic conditions (OR 1.51) and TCM use for adults with one chronic condition (OR 1.48). The increase in the OR of the use of Chinese herbs and traumatology manipulative therapy according to the number of chronic conditions was not as substantial as that of acupuncture-moxibustion. The frequency of TCM use exhibited an increasing trend with the increase in the number of chronic conditions (p<.001). Among the seven common types of chronic conditions for adults, TCM use for adults with arthropathy (OR 2.01) was the highest.

CONCLUSION

The probability and frequency of TCM use increased as the number of chronic conditions increased. The probability of Chinese herbs use, traumatology manipulative therapy use, and, particularly, acupuncture-moxibustion use increased as the number of chronic conditions increased. We suggest that government policy makers emphasize administering integrated TCM and WM care to people with chronic conditions or MCC.

Chronic disease self-management program in the workplace: opportunities for health improvement

Disease management is becoming increasingly important in workplace health promotion given the aging workforce, rising chronic disease prevalence, and needs to maintain a productive and competitive American workforce. Despite the widespread availability of the Chronic Disease Self-Management Program (CDSMP), and its known health-related benefits, program adoption remains low in workplace settings. The primary purpose of this study is to compare personal and delivery characteristics of adults who attended CDSMP in the workplace relative to other settings (e.g., senior centers, healthcare organizations, residential facilities). This study also contrasts characteristics of CDSMP workplace participants to those of the greater United States workforce and provides recommendations for translating CDSMP for use in workplace settings. Data were analyzed from 25,664 adults collected during a national dissemination of CDSMP. Only states and territories that conducted workshops in workplace settings were included in analyses (n = 13 states and Puerto Rico). Chi-squared tests and t-tests were used to compare CDSMP participant characteristics by delivery site type. CDSMP workplace participant characteristics were then compared to reports from the United States Bureau of Labor Statistics. Of the 25,664 CDSMP participants in this study, 1.7% (n = 435) participated in workshops hosted in worksite settings. Compared to CDSMP participants in non-workplace settings, workplace setting participants were significantly younger and had fewer chronic conditions. Differences were also observed based on chronic disease types. On average, CDSMP workshops in workplace settings had smaller class sizes and workplace setting participants attended more workshop sessions. CDSMP participants in workplace settings were substantially older and a larger proportion were female than the general United States workforce. Findings indicate opportunities to translate CDSMP for use in the workplace to reach new target audiences.

Establishing chronic condition concordance and discordance with diabetes: a Delphi study

BACKGROUND

The vast majority of patients with diabetes have multiple chronic conditions, increasing complexity of care; however, clinical practice guidelines, interventions, and public reporting metrics do not adequately address the interaction of these multiple conditions. To advance the understanding of diabetes clinical care in the context of multiple chronic conditions, we must understand how care overlaps, or doesn't, between diabetes and its co-occurring conditions. This study aimed to determine which chronic conditions are concordant (share care goals with diabetes) and discordant (do not share care goals) with diabetes care, according to primary care provider expert opinion.

METHODS

Using the Delphi technique, we administered an iterative, two-round survey to 16 practicing primary care providers in an academic practice in the Midwestern USA. The expert panel determined which specific diabetes care goals were also care goals for other chronic conditions (concordant) and which were not (discordant). Our diabetes care goals were those commonly used in quality reporting, and the conditions were 62 ambulatory-relevant condition categories.

RESULTS

Sixteen experts participated and all completed both rounds. Consensus was reached on the first round for 94% of the items. After the second round, 12 conditions were concordant with diabetes care and 50 were discordant. Of the concordant conditions, 6 overlapped in care for 4 of 5 diabetes care goals and 6 overlapped for 3 of 5 diabetes care goals. Thirty-one discordant conditions did not overlap with any of the diabetes care goals, and 19 overlapped with only 1 or 2 goals.

CONCLUSIONS

This study significantly adds to the number of conditions for which we have information on concordance and discordance for diabetes care. The results can be used for future studies to assess the impact of concordant and discordant conditions on diabetes care, and may prove useful in developing multimorbidity guidelines and interventions.

Activity limitations predict health care expenditures in the general population in Belgium

Background

Disability and chronic conditions both have an impact on health expenditures and although they are conceptually related, they present different dimensions of ill-health. Recent concepts of disability combine a biological understanding of impairment with the social dimension of activity limitation and resulted in the development of the Global Activity Limitation Indicator (GALI). This paper reports on the predictive value of the GALI on health care expenditures in relation to the presence of chronic conditions.

Methods

Data from the Belgian Health Interview Survey 2008 were linked with data from the compulsory national health insurance (n = 7,286). The effect of activity limitation on health care expenditures was assessed via cost ratios from multivariate linear regression models. To study the factors contributing to the difference in health expenditure between persons with and without activity limitations, the Blinder-Oaxaca decomposition method was used.

Results

Activity limitations are a strong determinant of health care expenditures. People with severe activity limitations (5.1%) accounted for 16.9% of the total health expenditure, whereas those without activity limitations (79.0%), were responsible for 51.5% of the total health expenditure. These observed differences in health care expenditures can to some extent be explained by chronic conditions, but activity limitations also contribute substantially to higher health care expenditures in the absence of chronic conditions (cost ratio 2.46; 95% CI 1.74-3.48 for moderate and 4.45; 95% CI 2.47-8.02 for severe activity limitations). The association between activity limitation and health care expenditures is stronger for reimbursed health care costs than for out-of-pocket payments.

Conclusion

In the absence of chronic conditions, activity limitations appear to be an important determinant of health care expenditures. To make projections on health care expenditures, routine data on activity limitations are essential and complementary to data on chronic conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1607-7) contains supplementary material, which is available to authorized users.

Health-care costs and utilization related to long- or short-acting antiepileptic monotherapy use

PURPOSE

This study aimed to compare health-care utilization and costs in patients treated with long-acting (LA) vs. short-acting (SA) antiepileptic drug (AED) monotherapy.

METHODS

We conducted a cross-sectional study of claims from the OptumInsight™ database. Our analysis was restricted to adults diagnosed with epilepsy and who used AED monotherapy. Patients were excluded if they used >1 type of AED, had <9months of treatment, or had a treatment gap of >60days. Antiepileptic drugs were classified as LA or SA based on published data and expert opinion. Medical and pharmacy claims were used to estimate health-care utilization and costs, and baseline group differences were adjusted using multivariate analyses.

RESULTS

There were 4058 (49.6%) LA AED users and 4122 (50.4%) SA AED users. Medication possession ratios (MPRs) were not significantly different between LA AED users and SA AED users (P=0.125). Long-acting AED users had lower mean overall health-care costs ($9757 vs. $12,689), lower epilepsy-related costs ($3539 vs. $5279), and lower rate of overall (8.8% vs. 10.9%) and epilepsy-related hospitalizations (5.7% vs. 7.6%) compared with SA AED users (all P<0.01). After adjusting for demographics and clinical characteristics, mean overall costs were lower by $686 and the mean epilepsy-related costs were lower by $894 in LA AED users.

CONCLUSION

Although MPRs were similar in LA AED and SA AED groups, patients treated with LA monotherapy had a lower economic burden compared with those treated with SA monotherapy, indicating that using AEDs with extended duration of action is associated with decreased health-care use and lower health-care costs.

The impact of a patient's concordant and discordant chronic conditions on diabetes care quality measures

AIMS

Most patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality.

METHODS

Logistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics.

RESULTS

A higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions.

CONCLUSIONS

Having more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patient's comorbidities, including the absence of comorbidities, especially concordant comorbidities.

Chronic condition combinations and health care expenditures and out-of-pocket spending burden among adults, Medical Expenditure Panel Survey, 2009 and 2011

INTRODUCTION

Little is known about how combinations of chronic conditions in adults affect total health care expenditures. Our objective was to estimate the annual average total expenditures and out-of-pocket spending burden among US adults by combinations of conditions.

METHODS

We conducted a cross-sectional study using 2009 and 2011 data from the Medical Expenditure Panel Survey. The sample consisted of 9,296 adults aged 21 years or older with at least 2 of the following 4 highly prevalent chronic conditions: arthritis, diabetes mellitus, heart disease, and hypertension. Unadjusted and adjusted regression techniques were used to examine the association between chronic condition combinations and log-transformed total expenditures. Logistic regressions were used to analyze the relationship between chronic condition combinations and high out-of-pocket spending burden.

RESULTS

Among adults with chronic conditions, adults with all 4 conditions had the highest average total expenditures ($20,016), whereas adults with diabetes/hypertension had the lowest annual total expenditures ($7,116). In adjusted models, adults with diabetes/hypertension and hypertension/arthritis had lower health care expenditures than adults with diabetes/heart disease (P < .001). In adjusted models, adults with all 4 conditions had higher expenditures compared with those with diabetes and heart disease. However, the difference was only marginally significant (P = .04).

CONCLUSION

Among adults with arthritis, diabetes, heart disease, and hypertension, total health care expenditures differed by type of chronic condition combinations. For individuals with multiple chronic conditions, such as heart disease and diabetes, new models of care management are needed to reduce the cost burden on the payers.