Length of stay and costs for asthma patients by hospital characteristics--a five-year population-based analysis

Cost-effectiveness analysis of budesonide/formoterol SMART therapy versus salmeterol/fluticasone plus as-needed SABA among patients ≥12 years with moderate asthma from the Chinese societal perspective

OBJECTIVES

To evaluate the cost-effectiveness of budesonide/formoterol reliever and maintenance therapy compared with salmeterol/fluticasone plus salbutamol as reliever therapy for asthma patients ≥12 years from the societal perspective in China.

METHODS

A Markov model was developed with three health states (non-exacerbation, exacerbation, and death) with a lifetime horizon. The exacerbation rates were obtained from a prospective cohort study conducted in Chinese asthma patients. Healthcare resources utilization data were estimated based on current clinical asthma management guidelines. Asthma-related mortality, cost input and utility values were derived from public database and literature. Model robustness was assessed with one-way sensitivity and probabilistic sensitivity analyses.

RESULTS

Compared with salmeterol/fluticasone plus salbutamol, budesonide/formoterol reliever and maintenance therapy led to fewer exacerbation events (13.6 vs. 15.9) and 0.0077 quality-adjusted life years (QALY) gain at an additional cost of ¥196.38 over lifetime. The base case incremental cost-effectiveness ratio (ICER) was ¥25,409.98 per QALY gained. The variables that had most impact on the model output included drug costs and medication adherence. At a willingness-to-pay threshold of ¥257,094/QALY (3 times of gross domestic product per capita in China in 2022), the probability of budesonide/formoterol maintenance and reliever therapy being cost-effective versus salmeterol/fluticasone plus as-needed salbutamol was 83.00%.

CONCLUSION

From the societal perspective, budesonide/formoterol reliever and maintenance therapy is likely to be a cost-effective option compared with salmeterol/fluticasone plus as-needed salbutamol for Chinese asthma patients ≥12 years.

Medical resource utilization and the associated costs of asthma in China: a 1-year retrospective study

BACKGROUND

Despite evidence that severe and poorly controlled asthma are associated with more clinical unmet needs and intensive utilization of healthcare resources, limited data is available on severe asthma expenditure in China. The study aimed to assess Medical Resource Utilization (MRU) costs of asthma and explore the cost drivers in order to better understand the economic burden of the Chinese population suffered from asthma.

METHODS

A retrospective analysis was conducted using Chinese sampled national claim database. Patients aged 6 years and above with primary diagnosis of asthma and asthma-related medical visit/hospitalization during 2015 were included. Medication was used as a proxy per the GINA and China guideline to identify asthma severity (i.e. mild, moderate, and severe). multiple linear regression model was conducted to identify MRU costs drivers.

RESULTS

7,254 patients diagnosed with asthma were included: 4,529 (62.4%), 2,200 (30.3%), and 525 (7.2%) had mild, moderate, and severe asthma, respectively. On average, each severe patient spent 6,782 Chinese Yuan (CNY) on asthma treatment and had 57.0% hospitalization rate during the year, 3.9- and 4.4-fold of the average of overall population (P < 0.001 for both). The proportion of patients experiencing exacerbation significantly higher in the severe asthma population (66.5%; P < 0.001) compared to mild (30.0%) and moderate (16.8%) groups. In subgroup with 1,660 samples had annual consecutive data, severe patients had annual cost of CNY 8,314 and 52.2% hospitalization rate. 13% of severe patients who had frequent severe exacerbation (≥ 2 events) experienced the highest annual average cost CNY 23,037, P < 0.001) whereas children aged from 6 to 14 with a lower annual cost of CNY 1,094.2, 1,660.2 and 3,020.2 for mild, moderate, and severe patients respectively. The multiple model identified degree of severity, control status, complications, age, and live region as independent drivers of MRU costs.

CONCLUSIONS

Chinese asthma patients bear heavy economic burden. Severe asthma associated with higher MRU (mainly from hospitalization) and costs compared with mild to moderate asthma in China. More efforts should be devoted to the control of the disease severity and complication as the main drivers of asthma cost.

Financial Performance of SDG Mutual Funds Focused on Biotechnology and Healthcare Sectors

Measures favoring healthy lives among populations around the world are essential to reduce social inequalities. Mutual funds could play an important role funding these measures if they are able to attract socially concerned investors by improving their wealth. This study analyzes the financial performance of mutual funds focused on the biotechnology and healthcare sectors related to UN sustainable development goal 3 (SDG 3), comparing their risk-adjusted return with that achieved by conventional mutual funds. This study implements Carhart’s multifactor model and Bollen and Busse’s timing multifactor model on a sample of 34 biotechnology and 178 healthcare mutual funds and 4352 conventional mutual funds. The results show that biotechnology and healthcare mutual funds perform similarly, while both of them outperform conventional mutual funds. This outperformance of biotechnology and healthcare funds is driven by the superior stock-picking skills of their managers with regards to those of conventional fund managers, while managers of biotechnology, healthcare, and conventional mutual funds present similar poor market timing ability. Mutual funds specialized in biotechnology and healthcare sectors related to sustainable development goal 3 (SDG 3) outperform conventional mutual funds.

Associations Between Social Factor Documentation and Hospital Length of Stay and Readmission Among Children

BACKGROUND AND OBJECTIVES

Social risk factors are linked to children's health, but little is known about how frequently these factors are documented using the International Classification of Diseases (ICD) or whether documentation is associated with health care use outcomes. Using a large administrative database of pediatric hospitalizations, we examined the prevalence of ICD social risk code documentation and hypothesized that social code documentation would be associated with longer length of stay (LOS) and readmission.

METHODS

We analyzed hospitalizations of children ages ≤18 using the 2012 Nationwide Readmissions Database. The following ICD social codes were used as predictors: family member with alcohol and/or drug problem, history of abuse, parental separation, foster care, educational circumstance, housing instability, other economic strain, and legal circumstance. Outcomes included long LOS (top quintile) and readmission within 30 days after discharge. Covariates included individual, hospital, and season variables.

RESULTS

Of 926 073 index hospitalizations, 7432 (0.8%) had International Classification of Diseases, Ninth Revision, social codes. Social code documentation was significantly associated with long LOS. Adjusting for covariates, family alcohol and/or drug problem (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.16-2.35), foster care (OR 2.37, 95% CI 1.53-3.65), other economic strain (OR 2.12, 95% CI 1.38-3.26), and legal circumstances (OR 1.66; 95% CI 1.02-2.71) remained significant predictors of long LOS. Social code documentation was not associated with readmission after adjusting for covariates.

CONCLUSIONS

Social ICD codes are associated with prolonged LOS and readmission in pediatric hospitalizations, but they are infrequently documented. Future work exploring these associations could help to determine if addressing social risk factors in inpatient settings might improve child health outcomes.

Ohio Pediatric Asthma Repository: Opportunities to Revise Care Practices to Decrease Time to Physiologic Readiness for Discharge

BACKGROUND

Large-scale, multisite studies in which researchers evaluate patient- and systems-level factors associated with pediatric asthma exacerbation outcomes are lacking. We sought to investigate patient-level risks and system-level practices related to physiologic readiness for discharge (PRD) in the prospective Ohio Pediatric Asthma Repository.

METHODS

Participants were children ages 2 to 17 years admitted to an Ohio Pediatric Asthma Repository hospital for asthma exacerbation. Demographics, disease characteristics, and individual hospital practices were collected. The primary outcome was PRD timing (hours from admission or emergency department [ED] presentation until the first 4-hour albuterol spacing).

RESULTS

Data for 1005 participants were available (865 ED presentations). Several nonstandard care practices were associated with time to PRD (P < .001). Continuous pulse oximetry was associated with increased time to PRD (P = .004). ED dexamethasone administration was associated with decreased time to PRD (P < .001) and less ICU admittance and intravenous steroid use (P < .0001). Earlier receipt of chest radiograph, antibiotics, and intravenous steroids was associated with shorter time to PRD (P < .05). Care practices associated with shorter time to PRD varied markedly by hospital.

CONCLUSIONS

Substantial variation in care practices for inpatient asthma treatment exists among children's hospital systems in Ohio. We found several modifiable, system-level factors and therapies that contribute to PRD that warrant further investigation to identify the best and safest care practices. We also found that there was no standardized measure of exacerbation severity used across the hospitals. The development of such a tool is a critical gap in current practice and is needed to enable definitive comparative effectiveness studies of the management of acute asthma exacerbation.

Risk Factors for Prolonged Length of Stay or Complications During Pediatric Respiratory Hospitalizations

BACKGROUND AND OBJECTIVES

Respiratory illnesses are the leading cause of pediatric hospitalizations in the United States, and a major focus of efforts to improve quality of care. Understanding factors associated with poor outcomes will allow better targeting of interventions for improving care. The objective of this study was to identify patient and hospital factors associated with prolonged length of stay (LOS) or complications during pediatric hospitalizations for asthma or lower respiratory infection (LRI).

METHODS

Cross-sectional study of hospitalizations of patients <18 years with asthma or LRI (bronchiolitis, influenza, or pneumonia) by using the nationally representative 2012 Kids Inpatient Database. We used multivariable logistic regression models to identify factors associated with prolonged LOS (>90th percentile) or complications (noninvasive ventilation, mechanical ventilation, or death).

RESULTS

For asthma hospitalizations(n = 85 320), risks for both prolonged LOS and complications were increased with each year of age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.05-1.07; AOR 1.05, 95% CI 1.03-1.07, respectively for each outcome) and in children with chronic conditions (AOR 4.87, 95% CI 4.15-5.70; AOR 21.20, 95% CI 15.20-29.57, respectively). For LRI hospitalizations (n = 204 950), risks for prolonged LOS and complications were decreased with each year of age (AOR 0.98, 95% CI 0.97-0.98; AOR 0.95, 95% CI 0.94-0.96, respectively) and increased in children with chronic conditions (AOR 9.86, 95% CI 9.03-10.76; AOR 56.22, 95% CI 46.60-67.82, respectively). Risks for prolonged LOS for asthma were increased in large hospitals (AOR 1.67, 95% CI 1.32-2.11) and urban-teaching hospitals (AOR 1.62, 95% CI 1.33-1.97).

CONCLUSIONS

Older children with asthma, younger children with LRI, children with chronic conditions, and those hospitalized in large urban-teaching hospitals are more vulnerable to prolonged LOS and complications. Future research and policy efforts should evaluate and support interventions to improve outcomes for these high-risk groups (eg, hospital-based care coordination for children with chronic conditions).

Role of health education and self-action plan in improving the drug compliance in bronchial asthma

BACKGROUND

Considering the prevalence and associated burden of disease due to bronchial asthma, it is mandatory to obtain an optimal control of the disease and to improve outcomes for these patients. But it has been observed that there is very poor adherence to the inhalational therapy which leads to the suboptimal control of the disease.

OBJECTIVES OF THE STUDY

To study the adherence for aerosol therapy in bronchial asthma patients and to assess the impact of health education and self-action plan in improving the compliance to the therapy.

METHODOLOGY

A prospective study was done in a total of 500 bronchial asthma patients over a period of 2 years. Once included in the study, the patients were followed-up for a total of 12 weeks for calculation of nonadherence to the aerosol therapy. In nonadherent patients, we employed various health education strategies to improve the compliance in these cases.

RESULTS

A total of 500 patients of bronchial asthma who were started on aerosol therapy over duration of 2 years were included in the study. At the end of 12 weeks, it was observed that, only 193 patients (38.6%) had regular compliance and 307 patients (61.4%) were noncompliant to aerosol therapy as prescribed for bronchial asthma. Factors that were associated with poor compliance were: Lower educational level status, poor socioeconomic status, cumbersome regimens, dislike of medication, and distant pharmacies. Nondrug factors that reduced the compliance were: Fears about side effects, anger about condition or its treatment, forgetfulness or complacency, and patient's ill attitudes toward health. After employing the various strategies for improving the compliance in these patients, the compliance increased in 176 patients (57.3%) among the earlier defaulted patients, while the remaining 131 patients (42.7%) were found to be noncompliant even after various educational techniques.

CONCLUSION

Noncompliance in asthma management is a fact of life and no single compliance improving strategy probably will be as effective as a good physician-patient relationship. Optimal self-management allowing for optimization of asthma control by adjustment of medications may be conducted by either self-adjustment with the aid of a written action plan or by regular medical review. Individualized written action plans based on peak expiratory flow are equivalent to action plans based on symptoms.

Economic burden of asthma: a systematic review

BACKGROUND

Asthma is associated with enormous healthcare expenditures that include both direct and indirect costs. It is also associated with the loss of future potential earnings related to both morbidity and mortality. The objective of the study is to determine the burden of disease costs associated with asthma.

METHODS

We performed a systematic search of MEDLINE, EMBASE, CINAHL, CDSR, OHE-HEED, and Web of Science Databases between 1966 and 2008.

RESULTS

Sixty-eight studies met the inclusion criteria. Hospitalization and medications were found to be the most important cost driver of direct costs. Work and school loss accounted for the greatest percentage of indirect costs. The cost of asthma was correlated with comorbidities, age, and disease severity.

CONCLUSION

Despite the availability of effective preventive therapy, costs associated with asthma are increasing. Strategies including education of patients and physicians, and regular follow-up are required to reduce the economic burden of asthma.

Cost of hospitalizing asthma patients in a regional hospital in Thailand

BACKGROUND AND OBJECTIVE

The hospitalization of asthma patients accounts for substantial costs in any health-care system. However, the utilization of medical resources and the cost of hospitalizing asthma patients in Thailand have never been evaluated. This study aimed to evaluate the utilization of health-care resources and itemize the cost of hospitalizing asthma patients in a regional hospital in north-east Thailand.

METHODS

A cross-sectional, retrospective study was conducted at Surin Hospital, a 697-bed, regional hospital in north-east Thailand. The study included 183 adults (> or =15 years of age) who were admitted with acute asthma. Demographic data, resource-utilization parameters and itemized costs were recorded.

RESULTS

The average hospital cost was 5,809.3 +/- 6,587.4 Thai Baht (US $134.5 +/- 152.5) per patient (range, 740-57,980 Thai Baht or US $17.1-1,342.1). Medications were the primary hospital expense (47.2%), followed by hospital charges (13.5%), nursing care (13.0%) and respiratory therapy (12.2%). Fifteen per cent of patients accounted for 45% of total hospital costs. Significant predictors of increased total hospital cost were: (i) age > or =60 years; (ii) presence of comorbid conditions; (iii) admission to the intensive care unit; and/or (iv) prolonged hospital stay.

CONCLUSION

Despite the low unit costs for inpatient care in Thailand, the cost of hospitalizing asthma patients (especially the elderly) constitutes a substantial burden to the health-care system.

Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes

BACKGROUND

A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence.

OBJECTIVE

To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA.

METHODS

A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval.

RESULTS

There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001).

CONCLUSION

Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates.

CLINICAL IMPLICATIONS

Patients with asthma who leave AMA are at increased risk of relapse.

Physician and Hospital Characteristics Related to Length of Stay for Acute Myocardial Infarction Patients A 3-Year Population-Based Analysis

BACKGROUND

The lack of studies on the simultaneous contributions of hospital and physician to the length of stay (LOS) for acute myocardial infarction (AMI) has hampered the development of hospital- and physician-level strategies by clinicians and policymakers. This study used 3 years of population-based data to examine the relationships of physician and hospital characteristics with LOS for AMI patients in Taiwan.

METHODS AND RESULTS

Multiple regression analysis was carried out to explore the relationships, using the 2001-2003 National Health Insurance Research Database of the National Health Research Institute, Taiwan. The study samples were identified by a principal diagnosis of AMI (ICD-9-CM code 410), with a total of 19,907 eligible admissions. The mean LOS was 9.1 days. The results revealed that compared with district hospitals, the LOS was significantly longer in both medical centers and regional hospitals (both p<0.001). The LOS among patients attended by cardiologists was 28.0% shorter than those attended by physicians specializing in surgery, family medicine, or emergency medicine.

CONCLUSIONS

The results of this study demonstrate that there are wide variations among the different types of physician and levels of hospital in the LOS for AMI patients, which highlights the importance of developing national treatment protocols for AMI in order to reduce variations in hospital and physician behaviors.