Health care resource utilization and costs in patients with painful diabetic neuropathy treated with 10 kHz spinal cord stimulation therapy

BACKGROUND: Diabetic peripheral neuropathy, a common comorbidity of diabetes, is a neurodegenerative disorder that targets sensory, autonomic, and motor nerves frequently associated with painful diabetic neuropathy (PDN). PDN carries an economic burden as the result of reduced work and productivity. A recent multicenter randomized controlled trial, SENZA-PDN (NCT03228420), assessed the impact of high-frequency (10 kHz) spinal cord stimulation (SCS) on pain relief. The effects of high-frequency SCS on health care resource utilization and medical costs are not known. OBJECTIVE: To evaluate the effect of high-frequency (10 kHz) SCS on health care resource utilization (HRU) and medical costs in patients with PDN using data from the SENZA-PDN trial. METHODS: Participants with PDN were randomly assigned 1:1 to receive either 10 kHz SCS plus conventional medical management (CMM) (SCS treatment group) or CMM alone (CMM treatment group). Patient outcomes and HRU up to the 6-month follow-up are reported here. Costs (2020 USD) for each service was estimated based on publicly available Medicare fee schedules, Medicare claims data, and literature. HRU metrics of inpatient and outpatient contacts and costs are reported as means and SDs. Univariate and bivariate analyses were used to compare SCS and CMM treatment groups at 6 months. RESULTS: At 6-month follow up, the SCS arm experienced approximately half the mean rate of hospitalizations per patient compared with the CMM treatment group (0.08 vs 0.15; P = 0.066). The CMM treatment group's total health care costs per patient were approximately 51% higher compared with the SCS treatment group (equivalent to mean annual cost per patient of $9,532 vs $6,300). CONCLUSIONS: Our analysis of the SENZA-PDN trial indicates that the addition of 10 kHz SCS therapy results in lower rates of hospitalization and consequently lower health care costs among patients with PDN compared with those receiving conventional management alone.

Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah

In the United States, the top 1% and top 5% of health care spenders account for 23% and 50% of total health care spending, respectively. These high spenders have been coined the term super utilizers (SU). The aim of this study was to identify the characteristics associated with these patients to aid in developing public health interventions aimed at transitioning patients out of the SU category and thus ultimately helping to control health care costs. The authors utilized the Utah All-Payer Claims Database and Utah Population Database from 2013 to 2015 to identify demographics, comorbid conditions, health care utilization, and cost characteristics of persistent super utilizers (PSU) (≥3 hospitalizations per year for 3 years) of health care compared with persistent nonsuper utilizers (PNSU) (<3 hospitalizations per year for 3 years). Multivariable logistic regression was utilized to identify the characteristics associated with PSU versus PNSU. Higher outpatient/Emergency Department/noninpatient (eg, visits with imaging and Centers for Medicare & Medicaid Services preventive visits) health care utilization and spending, and prevalence of comorbid disease and psychosocial conditions were associated with PSU. In multivariable analysis, factors such as heart disease, chronic kidney disease (CKD), diabetes, alcohol abuse, and depression were statistically significantly associated with higher odds of PSU, with the most noteworthy being CKD (odds ratio [OR] 6.85, 95% confidence interval [95% CI] 5.84-8.02; P < 0.001), alcohol abuse (OR 5.90, 95% CI 4.49-7.69; P < 0.001), and heart diseases (OR 4.41, 95% CI 3.74-5.18; P < 0.001). The annual health care cost of a PSU is about 11.5 times greater than a PNSU ($54,776 vs. $4801; P < 0.001).

Association of chronic pain with comorbidities and health care utilization: a retrospective cohort study using health administrative data

ABSTRACT

Health administrative data provide a potentially robust information source regarding the substantial burden chronic pain exerts on individuals and the health care system. This study aimed to use health administrative data to estimate comorbidity prevalence and annual health care utilization associated with chronic pain in Newfoundland and Labrador, Canada. Applying the validated Chronic Pain Algorithm to provincial Fee-for-Service Physician Claims File data (1999-2009) established the Chronic Pain (n = 184,580) and No Chronic Pain (n = 320,113) comparator groups. Applying the Canadian Chronic Disease Surveillance System coding algorithms to Claims File and Provincial Discharge Abstract Data (1999-2009) determined the prevalence of 16 comorbidities. The 2009/2010 risk and person-year rate of physician and diagnostic imaging visits and hospital admissions were calculated and adjusted using the robust Poisson model with log link function (risks) and negative binomial model (rates). Results indicated a significantly higher prevalence of all comorbidities and up to 4 times the odds of multimorbidity in the Chronic Pain Group (P-value < 0.001). Chronic Pain Group members accounted for 58.8% of all physician visits, 57.6% of all diagnostic imaging visits, and 54.2% of all hospital admissions in 2009/2010, but only 12% to 16% of these were for pain-related conditions as per recorded diagnostic codes. The Chronic Pain Group had significantly higher rates of physician visits and high-cost hospital admission/diagnostic imaging visits (P-value < 0.001) when adjusted for demographics and comorbidities. Observations made using this methodology supported that people identified as having chronic pain have higher prevalence of comorbidities and use significantly more publicly funded health services.

Chronic non-cancer pain and its association with healthcare use and costs among individuals with obstructive sleep apnea

Aim: To evaluate the impact of chronic non-cancer pain (CNCP) on healthcare use and costs among individuals diagnosed with obstructive sleep apnea (OSA). Materials & methods: Using the IQVIA PharMetrics^® Plus database, we identified individuals (18-64 years old) during 2007-2014, divided into two groups: OSA + CNCP versus OSA-only. Generalized linear models were used to analyze binary and count outcomes. Results: Relative to OSA-only controls, OSA + CNCP cases had increased odds for inpatient and emergency department visits and higher rates for physician office visits, non-physician outpatient visits, and prescription drug fills. Relative to controls, direct healthcare costs for cases were higher, primarily driven by inpatient and non-physician outpatient visit costs. Conclusion: Relative to OSA-only controls, OSA + CNCP cases displayed increased healthcare use and costs across all points of service.

Cost-effectiveness of a collaborative care program for managing major depression and chronic musculoskeletal pain in primary care: Economic evaluation alongside a randomized controlled trial

BACKGROUND

We designed a collaborative care program for the integrated management of chronic musculoskeletal pain and depression, which frequently coexist in primary care patients. The aim of this study was to evaluate the cost-effectiveness of this program compared with care as usual.

METHODS

We performed a cost-effectiveness analysis alongside a randomized clinical trial. Results were monitored over a 12-month period. The primary outcome was the incremental cost-effectiveness ratio (ICER). We performed cost-effectiveness analyses from the perspectives of the healthcare system and society using an intention-to-treat approach with imputation of missing values.

RESULTS

We evaluated 328 patients (167 in the intervention group and 161 in the control group) with chronic musculoskeletal pain and major depression at baseline. From the healthcare system perspective, the mean incremental cost was €234 (p = .17) and the mean incremental effectiveness was 0.009 QALYs (p = .66), resulting in an ICER of €23,989/QALY. Costs from the societal perspective were €235 (p = .16), yielding an ICER of €24,102/QALY. These estimates were associated with a high degree of uncertainty illustrated on the cost-effectiveness plane.

CONCLUSIONS

Contrary to our expectations, the collaborative care program had no significant effects on health status, and although the additional costs of implementing the program compared with care as usual were not high, we were unable to demonstrate a favorable cost-effectiveness ratio, largely due to the high degree of uncertainty surrounding the estimates.

Emergency Department Visits and Overnight Hospital Stays among Persons Aged 50 and Older Who Use and Misuse Opioids

Opioid misuse and adverse health outcomes are serious problems among the 50+ age group. Using data from the 2015-2016 National Survey of Drug Use and Health (N = 17,608 respondents aged 50+), we examined emergency department (ED) visits and hospitalizations among those who reported (1) no opioid use in the past year (61.4%); (2) opioid use but no misuse (36.0%); and (3) opioid misuse (2.6%). Compared to nonusers, those who reported use but no misuse or misuse had greater odds of any ED visit (AOR = 2.24, 95% CI = 2.05-2.47 and AOR = 1.99, 95% CI = 1.55-2.56, respectively) and hospitalization (AOR = 2.87, 95% CI = 2.48-3.32 and AOR = 2.57, 95% CI = 1.88-3.51, respectively); however, only those who used but did not misuse had more ED visits and longer hospital stays than nonusers. Those who misused opioids were younger, but they did not differ from those who used but did not misuse on ED visits and hospitalizations. Since those who misused had significantly higher rates of other substance use disorders and mental health problems than those who used but did not misuse, treatment of opioid misuse should also include help for these problems. Economically disadvantaged older adults suffering from chronic pain and opioid misuse also need assistance accessing effective pain treatment.

A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain

OBJECTIVE

To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization.

PATIENTS AND METHODS

We retrospectively evaluated health care utilization changes among 772 patients receiving long-term opioid therapy for chronic noncancer pain enrolled in a CSA between July 1, 2015, and December 31, 2015. We ascertained patient characteristics and utilization 12 months before and after CSA enrollment. Decreased utilization was defined as a decrease of 1 or more hospitalizations or emergency department visits and 3 or more outpatient primary and specialty care visits. Multivariate modeling assessed demographic characteristics associated with utilization changes.

RESULTS

The 772 patients enrolled in an opioid CSA during the study period had a mean ± SD age of 63.5±14.9 years and were predominantly female, white, and married. The CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14-0.19) and increased diagnostic radiology services (OR, 1.22; 95% CI, 1.02-1.47). After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have reduced hospitalizations (adjusted OR, 2.8; 95% CI, 1.3-6.0; P=.008), reduced outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2-3.2; P=.005), and reduced specialty care visits (adjusted OR, 2.0; 95% CI, 1.2-3.3; P=.006).

CONCLUSION

For patients receiving long-term opioid therapy for chronic noncancer pain, CSA enrollment is associated with reductions in primary care visits and increased radiologic service utilization. Patients with greater comorbidity were more likely to have reductions in hospitalizations, outpatient primary care visits, and outpatient specialty clinic visits after CSA enrollment. The observational nature of the study does not allow the conclusion that CSA implementation is the primary reason for these observed changes.

Health care utilization by veterans prescribed chronic opioids

Purpose

Ambulatory resources such as telephone calls, secure messages, nurse visits, and telephone triage are vital to the management of patients on chronic opioid therapy (COT). They are also often overlooked as health care services and yet to be broadly studied. The aim of the present study was to describe the Veterans Affairs (VA) health care utilization by patients based on COT, type, and amount of opioids prescribed.

Patients and methods

A retrospective chart review was done on 617 patients on COT at a VA primary care clinic. Instances of health care utilization (emergency department visits [EDVs], hospitalizations, clinic visits, telephone triage calls, telephone calls/secure messages/nurse visits) were obtained.

Results

Patients were likely to have more telephone calls, secure messages, or nurse visits if they were prescribed a schedule II opioid or if they were on more than one opioid. Model-based results found that patients on COT were more likely to have EDVs, telephone triage calls, and clinic contact compared to patients who were not on chronic opioids.

Conclusion

The results are despite having a Patient Aligned Care Team, which is the VA’s patient-centered medical home. This suggests that reducing health care utilization for patients on COT may not be possible with just a primary care involvement.

Pain Agreements and Healthcare Utilization in a Veterans Affairs Primary Care Population: A Retrospective Chart Review

Introduction

The prevalence of chronic pain is enormous. In America, the management of chronic pain and opioids remains a critical focus. Guidelines recommend pain agreements as part of the management of chronic pain and opioids; however, evidence of improvement in patient outcomes is lacking. An aspect of patient outcome includes utilization of healthcare resources, such as emergency department visits and hospitalizations. It remains uncertain whether the use of pain agreements lessens healthcare utilization.

Methods

Retrospective chart review of a Midwest Veterans Affairs primary care clinic. Subjects were veterans on chronic opioids between 1 April 2014 and 1 April 2015. Outcome measures included emergency department visits, hospitalizations, clinic visits, telephone triage, telephone/secure messages, and nurse visits.

Results

The charts of 635 veterans on chronic opioids were reviewed. Of these, 295 were on a pain agreement. There were no significant differences in demographics, medical, or psychiatric diagnoses between patients with and without pain agreements. There were significant differences in opioid schedule and number of opioids based on pain agreement (p < 0.01). Patients on pain agreements did not utilize healthcare resources less than patients without a pain agreement. In fact, patients on pain agreements were likely to have more telephone calls, secure messages, and nurse visits compared with patients not on an agreement (p = 0.02).

Conclusions

Pain agreements are becoming standard of care for chronic pain management. However, there continues to be a lack of evidence demonstrating improvement in healthcare outcomes with their use, despite guideline recommendations. Further studies are needed to examine specific patient outcomes, such as overdose and death, in regard to pain agreements.

Funding

Advancing a Healthier Wisconsin—Patient-Centered Outcomes Research Program.