Costs, charges, and reimbursements for persons with sickle cell disease

Higher hydroxyurea adherence among young adults with sickle cell disease compared to children and adolescents

BACKGROUND

Sickle cell disease (SCD) results in severe complications, such as anaemia and pain episodes. Hydroxyurea (HU) is efficacious in SCD, yet adherence remains low.

OBJECTIVE

To assess the relationship of HU adherence to health care utilization and patients' characteristics.

METHODS

This is a 5-year retrospective chart review. Patients' demographics and medical history were collected from the electronic medical record (EMR). HU adherence was evaluated using foetal haemoglobin "HbF%", mean corpuscular volume "MCV", and absolute neutrophil count "ANC". Age groups included children (<12 years), adolescents (12-17 years), and young adults (≥18 years).

RESULTS

A total of 113 SCD patients on HU were included (median age 14 years, IQR 10-20; 50% female; 88% HbSS). Young adults had significantly higher HU adherence compared to adolescents and children, including higher median HbF% (24.2 vs. 12.4 vs. 8.6, p = .003), MCV (fl) (106.4 vs. 96.2 vs. 95.4, p = .01) and lower ANC (10³/ml) (3.25 vs. 4.9 vs. 4.2, p = .01), respectively. Patients with chronic pain had lower HU adherence (HbF% 15.3 vs. 10.7, p = .04; ANC 3.6 vs. 6.3, p = .002; MCV 102.3 vs. 93.1, p = .1). Patients with higher HbF or MCV and lower ANC had significantly less frequent emergency room visits (r_s=-0.26, p = .01; r_s=-0.23, p = .01; r_s=0.24, p = .01) and hospitalizations (r_s=-0.27, p = .01; r_s=-0.31, p = .01; r_s=0.21, p = .02) as well as shorter length of stays (r_s=-0.27, p = .0045; r_s=-.34, p = 0.004; r_s=0.23, p = .02), respectively. Similar trends in HU adherence and health care utilization were seen in subgroup analysis of only HbSS patients. There was no significant association of HU adherence to patients' sex, socio-economic status, distance from hospital, and HU duration.

CONCLUSIONS

Young adults with SCD had significantly higher HU adherence compared to children and adolescents. Patients with lower HU adherence and/or chronic pain had increased health care utilization. Future studies examining barriers to adherence and evaluating interventions to optimize HU adherence in SCD are warranted.KEY MESSAGESYoung adults with SCD had significantly higher HU adherence, as reflected in their laboratory markers, compared to children and adolescents.Patients with higher HU adherence and/or those without chronic pain had lower or less frequent health care utilization.No significant association of HU adherence to patients' sex, socio-economic status and distance from hospital.

Economic burden of sickle cell disease in Brazil

Background

Sickle cell disease (SCD) may cause several impacts to patients and the whole society. About 4% of the population has the sickle cell trait in Brazil, and 60,000 to 100,000 have SCD. However, despite recognizing the significant burden of disease, little is known about SCD costs.

Objective

To estimate SCD societal costs based on disease burden modelling, under Brazilian societal perspective.

Methods

A disease burden model was built considering the societal perspective and a one-year time horizon, including direct medical and indirect costs (morbidity and mortality). The sum of life lost and disability years was considered to estimate disability-adjusted life years (DALYs). Data from a public database (DATASUS) and the prevalence obtained from literature or medical experts were used to define complications prevalence and duration. Costs were defined using data from the Brazilian public healthcare system table of procedures and medications (SIGTAP) and the human capital method.

Results

Annual SCD cost was 413,639,180 USD. Indirect cost accounted for the majority of burden (70.1% of the total; 290,158,365 USD vs 123,480,816 USD). Standard of care and chronic complications were the main source of direct costs among adults, while acute conditions were the main source among children. Vaso-occlusive crisis represented the complication with the highest total cost per year in both populations, 11,400,410 USD among adults and 11,510,960 USD among children.

Conclusions

SCD management may impose an important economic burden on Brazilian society that may reach more than 400 million USD per year.

Vaso-occlusive crises and costs of sickle cell disease in patients with commercial, Medicaid, and Medicare insurance - the perspective of private and public payers

AIM

To characterize vaso-occlusive crises (VOCs) and describe healthcare costs among commercially-insured, Medicaid-insured, and Medicare-insured patients with sickle cell disease (SCD).

MATERIALS AND METHODS

The IBM Truven Health MarketScan Commercial (2000-2018), Medicaid Analytic eXtract (2008-2014), and Medicare Research Identifiable Files (2012-2016) databases were used to identify patients with ≥2 SCD diagnoses. Study measures were evaluated during a 12-month follow-up period, stratified by annual number of VOCs (i.e. 0, 1, and ≥2).

RESULTS

Among 16,092 commercially-insured patients (mean age = 36.7 years), 35.3% had 1+ VOCs. Mean annual total all-cause healthcare costs were $15,747, $27,194, and $64,555 for patients with 0, 1, and 2+ VOCs, respectively. Total all-cause healthcare costs were mainly driven by inpatient (0 VOC = 31.0%, 1 VOC = 53.1%, 2+ VOCs = 65.4%) and SCD-related costs (0 VOC = 56.4%, 1 VOC = 78.4%, 2+ VOCs = 93.9%). Among 18,287 Medicaid-insured patients (mean age = 28.5 years, fee-for-service = 50.2%), 63.9% had 1+ VOCs. Mean annual total all-cause healthcare costs were $16,750, $29,880, and $64,566 for patients with 0, 1, and 2+ VOCs, respectively. Inpatient costs (0 VOC = 37.2%, 1 VOC = 64.3%, 2+ VOCs = 72.9%) and SCD-related costs (0 VOC = 60.9%, 1 VOC = 73.8%, 2+ VOCs = 92.2%) accounted for a significant proportion of total all-cause healthcare costs. Among 15,431 Medicare-insured patients (mean age = 48.2 years), 55.1% had 1+ VOCs. Mean annual total all-cause healthcare costs were $21,877, $29,250, and $58,308 for patients with 0, 1, and ≥2 VOCs, respectively. Total all-cause healthcare costs were mainly driven by inpatient (0 VOC = 47.9%, 1 VOC = 54.9%, 2+ VOCs = 67.5%) and SCD-related costs (0 VOC = 74.9%, 1 VOC = 84.4%, 2+ VOCs = 95.3%).

LIMITATIONS

VOCs managed at home were not captured. Analyses were descriptive in an observational setting; thus, no causal relationships can be inferred.

CONCLUSIONS

A high proportion of patients experienced VOCs across payers. Furthermore, inpatient and SCD-related costs accounted for a significant proportion of total all-cause healthcare costs, which increased with VOC frequency.

Cost of health care for paediatric patients with sickle cell disease: An analysis of resource use and costs in a European country

BACKGROUND

While multiple studies have examined the cost of health care for one aspect of sickle cell disease care, few have focussed on the overall cost of comprehensive care for sickle cell disease.

METHODS

We conducted a retrospective cohort study of children with sickle cell disease treated in a comprehensive care centre from 1 January 2015 to 31 December 2016. Health care utilisation of included patients was based upon data from two main sources. The clinical practice guideline was used to determine the expected resource use of routine comprehensive care (planned elective care), and the financial claims database was used to estimate real-world resource use associated with acute and inpatient care (additional care).

RESULTS

A total of 125 children with sickle cell disease were analysed. Expenditures for these patients averaged €5049 [standard deviation (SD) €1634] per child per year. Total yearly costs per patient varied considerably, ranging from €669 to €84 010, and less than 15% of patients were responsible for 50% of the health care costs. The majority (37%) of costs was associated with inpatient hospital care, which increased by age group, 27% with diagnostics, 19% with treatment, 11% with outpatients' visits and 6% with emergency care.

CONCLUSION

We have described real-world resource use and expenditures for children with sickle cell disease in a European comprehensive care centre. It seems that costs of a comprehensive approach with effective management in the outpatient setting is favourable when compared to episodic health care.

Healthcare utilization and hydroxyurea adherence in youth with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) complications lead to poor health-related quality of life (HRQOL) and increased healthcare utilization in this population, which could be mitigated with hydroxyurea therapy; however, adherence is suboptimal. We assessed the relationship of healthcare utilization to hydroxyurea adherence and HRQOL amongst youth with SCD.

METHODS

Thirty-four patients with SCD (median age 14 years, IQR 12-18) on hydroxyurea participated in this cross-sectional study and completed Morisky Adherence Scale 8-items and Patient Reported Outcomes Measurement Information System (PROMIS®) HRQOL measures. A medical chart review was conducted to assess healthcare utilization.

RESULTS

Participants with more frequent hospitalizations and emergency room (ER) visits and longer length of stay (LOS) had significantly lower fetal hemoglobin (r_s=-0.44; r_s=-0.45; r_s=-0.46, p < 0.05) and mean corpuscular volume (r_s=-0.47; r_s=-0.42; r_s=-0.48, p < 0.05), respectively. More frequent hospitalizations and ER visits and longer LOS correlated significantly with worse fatigue (r_s=0.51; r_s=0.41; r_s=0.53, p < 0.05), pain (r_s=0.41; r_s=0.38; r_s=0.47, p < 0.05), physical function mobility (r_s=-0.67; r_s=-0.59; r_s=-0.67, p < 0.05), depression (r_s=0.38; r_s=0.31; r_s=0.42, p < 0.05), and social isolation (r_s=0.76; r_s=0.76; r_s=-0.84, p < 0.05), respectively.

CONCLUSIONS

We conclude that increased healthcare utilization in youth with SCD is associated with low adherence to hydroxyurea and worse HRQOL domain scores. It is important emphasize the clinical benefits of high adherence to hydroxyurea, particularly among youth with SCD. Future longitudinal studies are warranted to assess the directionality of these relationships, and may reveal modifiable behavioral factors associated with early changes in hydroxyurea adherence levels.

Association between Participants' Characteristics, Patient-Reported Outcomes, and Clinical Outcomes in Youth with Sickle Cell Disease

Background

Sickle cell disease (SCD) is a chronic debilitating illness. SCD-related complications result in substantial impairment in quality of life (QOL). Our study objective was to assess the relationship of participants' characteristics, QOL, hydroxyurea adherence, and SCD-related clinical outcomes in youth with SCD.

Procedure

A single-center cross-sectional study. Thirty-four youth with SCD enrolled from clinic between January and December 2015. Participants completed PROMIS® measures and ©Modified Morisky Adherence Scale.

Results

Participants had a mean age of 14.8 (SD 2.9) years and 41% were female. Participants' age correlated with fatigue (r_s=0.48; P=0.006), pain (r_s=0.32; P=0.07), and anxiety (r_s=0.33; P=0.06) scores. Participants with chronic pain had worse upper extremity physical function (P=0.05), pain (P=0.04), anxiety (P=0.05), and depression (P=0.05). Males reported significantly higher hydroxyurea adherence (5.4 versus 3.6, P=0.02) compared to females. Participants with chronic pain had more frequent hospitalizations (P=0.02), emergency room visits (P=0.04), and longer total length of hospital stays over 12-month period (P=0.01).

Conclusions

Older and female participants had worse QOL scores, and males reported higher hydroxyurea adherence. Participants with chronic pain reported significant impairment in different QOL domains and had increased healthcare utilization. Future longitudinal studies examining the relationship between participants' characteristics, QOL, hydroxyurea adherence, and SCD-related clinical outcomes are needed.

Emergency Department (ED), ED Observation, Day Hospital, and Hospital Admissions for Adults with Sickle Cell Disease

Introduction

Use of alternative venues to manage uncomplicated vaso-occlusive crisis (VOC), such as a day hospital (DH) or ED observation unit, for patients with sickle cell anemia, may significantly reduce admission rates, which may subsequently reduce 30-day readmission rates.

Methods

In the context of a two-institution quality improvement project to implement best practices for management of patients with sickle cell disease (SCD) VOC, we prospectively compared acute care encounters for utilization of 1) emergency department (ED); 2) ED observation unit; 3) DH, and 4) hospital admission, of two different patient cohorts with SCD presenting to our two study sites. Using a representative sample of patients from each institution, we also tabulated SCD patient visits or admissions to outside hospitals within 20 miles of the patients’ home institutions.

Results

Over 30 months 427 patients (297 at Site 1 and 130 at Site 2) initiated 4,740 institutional visits, totaling 6,627 different acute care encounters, including combinations of encounters. The range of encounters varied from a low of 0 (203 of 500 patients [40.6%] at Site 1; 65 of 195 patients [33.3%] at Site 2), and a high of 152 (5/month) acute care encounters for one patient at Site 2. Patients at Site 2 were more likely to be admitted to the hospital during the study period (88.4% vs. 74.4%, p=0.0011) and have an ED visit (96.9% vs. 85.5%, p=0.0002). DH was used more frequently at Site 1 (1.207 encounters for 297 patients at Site 1, vs. 199 encounters for 130 patients at Site 2), and ED observation was used at Site 1 only. Thirty-five percent of patients visited hospitals outside their home academic center.

Conclusion

In this 30-month assessment of two sickle cell cohorts, healthcare utilization varied dramatically between individual patients. One cohort had more hospital admissions and ED encounters, while the other cohort had more day hospital encounters and used a sickle cell disease observation VOC protocol. One-third of patients sampled visited hospitals for acute care outside of their care providers’ institutions.

Needs Assessment for Patients with Sickle Cell Disease in South Carolina, 2012

OBJECTIVE

We conducted a needs assessment for patients with sickle cell disease (SCD) in South Carolina using statewide administrative data to examine acute care utilization during a defined 12-month period. The data were collected to provide information for state and regional service providers, managed care companies, and policy makers to identify demographic gaps in care and inform policy and educational efforts to improve care.

METHODS

We obtained records on emergency department visits and hospitalizations through patient-based uniform billing data. We stratified analyses of acute care utilization and 30-day readmission rates by patient age, region, and expected payer.

RESULTS

Young adults, those with public insurance, and those who resided in a region with the largest number of patients had the highest rates of acute care utilization and 30-day readmissions. Patients who resided in a largely rural area without access to comprehensive care also had high rates of acute care utilization and readmissions. The pattern of readmissions data suggested that data on 7- or 14-day readmission rates, in addition to data on 30-day readmission rates, could be used as benchmarks of quality of care for adult patients with SCD.

CONCLUSION

Administrative datasets can provide important information on demographic gaps in care for patients with SCD. The results highlight both national and regional issues in the provision of health-care services for patients with SCD.

A retrospective analysis of the cost of hospitalizations for sickle cell disease with crisis in England, 2010/11

BACKGROUND

Sickle cell disease (SCD) is an inherited blood disorder which may result in a broad range of complications including recurring and severe episodes of pain--sickle 'crises'--which require frequent hospitalizations. We assessed the cost of hospitalizations associated with SCD with crisis in England.

METHODS

Hospital Episodes Statistics data for all hospital episodes in England between 2010 and 2011 recording Sickle Cell Anaemia with Crisis as primary diagnosis were used. The total cost of admissions and exceeded length of stay due to SCD were assessed using Healthcare Resource Groups tariffs. The impact of patients' characteristics on SCD admissions costs and the likelihood of incurring extra bed days were also examined.

RESULTS

In 2010-11, England had 6077 admissions associated with SCD with crisis as primary diagnosis. The total cost for these admissions for commissioners was £18,798 255. The cost of admissions increases with age (children admissions costs 50% less than adults). Patients between 10 and 19 years old are more likely to stay longer in hospital compared with others.

CONCLUSION

SCD represents a significant cost for commissioners and the NHS. Further work is required to assess how best to manage patients in the community, which could potentially lead to a reduction in hospital admissions and length of stay, and their associated costs.

Hydroxyurea use and hospitalization trends in a comprehensive pediatric sickle cell program

Background

A decline in hospitalizations and pain episodes among those with sickle cell disease (SCD) who take hydroxyurea (HU) has been shown when compared to pre-HU patterns but paradoxically, when compared to those who have never been treated, HU recipients often have more frequent hospitalizations. This analysis evaluates the impact of increasing usage of HU on trends in hospitalizations and blood transfusions within a large SCD treatment program.

Methods

Eligibility was restricted to patients with Hb SS or Hb Sβ⁰-thalassemia who were 2–18 years old between 2006–2010 and received care at St. Jude Children's Research Hospital (N = 508). Hospitalizations and blood transfusions were calculated for each of the years under study for those exposed and never exposed to HU. Differences in number of hospitalizations before and after HU initiation were compared.

Results

The proportion of patients receiving HU increased by 4% per year on average. In the HU exposed group, a modest decline in mean per-patient hospitalizations and per-patient hospital days occurred, while those never exposed to HU trended toward a slight increase over time. Rates of blood transfusions declined among those on HU but not in patients never exposed to HU. Patients on HU had a median of one fewer hospital admission in the year after initiation of HU, compared to the year prior. Two deaths occurred in the patient population, both of whom were not exposed to HU.

Conclusions

Increasing usage of HU was concurrent with decreased hospitalization rates and blood transfusions. Our results support the utility of HU on decreasing hospitalizations and transfusions for patients with SCD outside of the clinical trial setting.

Shorter hospitalization trends among children with sickle cell disease

BACKGROUND

Vaso-occlusive crises (VOC) contribute to frequent hospitalizations among children with sickle cell disease (SCD). The objective of this study was to determine whether length of stay (LOS) has decreased for VOC hospitalizations between 1997 and 2009.

PROCEDURE

We analyzed pediatric discharges (aged 0-18) with a primary or secondary diagnosis of SCD with crisis from the Kid's Inpatient Database (years 1997, 2003, and 2009), a nationally representative sample of pediatric hospital discharges. We conducted bivariate and multivariate, sample-weighted linear regression analyses to determine associations between independent variables (patient demographics, hospital characteristics, co-diagnoses, and procedures) and LOS.

RESULTS

Both the number (22,661-21,741) and proportion of VOC hospitalizations (0.34-0.29%) among all pediatric hospitalizations marginally decreased between 1997 and 2009 (P < 0.01). Mean LOS decreased from 4.59 to 4.21 days (P < 0.01). For all study years, older age was the only socio-demographic variable associated with longer LOS, controlling for other factors. Between 1997 and 2009, LOS decreased for all age categories, with the largest statistically significant reduction occurring among adolescents (5.69-4.76 days).

CONCLUSIONS

Nationally representative hospital data indicate modest but meaningful reductions in LOS for children with VOC over a 12-year period. Adolescents who typically have the greatest disease severity showed the largest reduction in LOS. However, adolescents continue to account for a large proportion of inpatient stays for VOC. These findings illustrate that the adolescent period is a critical time in the lifespan for targeted intervention.

High resource hospitalizations among children with vaso-occlusive crises in sickle cell disease

BACKGROUND

Vaso-occlusive crises (VOCs) contribute to frequent hospitalizations among children with sickle cell disease (SCD). The objective of this study was to identify factors associated with high resource utilization during hospitalizations for VOC.

PROCEDURE

We analyzed pediatric discharges 0-18 years of age with a primary diagnosis of SCD with crisis from the 2006 Kids' Inpatient Database, a nationally representative sample of pediatric hospital discharges. High resource hospitalizations were defined as those in the highest decile for total charges. We conducted sample-weighted regression analyses to determine associations between independent variables (patient demographics, hospital characteristics, illness severity) and high resource use.

RESULTS

There were 9,893 (0.371%) discharges for children with VOCs. Median total hospitalization charges were $10,691. In multivariate analysis, children 15-18 years of age (odds ratio [OR] 3.39, 95% confidence interval [CI] 2.54-4.53), 10-14 years of age (OR 2.72, 95% CI 2.07-3.59), and 5-9 years of age (OR 1.74, 95% CI 1.30-2.34) had higher odds of high resource hospitalizations compared to children 0-4 years of age. Care in a children's hospital had three times the odds of high resource use compared to care in a general hospital. Discharges with secondary diagnoses including pneumonia (OR 2.46, 95% CI 1.96-3.09) and constipation (OR 1.78, 95% CI 1.31-2.40) were also associated with high resource use.

CONCLUSIONS

Older age and secondary diagnoses were associated with high resource use during VOC hospitalizations. These findings suggest the need to improve adherence to comprehensive care among older children to prevent VOCs and standardize protocols to manage VOC complications.

Sickle cell disease in California: sociodemographic predictors of emergency department utilization

BACKGROUND

Patients with sickle cell disease (SCD) visit emergency departments (EDs) in rates leading to a significant health system burden. However, limited comprehensive evaluations of utilization patterns have been published using data connecting visits to patients across facilities. This study aims to examine sociodemographic predictors of ED utilization in SCD.

PROCEDURE

This retrospective cohort study employed 2007 data from the California Office of Statewide Health Planning and Development (OSHPD). Data included all ED encounters from California hospitals; identifiers connected each visit to an individual patient, across all facilities in the state. Multivariate regression techniques evaluated sociodemographic predictors of utilization while adjusting for confounding variables.

RESULTS

In 2007, 2,920 California patients with SCD made 16,364 ED visits. Adults ≥ 21 years of age had higher ED visit rates than children and were more likely to both be in the highest tier of users and visit multiple facilities. Patients living further from a self-identified provider of comprehensive SCD care had higher rates of ED visits and a lower likelihood of hospitalization from the ED. Publicly insured patients had higher rates of ED visits and were more likely to be in the highest tier of users than were the privately insured or uninsured.

CONCLUSIONS

Adulthood ≥ 21 years of age, distance from comprehensive SCD care, and insurance status are significant predictors of ED utilization in SCD. As a routine source of care decreases ED utilization, these findings prompt concern that these factors act as barriers to accessing comprehensive SCD care.

Medical-legal partnership: impact on patients with sickle cell disease

OBJECTIVE

To determine the types of legal problems addressed by the Health Law Partnership (HeLP) and the impact of the legal interventions in pediatric patients with sickle cell disease (SCD) or its variants. We hypothesized that an interdisciplinary team that includes lawyers would positively affect the social determinants of health that affect patients with SCD.

METHODS

The HeLP database was retrospectively queried for all patients with the diagnosis of SCD or 1 of its variants who had been seen by the lawyers of HeLP between April 2004 and September 2010. Data collected in this cohort of patients included income level of the patient/client, the initial presenting problems, any patient/parent/guardian problems identified during the legal checkup, and the type of legal assistance provided. Estimated annualized financial outcomes were calculated.

RESULTS

From April 2004 through September 2010, 71 parents/guardians with 76 children with SCD were referred to the HeLP for legal intervention. Of the 71 parents/guardians, 33 were at <100% of the federal poverty level. There were 106 initial case problems identified in the 71 parents/guardians; 51 of 106 problems were directly related to the child. An additional 93 issues were identified during the legal checkup. Of 106 cases, 99 were closed with 21 resulting in a measurable gain of benefits.

CONCLUSIONS

In a cohort of families of children with SCD, incorporating access to legal services as part of the care plan resulted in a positive impact on these patients/parents/guardians. The impact was directly attributable to the intervention of the HeLP.

Sickle-cell disease in California: a population-based description of emergency department utilization

BACKGROUND

Acute and chronic clinical manifestations of sickle-cell disease (SCD) lead to significant healthcare utilization, especially of the emergency department (ED). Limited population-level data are available in SCD with the ability to connect patients to visits, leaving us with minimal description of utilization patterns.

PROCEDURE

Using ED discharge data with links between patients and visits, we sought to describe the California SCD population and its ED utilization patterns across facilities. Non-public California Office of Statewide Health Planning and Development data employ unique patient identifiers, linking patients, and visits.

RESULTS

SCD patients of all ages are heavily reliant on Medicaid (46%). The majority of SCD Californians visit an ED more than once during a year (69%), but only a minority use more than one facility during a year (34%). However, adults with SCD have multiple visits and utilize multiple EDs in higher proportions than do children (72% vs. 60% and 40% vs. 21%, respectively). A higher proportion of visits to the ED are made by SCD adults, but a higher proportion of visits by children result in hospital admission. Uninsured adults outnumber uninsured children (16% vs. 5%).

CONCLUSIONS

ED utilization by the California SCD population is described on a population level. Utilization patterns by adults point towards increased utilization in the population no longer eligible for Title V pediatric coverage for their disease. Further investigation using population-level socioeconomic and geographic correlates is warranted to evaluate the factors leading to ED utilization in SCD.

Health status and healthcare use in a national sample of children with sickle cell disease

BACKGROUND

There is a paucity of population-based data describing health status and use of health services among children with sickle cell disease (SCD).

PURPOSE

This study provides estimates of co-occurring conditions, health impact and utilization, and barriers to care for a national sample of children with SCD.

METHODS

Data were derived from the 1997-2005 National Health Interview Survey Child Sample Core. The study included 192 children aged 0-17 years with SCD whose race was reported as black or African-American, and 19,335 children without SCD of the same age and race. Parents or other knowledgeable adults reported on medical and developmental conditions, health status, and healthcare use and access.

RESULTS

After adjusting for demographic characteristics, black children with SCD had higher odds of frequent severe headaches or migraines, intellectual disabilities, regular use of prescription medication, and fair or poor health status compared with black children without SCD. While healthcare and special education services use were generally higher for black children with SCD than for black children in the general population, those with SCD also had higher odds of reporting delays in accessing health care.

CONCLUSIONS

The health burden for children with SCD and their families is profound and may be exacerbated by barriers to accessing comprehensive medical care. Additional study of the extent of unmet needs for U.S. children with SCD is warranted.

Health care utilization and expenditures for privately and publicly insured children with sickle cell disease in the United States

BACKGROUND

There are no current national estimates on health care utilization and expenditures for US children with sickle cell disease (SCD).

PROCEDURE

We used the MarketScan Medicaid Database and the MarketScan Commercial Claims and Encounters Database for 2005 to estimate health services use and expenditures. The final samples consisted of 2,428 Medicaid-enrolled and 621 privately insured children with SCD.

RESULTS

The percentage of children with SCD enrolled in Medicaid with an inpatient admission was higher compared to those privately insured (43% vs. 38%), yet mean expenditures per admission were 35% lower ($6,469 vs. $10,013). The mean number of emergency department (ED) visits was 49% higher for Medicaid-enrolled children compared to those with private insurance (1.36 vs. 0.91), but mean expenditures per ED visit were 28% lower. The mean number of non-ED outpatient visits was similar (12.6 vs. 11.5) but mean expenditures were 40% lower for the Medicaid-enrolled children ($3,557 vs. $5,908). The mean expenditures on drug claims were higher among those with Medicaid than private insurance ($1,049 vs. $531). Mean total expenditures for children with SCD enrolled in Medicaid were 25% lower than for privately insured children ($11,075 vs. $14,722). The samples were comparable with respect to SCD-related inpatient discharge diagnoses and use of outpatient blood transfusions.

CONCLUSIONS

Children with SCD enrolled in Medicaid had lower expenditures than privately insured children, despite higher utilization of medical care, which indicates lower average reimbursements. Research is needed to assess the quality of care delivered to Medicaid-enrolled children with SCD and its relation to health outcomes.

The cost of health care for children and adults with sickle cell disease

Although sickle cell disease (SCD) is marked by high utilization of medical resources, the full cost of care for patients with SCD, including care not directly related to SCD, is unknown. The purpose of this study was to estimate the total cost of medical care for a population of children and adults with SCD. We used data from individuals diagnosed with SCD enrolled in the Florida Medicaid program during 2001-2005 to estimate total, SCD-related, and non-SCD-related cost per patient-month based on patient age at the time of health care use. Across the 4,294 patient samples, total health care costs generally rose with age, from $892 to $2,562 per patient-month in the 0-9- and 50-64-year age groups, respectively. Average cost per patient-month was $1,389. Overall, 51.8% of care was directly related to SCD, the majority of which (80.5%) was associated with inpatient hospitalizations. Notably, non-SCD-related costs were substantially higher than those reported for the general US population. These results suggest a discounted (3% discount rate) lifetime cost of care averaging $460,151 per patient with SCD. Interventions designed to prevent SCD complications and avoid hospitalizations may reduce the significant economic burden of the disease.

Healthcare utilization and expenditures for low income children with sickle cell disease

BACKGROUND

While multiple studies have examined the healthcare burden of sickle cell disease (SCD) in adults, few have specifically focused on healthcare utilization and expenditures in children. The objective of this study was to characterize the healthcare utilization and costs associated with the care of low-income children with SCD in comparison to other children of similar socioeconomic status.

PROCEDURE

For the study period, 2004-2007, we conducted a retrospective, cross-sectional descriptive analysis of administrative claims data from a managed care plan exclusively serving low-income children with Medicaid and the State Children's Health Insurance Plan (SCHIP). Patient demographics, continuity of insurance coverage, healthcare utilization, and expenditures were collected for all children enrolled with SCD and the general population within the health plan for comparison.

RESULTS

On average, 27% of members with SCD required inpatient hospitalization and 39% utilized emergency care in a given calendar year. Both values were significantly higher than those of the general health plan population (P < 0.0001). Across the study period, 63% of members with SCD averaged one well child check per year and 10% had a minimum of one outpatient visit per year to a hematologist for comprehensive specialty care.

CONCLUSIONS

Low-income children with SCD demonstrate significantly higher healthcare utilization for inpatient care, emergency center care, and home health care compared to children with similar socio-demographic characteristics. A substantial proportion of children with SCD may fail to meet minimum guidelines for outpatient primary and hematology comprehensive care.

Costs, quality of life, treatment satisfaction and compliance in patients with beta-thalassemia major undergoing iron chelation therapy: the ITHACA study

OBJECTIVES

Iron chelation treatment (ICT) in beta-thalassemia major (beta-TM) patients undergoing blood transfusions can cause low satisfaction, low compliance, with possible negative consequences on treatment success, patients' wellbeing, and costs. The purpose was to estimate the societal burden attributable to beta-TM in terms of direct and indirect costs, health-related quality-of-life (HRQoL), satisfaction and compliance with ICT in patients undergoing transfusions and ICT.

RESEARCH DESIGN AND METHODS

The naturalistic, multicenter, longitudinal Italian-THAlassemia-Cost-&-Outcomes-Assessment (ITHACA) cost-of-illness study was conducted involving patients of any age, on ICT for at least 3 years, who were enrolled at 8 Italian Thalassemia Care Centers. Costs were estimated from the societal perspective, quantified with tariffs, prices, or net earnings valid in 2006.

RESULTS

One-hundred and thirty-seven patients were enrolled (median age = 28.3, 3-48 years, 49.6% male) and retrospectively observed for a median of 11.6 months. Mean direct costs were euro1242/patient/month, 55.5% attributable to ICT, 33.2% attributable to transfusions. Relevant quantity and quality of productivity was lost. Both physical and mental components of HRQoL were compromised. Little difficulties remembering to take ICT and positive satisfaction with the perceived effectiveness of therapy were declared, but not good levels of satisfaction with acceptance, perception of side effects and burden of ICT.

CONCLUSIONS

The management of beta-TM patients undergoing transfusions and ICT is efficacious, although costly, but overall benefits were not always perceived as optimal by patients. Efforts must be focused to improve patients' acceptance and satisfaction with their therapy; this would contribute to a better compliance and hence an increase in treatment effectiveness and patients' overall wellbeing, with expected improved allocation of human and economic resources.

Variation in hospitalizations and hospital length of stay in children with vaso-occlusive crises in sickle cell disease

OBJECTIVE

As a measure of morbidity of vaso-occlusive crises (VOC) in sickle cell disease, we used a national hospital discharge database, the Kids' Inpatient Database (KID), to determine the number of hospitalizations and hospital length of stay (LOS) by age.

PROCEDURE

Nationally weighted hospital discharges for VOC in children with sickle cell disease were analyzed using data from 2,500 hospitals in the Healthcare Cost and Utilization Project (HCUP) KID. Number of discharges and hospital LOS by age group were analyzed. Multiple linear regression was performed to analyze the effect of age on hospital LOS.

RESULTS

There were 20,271 hospital discharges for children with sickle cell disease and VOC. Mean age (SD) at time of admission was 10.6 (5.38) years with 49% being males. The overall average LOS was 4.4 days. There were differences in the number of hospital discharges by age group (P < 0.001). In addition, there was a difference in LOS by age group (P < 0.0001). After controlling for potential confounders, older age was associated with a longer LOS (P < 0.0001).

CONCLUSIONS

Older children with sickle cell disease and VOC have increased hospitalizations and longer LOS. This age effect should be considered when measuring the effect of an intervention on hospital utilization in these children.

Identifying undiagnosed primary immunodeficiency diseases in minority subjects by using computer sorting of diagnosis codes

BACKGROUND

Primary immunodeficiency diseases occur in all populations, but these diagnoses are rarely made in minority subjects in the United States.

OBJECTIVE

We sought to develop and validate a method to identify patients without diagnoses but with immunodeficiency in an urban hospital with a substantial minority patient population.

METHODS

We developed a scoring algorithm on the basis of International Classification of Disease, Ninth Revision (ICD-9) codes to identify all hospitalized patients age 60 years or less who had been given a diagnosis of 2 or more of 174 ICD-9-coded complications associated with immunodeficiency. Codes were weighted for severity and expressed as a sum for all admissions between October 1, 1995, and December 31, 2002. Patients with, for example, cancer or HIV or those after transplantation or major surgery were excluded. Demographic features of subjects with aggregated ICD-9 codes suggestive of immunodeficiency were compared with those of other inpatients; 59 computer-selected subjects were then tested for immune defects.

RESULTS

The computer-identified group contained 533 patients (0.4% of all inpatients), who had been hospitalized 2683 times. The median age was 6.6 years. Sixty-five percent were African American or Hispanic, and 61% were insured by Medicaid, which is significantly more than other inpatients younger than 60 years of age (median age, 32.6 years; 37% minority, 27% insured by Medicaid; P<.0001). Primary immunodeficiency was found in 17 (29%) of the 59 subjects tested. Thirteen other patients had secondary immune defects, and 86% of immunodeficient subjects were Hispanic or African American.

CONCLUSIONS

An ICD-9-based scoring algorithm identifies patients demographically different from other hospitalized subjects who have multiple illnesses suggestive of immunodeficiency. This group contains undiagnosed minority patients with immunodeficiency.

Declining stroke rates in Californian children with sickle cell disease

Although the Stroke Prevention Trial in Sickle Cell Anemia (STOP) demonstrated the efficacy of blood transfusions for primary stroke prevention in high-risk children with sickle cell disease (SCD) in 1998, the impact of this trial on public health has not been studied. Our objective was to determine whether stroke rates in Californian children with SCD have declined since 1998. Using a California-wide hospital discharge database, we identified all first admissions for stroke in children with SCD from 1991 through 2000. Annual stroke incidence rates were calculated as the number of admissions divided by the estimated population of Californian children with SCD in that year. For 1991-2000, 93 children with SCD were admitted to Californian hospitals with a first stroke during 12 030 person-years of follow-up; 92.5% were ischemic and 7.5% hemorrhagic. Overall, the rate of first stroke was 0.77/100 person-years. For the study years 1991-1998, the rate for first stroke was 0.88/100 person-years compared to 0.50 in 1999 and 0.17 in 2000 (P <.005 for trend). Since the publication of the STOP study in 1998, annual rates of admissions for first stroke for Californian children with SCD have declined.

Accuracy of identification of patients with immune thrombocytopenic purpura through administrative records: a data validation study

Administrative data are commonly used to estimate the prevalence of a disease, but the validity of the coding system needs to be evaluated before its use. We assessed the validity of the International Classification of Disease, 9(th) version, Clinical Modification (ICD-9-CM) code of 287.3 for identifying patients with immune thrombocytopenic purpura (ITP). Administrative data from inpatients and outpatients seen were retrieved if the patient or insurer was billed with one of three ICD-9-CM codes for thrombocytopenic disorders, 287.3, 287.4, and 287.5, as a primary or secondary diagnosis; or was physician-identified as having ITP. The electronic medical records for these patients were systematically reviewed to identify patients with ITP and with non-ITP diagnoses. Sensitivity, specificity, positive and negative predictive values, and kappa scores were calculated separately for inpatients and outpatients. Four-hundred eighteen records were reviewed. Among inpatients, the sensitivity of code 287.3 for indicating a diagnosis of ITP was 100% [95% confidence interval 94-100%]. The specificity was 89% [95% confidence interval 84-94%]. The percent agreement was 92%, and the kappa statistic was 0.80. For outpatients, the sensitivity of the billing code 287.3 was 84% [95% confidence interval 76-91%], a conservative estimate because of how the patients with other diagnoses were selected. The specificity for outpatients was 66% [95% confidence interval 56-76%]. ICD-9-CM code 287.3 in administrative billing data is likely to be sufficiently sensitive and specific, particularly when inpatient data are used, for the estimation of the prevalence of ITP.

Sickle cell anaemia: epidemiology and cost of illness

The purpose of this paper was to review the research examining the epidemiology of and costs associated with sickle cell anaemia (SCA). Although there is general acceptance that Black populations are at greatest risk of the disease, estimates of disease incidence and prevalence vary greatly among different Black populations. In addition, the sickle cell haemoglobinopathy poses a health problem to many other ethnic groups, including populations native to Italy, Greece, Turkey, Saudi Arabia, India, Pakistan, Bangladesh, China, and Cyprus. As penicillin prophylaxis has been shown to reduce the risk of sepsis among children with SCA, many governments have established newborn screening programmes to improve the health outcomes for patients with this disease. As a group, patients with SCA incur large numbers of hospital admissions, emergency department visits, and outpatient visits, often at substantial costs, hence, obtaining adequate health insurance is a problem for many patients. A common theme present in studies reviewed in this article is that a small proportion of patients tends to account for a majority of the total healthcare costs. As new diagnostic methods and treatment options become available, balancing costs associated with SCA and quality of healthcare will continue to present challenges to many healthcare providers and insurers.