Medical cost trajectories and onsets of cancer and noncancer diseases in US elderly population

Quantifying the Value of Reduced Health Disparities: Low-Dose Computed Tomography Lung Cancer Screening of High-Risk Individuals Within the United States

OBJECTIVE

This study aimed to measure the value of increasing lung cancer screening rates for high-risk individuals and its impact on health disparities.

METHODS

The model estimated changes in health economic outcomes if low-dose computed tomography screening increased from current to 100% compliance, following clinical guidelines. Current low-dose computed tomography screening rates were estimated by income, education, and race, using 2017-2019 Behavioral Risk Factor Surveillance System data. The model contained a decision tree module to segment the population by screening outcomes and a Markov chain module to estimate cancer progression over time. Model parameters included information on survival, quality of life, and costs related to cancer diagnosis, treatment, and adverse events. Distributional cost-effectiveness analysis estimated the net monetary value from reduced health disparities-measured using quality-adjusted life expectancy-across income, education, and race groups. Outcomes were assessed over 30 years.

RESULTS

Lung cancer screening eligibility using US Preventive Services Task Force guidelines was higher for individuals with income <$15 000 (47.2%) and without a high-school education (46.1%) than individuals with income >$50 000 (16.6%) and with a college degree (13.5%), respectively. Increasing lung cancer screening to 100% compliance was cost-effective ($64 654 per quality-adjusted life-year) and produced economic value by up to $560 per person ($182.1 billion for United States overall). Up to 32.2% of the value was due to reductions in health disparities.

CONCLUSIONS

Significant value in increasing lung cancer screening rates derived from reducing health disparities. Policy makers and clinicians may not be appropriately prioritizing cancer screening if value from reducing health disparities is unconsidered.

Feasibility of a prehabilitation programme dedicated to older patients with cancer before complex medical-surgical procedures: the PROADAPT pilot study protocol

BACKGROUND

Ageing is associated with an increased prevalence of comorbidities and sarcopenia as well as a decline of functional reserve of multiple organ systems, which may lead, in the context of the disease-related and/or treatment-related stress, to functional deconditioning. The multicomponent 'Prehabilitation & Rehabilitation in Oncogeriatrics: Adaptation to Deconditioning risk and Accompaniment of Patients' Trajectories (PROADAPT)' intervention was developed multiprofessionally to implement prehabilitation in older patients with cancer.

METHODS

The PROADAPT pilot study is an interventional, non-comparative, prospective, multicentre study. It will include 122 patients oriented to complex medical-surgical curative procedures (major surgery or radiation therapy with or without chemotherapy). After informed consent, patients will undergo a comprehensive geriatric assessment and will be offered a prehabilitation kit that includes an advice booklet with personalised objectives and respiratory rehabilitation devices. Patients will then be called weekly and monitored for physical and respiratory rehabilitation, preoperative renutrition, motivational counselling and iatrogenic prevention. Six outpatient visits will be planned: at inclusion, a few days before the procedure and at 1, 3, 6 and 12 months after the end of the procedure. The main outcome of the study is the feasibility of the intervention, defined as the ability to perform at least one of the components of the programme. Clinical data collected will include patient-specific and cancer-specific characteristics.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ile de France 8 ethics committee on 5 June 2018. The results of the primary and secondary objectives will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03659123. Pre-results of the trial.

Cost trajectories as a measure of functional resilience after hospitalization in older adults

BACKGROUND

Administrative data sets lack functional measures.

AIM

We examined whether trajectories of cost can be used as a marker of functional recovery after hospitalization.

METHODS

Secondary analysis of the National Health and Aging Trends Study merged with Centers for Medicare and Medicaid Services data. Community-dwelling participants with a first hospitalization occurring after any annual survey were included (N = 937). Monthly total cost trajectories were constructed for the 3 months before and 3 months following hospitalization. Growth mixture models identified groups of patients with similar trajectories. The association of cost classes with five functional outcomes was examined using multivariate models, controlling for pre-hospitalization function and lead time.

RESULTS

Four cost trajectory classes describing common recovery patterns were identified-persistently high, persistently moderate, low-spike-recover, and low variable. Cost class membership was significantly associated with change in Activities of Daily Living (ADL), instrumental ADL, Short Physical Performance Battery, and grip strength (p < 0.005), but not gait speed (p = 0.08). The proportion of patients who maintained or improved SPPB score was 46.8% in the persistently high, 49.2% in the persistently moderate, 52.7% in the low-spike-recover, and 57.2% in the low-variable groups. In models adjusted for known predictors of functional outcome, the magnitude and direction of association was maintained but significance was lost, indicating that cost trajectories' mirror is mediated by predictors of recovery not available in administrative data.

CONCLUSION

Cost trajectories and total costs are associated with functional recovery following hospitalization in older adults. Cost may be useful as a measure of recovery in administrative data.

Financial burden of cancer care under the Affordable Care Act: Analysis of MEPS-Experiences with Cancer Survivorship 2011 and 2016

PURPOSE

To examine whether the implementation of Affordable Care Act (ACA) reduced the financial burden associated with cancer care among non-elderly cancer survivors.

METHODS

Using data from the MEPS-Experiences with Cancer Survivorship Survey, we examined whether there was a difference in financial burden associated with cancer care between 2011 (pre-ACA) and 2016 (post-ACA). Two aspects of financial burden were considered: (1) self-reported financial burden, whether having financial difficulties associated with cancer care and (2) high-burden spending, whether total out-of-pocket (OOP) spending incurred in excess of 10% or 20% of family income. Generalized linear regression models were estimated to adjust the OOP expenditures (reported in 2016 US dollar).

RESULTS

Our sample included adults aged 18-64 with a confirmed diagnosis of any cancer in 2011 (n = 655) and in 2016 (n = 490). There was no apparent difference in the prevalence of cancer survivors reporting any financial hardship or being with high-burden spending between 2011 and 2016. The mean OOP decreased by $268 (95% CI, - 384 to - 152) after the ACA. However, we found that the mean premium payments increased by $421 (95% CI, 149 to 692) in the same period.

CONCLUSIONS

The ACA was associated with reduced OOP for health services but increased premium contributions, resulting in no significant impact on perceived financial burden among non-elderly cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

The financial hardship of cancer survivorship points to the need for the development of provisions that help cancer patients reduce both perceived and materialized burden of cancer care under ongoing health reform.

What do young doctors know of palliative care; how do they expect the concept to work? : A 'palliative care' knowledge and opinion survey among young doctors

Objectives

Discipline of palliative care is still evolving in developed parts of the world while it remains at an infantile stage in Sri Lanka which has not been formally assessed as of today. We aimed at evaluating the level of palliative care knowledge and opinions among young medical graduates. A descriptive cross-sectional study was carried out among pre-residency medical graduates of Sri Lanka through a social media based online survey. The pre-tested questionnaire assessed the level of knowledge on general principles, service organization, clinical management and ethical considerations while it also evaluated their opinions.

Results

Response rate was 35.8% (n = 351). The average score among the respondents was 37.25% [standard deviation (SD) = 11.975]. Specific knowledge on “general principles” was adequate (score ≥ 50%) with an average of 62.61%, SD = 24.5 while “ethics” was observed to be the area with the poorest knowledge (average score = 19.55%, SD = 22). Average scores for “service organization” and “managerial aspects” were 34.54%, SD = 17.6 and 32.26%, SD = 22.3, respectively. The majority (> 90%) believed that de-novo establishment of hospice, hospital and community-based palliative services would sustainably improve holistic patient care. Measures must be taken to optimize basic palliative care knowledge among the undergraduates in view of achieving Universal Health Coverage in the long term.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4462-2) contains supplementary material, which is available to authorized users.

Semiparametric Estimation of Longitudinal Medical Cost Trajectory

Estimating the average monthly medical costs from disease diagnosis to a terminal event such as death for an incident cohort of patients is a topic of immense interest to researchers in health policy and health economics because patterns of average monthly costs over time reveal how medical costs vary across phases of care. The statistical challenges to estimating monthly medical costs longitudinally are multifold; the longitudinal cost trajectory (formed by plotting the average monthly costs from diagnosis to the terminal event) is likely to be nonlinear, with its shape depending on the time of the terminal event, which can be subject to right censoring. The goal of this paper is to tackle this statistically challenging topic by estimating the conditional mean cost at any month t given the time of the terminal event s. The longitudinal cost trajectories with different terminal event times form a bivariate surface of t and s, under the constraint t ≤ s. We propose to estimate this surface using bivariate penalized splines in an Expectation-Maximization algorithm that treats the censored terminal event times as missing data. We evaluate the proposed model and estimation method in simulations and apply the method to the medical cost data of an incident cohort of stage IV breast cancer patients from the Surveillance, Epidemiology and End Results-Medicare Linked Database.

Theory of partitioning of disease prevalence and mortality in observational data

In this study, we present a new theory of partitioning of disease prevalence and incidence-based mortality and demonstrate how this theory practically works for analyses of Medicare data. In the theory, the prevalence of a disease and incidence-based mortality are modeled in terms of disease incidence and survival after diagnosis supplemented by information on disease prevalence at the initial age and year available in a dataset. Partitioning of the trends of prevalence and mortality is calculated with minimal assumptions. The resulting expressions for the components of the trends are given by continuous functions of data. The estimator is consistent and stable. The developed methodology is applied for data on type 2 diabetes using individual records from a nationally representative 5% sample of Medicare beneficiaries age 65+. Numerical estimates show excellent concordance between empirical estimates and theoretical predictions. Evaluated partitioning model showed that both prevalence and mortality increase with time. The primary driving factors of the observed prevalence increase are improved survival and increased prevalence at age 65. The increase in diabetes-related mortality is driven by increased prevalence and unobserved trends in time-periods and age-groups outside of the range of the data used in the study. Finally, the properties of the new estimator, possible statistical and systematical uncertainties, and future practical applications of this methodology in epidemiology, demography, public health and health forecasting are discussed.

Biodemographic Analyses of Longitudinal Data on Aging, Health, and Longevity: Recent Advances and Future Perspectives

Biodemography became one of the most innovative and fastest growing areas in demography. This progress is fueled by the growing variability and amount of relevant data available for analyses as well as by methodological developments allowing for addressing new research questions using new approaches that can better utilize the potential of these data. In this review paper, we summarize recent methodological advances in biodemography and their diverse practical applications. Three major topics are covered: (1) computational approaches to reconstruction of age patterns of incidence of geriatric diseases and other characteristics such as recovery rates at the population level using Medicare claims data; (2) methodological advances in genetic and genomic biodemography and applications to research on genetic determinants of longevity and health; and (3) biodemographic models for joint analyses of time-to-event data and longitudinal measurements of biomarkers collected in longitudinal studies on aging. We discuss how such data and methodology can be used in a comprehensive prediction model for joint analyses of incomplete datasets that take into account the wide spectrum of factors affecting health and mortality transitions including genetic factors and hidden mechanisms of aging-related changes in physiological variables in their dynamic connection with health and survival.

Comparison of health care needs of child family members of adults with alcohol or drug dependence versus adults with asthma or diabetes

OBJECTIVE

To compare the health problems, preventive care utilization, and medical costs of child family members (CFMs) of adults diagnosed with alcohol or drug dependence (AODD) to CFMs of adults diagnosed with diabetes or asthma.

METHODS

Child family members of adults diagnosed with AODD between 2002 and 2005 and CFMs of matched adults diagnosed with diabetes or asthma were followed up to 7 years after diagnosis of the index adult. Logistic regression was used to determine whether the CFMs of AODD adults were more likely to be diagnosed with medical conditions, or get preventive care, than the CFMs of adults with asthma or diabetes. Children's health services use was compared using multivariate models.

RESULTS

In Year 5 after index date, CFMs of adults with AODD were more likely to be diagnosed with depression and AODD than CFMs of adults with asthma or diabetes and were less likely to be diagnosed with asthma, otitis media, and pneumonia than CFMs of adults with asthma. CFMs of AODD adults were less likely than CFMs of adult asthmatic patients to have annual well-child visits. CFMs of AODD adults had similar mean annual total health care costs to CFMs of adults with asthma but higher total costs ($159/yr higher, confidence interval, $56-$253) than CFMs of adult diabetic patients. CFMs of adults with AODD had higher emergency department, higher outpatient alcohol and drug program, higher outpatient psychiatry, and lower primary care costs than CFMs of either adult asthmatic patients or diabetic patients.

CONCLUSION

Children in families with an alcohol- or drug-dependent adult have unique patterns of health conditions, and differences in the types of health services used, compared to children in families with an adult asthmatic or diabetic family member. However, overall cost and utilization for health care services is similar or only somewhat higher. This is the first study of its kind, and the results have implications for the reduction of parental alcohol or drug dependence stigma by health care providers, clearly an important issue in this era of health reform.

Cost for Treatment of Chronic Lymphocytic Leukemia in Specialized Institutions of Ukraine

OBJECTIVE

The aim of this study was to identify, from a health care perspective, the cost of treatment for chronic lymphocytic leukemia in specialized hospitals in Ukraine.

METHODS

Cost analysis was performed by using retrospective data between 2006 and 2010 from patient-file databases of two specialized hospitals (145 patients). Uncertainty was assessed by using bootstrapping and multivariate sensitivity analyses. Linear regression analysis was used to analyze whether patients' characteristics are related to health care costs. In addition, one-way analysis of variance (Welch test) and paired-sample t test were conducted to compare mean costs of treatment between the two hospitals and mean expenses for drugs and in-hospital stay.

RESULTS

The average annual cost for a patient's drug treatment is 2047 EUR. The cost of hospitalization was significantly lower (t = 5.026; significance two-tailed = 0.000) and equal to 541 EUR per person, resulting in total expenditures of 2589 EUR. Mean total costs in the bootstrap analysis were equal to 2584 EUR (median 2576 EUR, 97.5th percentile 3223 EUR; 2.5th percentile 1987 EUR). The regression analysis did not reveal a relation between patients' characteristics and health care costs, although hospital choice was an influential parameter (β = -0.260; significance = 0.002). Significant difference in mean costs of two analyzed hospitals was also confirmed by one-way analysis of variance (Welch statistics 19.222, P = 0.000).

CONCLUSIONS

Drug treatment comprises the largest portion of total costs, but differences between hospitals exist. Because many patients in Ukraine pay out of pocket for in-hospital drugs, these costs are a high economic burden for patients with chronic lymphocytic leukemia.

Recovery and survival from aging-associated diseases

OBJECTIVES

Considering disease incidence to be a main contributor to healthy lifespan of the US elderly population may lead to erroneous conclusions when recovery/long-term remission factors are underestimated. Using two Medicare-based population datasets, we investigated the properties of recovery from eleven age-related diseases.

METHODS

Cohorts of patients who stopped visiting doctors during a five-year follow-up since disease onset were analyzed non-parametrically and using the Cox proportional hazard model resulted in estimated recovery and survival rates and evaluated the health state of recovered individuals by comparing their survival with non-recovered patients and the general population.

RESULTS

Recovered individuals had lower death rates than non-recovered patients, therefore, patients who stopped visiting doctors are a healthier subcohort. However, they had higher death rates than in general population for all considered diseases, therefore the complete recovery does not occur.

CONCLUSION

Properties of recovery/long-term remission among the US population of older adults with chronic diseases were uncovered and evaluated. The results allow for a better quantifiable contribution of age-related diseases to healthy life expectancy and improving forecasts of health and mortality.

Analysis of skin cancer treatment and costs in the United States Medicare population, 1996-2008

BACKGROUND

There is a skin cancer epidemic in the United States.

OBJECTIVE

To examine skin cancer treatment modality, location, and cost and physician specialty in the Medicare population from 1996 to 2008.

METHODS

Centers for Medicare and Medicaid Services databases were used to examine skin cancer treatment procedures performed for Medicare beneficiaries.

RESULTS

From 1996 to 2008, the total number of skin cancer treatment procedures [malignant excision, destruction, and Mohs micrographic surgery (MMS)] increased from 1,480,645 to 2,152,615 (53% increase). The numbers of skin cancers treated by excision and destruction increased modestly (20% and 39%, respectively), but the number of MMS procedures increased more rapidly (248% increase). Dermatologists treated an increasing percentage (75-82%) of skin cancers during these years, followed by plastic and general surgery. In 2008, more than 90% of all skin cancers were treated in the office, with the remainder being treated in facility-based settings. Allowable charges paid to physicians by Medicare Part B for skin cancer treatments increased 137% from 1996 to 2008, from $266,960,673 to $633,448,103.

CONCLUSIONS

The number of skin cancer treatment procedures increased substantially from 1996 to 2008, as did overall costs to Medicare. Dermatologists treated the vast majority of skin cancers in the Medicare population, using a mix of treatment modalities, almost exclusively in the office setting.

Circulatory Diseases in the U.S. Elderly in the Linked National Long-Term Care Survey-Medicare Database: Population-Based Analysis of Incidence, Comorbidity, and Disability

Incidence rates of acute coronary heart disease (ACHD; including myocardial infarction and angina pectoris), stroke, and heart failure (HF) were studied for their age, disability, and comorbidity patterns in the U.S. elderly population using the National Long Term Care Survey (NLTCS) data linked to Medicare records for 1991-2005. Incidence rates increased with age with a decrease in the oldest old (stroke and HF) or were stable at all ages (ACHD). For all diseases, incidence rates were lower among institutionalized individuals and higher in individuals with higher comorbidity indices. The results could be used for understanding currently debated effects of biomedical research, screening, and therapeutic innovations on changes in disease incidence with advancing age as well as for projecting future Medicare costs.

Age patterns of incidence of geriatric disease in the U.S. elderly population: Medicare-based analysis

OBJECTIVES

To use the Medicare Files of Service Use (MFSU) to evaluate patterns in the incidence of aging-related diseases in the U.S. elderly population.

DESIGN

Age-specific incidence rates of 19 aging-related diseases were evaluated using the National Long Term Care Survey (NLTCS) and the Surveillance, Epidemiology, and End Results (SEER) Registry data, both linked to MFSU (NLTCS-M and SEER-M, respectively), using an algorithm developed for individual date at onset evaluation.

SETTING

A random sample from the entire U.S. elderly population (Medicare beneficiaries) was used in NLTCS, and the SEER Registry data covers 26% of the U.S. population.

PARTICIPANTS

Thirty-four thousand seventy-seven individuals from NLTCS-M and 2,154,598 from SEER-M.

MEASUREMENTS

Individual medical histories were reconstructed using information on diagnoses coded in MFSU, dates of medical services and procedures, and Medicare enrollment and disenrollment.

RESULTS

The majority of diseases (e.g., prostate cancer, asthma, and diabetes mellitus) had a monotonic decline (or decline after a short period of increase) in incidence with age. A monotonic increase in incidence with age with a subsequent leveling off and decline was observed for myocardial infarction, stroke, heart failure, ulcer, and Alzheimer's disease. An inverted U-shaped age pattern was detected for lung and colon carcinomas, Parkinson's disease, and renal failure. The results obtained from the NLTCS-M and SEER-M were in agreement (excluding an excess for circulatory diseases in the NLTCS-M). A sensitivity analysis proved the stability of the incidence rates evaluated.

CONCLUSION

The developed computational approaches applied to the nationally representative Medicare-based data sets allow reconstruction of age patterns of disease incidence in the U.S. elderly population at the national level with unprecedented statistical accuracy and stability with respect to systematic biases.

Long-term prediction of emergency department revenue and visitor volume using autoregressive integrated moving average model

This study analyzed meteorological, clinical and economic factors in terms of their effects on monthly ED revenue and visitor volume. Monthly data from January 1, 2005 to September 30, 2009 were analyzed. Spearman correlation and cross-correlation analyses were performed to identify the correlation between each independent variable, ED revenue, and visitor volume. Autoregressive integrated moving average (ARIMA) model was used to quantify the relationship between each independent variable, ED revenue, and visitor volume. The accuracies were evaluated by comparing model forecasts to actual values with mean absolute percentage of error. Sensitivity of prediction errors to model training time was also evaluated. The ARIMA models indicated that mean maximum temperature, relative humidity, rainfall, non-trauma, and trauma visits may correlate positively with ED revenue, but mean minimum temperature may correlate negatively with ED revenue. Moreover, mean minimum temperature and stock market index fluctuation may correlate positively with trauma visitor volume. Mean maximum temperature, relative humidity and stock market index fluctuation may correlate positively with non-trauma visitor volume. Mean maximum temperature and relative humidity may correlate positively with pediatric visitor volume, but mean minimum temperature may correlate negatively with pediatric visitor volume. The model also performed well in forecasting revenue and visitor volume.