Do Contemporary Cancer Survivors Experience Better Quality of Life? Evaluating a Decade of SEER Medicare Health Outcomes Survey Data

BACKGROUND

A cancer diagnosis may have deleterious effects on health-related quality of life (HRQOL) as adults age. This study examined differences in HRQOL between cancer and matched noncancer Medicare beneficiaries over 65, within and across two time periods.

METHODS

We used novel matching methods on data from the Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) data resource. We matched SEER-MHOS respondents with cancer from a recent period (2015-2019) to respondents with cancer from an earlier period (2008-2012). We then matched these two cohorts, without replacement, to contemporary cohorts without cancer diagnoses. We estimated Veteran's RAND 12-Item Short Form Survey Physical Component Summary (PCS) and Mental Component Summary (MCS) scores for all cohorts.

RESULTS

Our analysis found significantly higher mean MCS scores in the recent period for those with cancer relative to the recent noncancer control group. Breast and lung cancer presented positive and statistically significant trends. We found statistically insignificant differences in PCS scores between the two time periods. No cancer sites had different PCS scores over time compared with the comparison group.

CONCLUSIONS

Mental health for those with cancer improved more between 2008 and 2019 than a matched noncancer comparison group. Physical health remained stable across time. These findings highlight the importance of including a matched noncancer group when evaluating HRQOL outcomes.

IMPACT

SEER-MHOS respondents with cancer report stable PCS scores across 15 years of data and higher MCS scores relative to noncancer controls.

Evaluating the potential impact of rubella-containing vaccine introduction on congenital rubella syndrome in Afghanistan, Dem. Republic of Congo, Ethiopia, Nigeria, and Pakistan: A mathematical modeling study

We assessed the potential impact of introducing rubella-containing vaccine (RCV) on congenital rubella syndrome (CRS) incidence in Afghanistan (AFG), Democratic Republic of Congo (COD), Ethiopia (ETH), Nigeria (NGA), and Pakistan (PAK). We simulated several RCV introduction scenarios over 30 years using a validated mathematical model. Our findings indicate that RCV introduction could avert between 86,000 and 535,000 CRS births, preventing 2.5 to 15.8 million disability-adjusted life years. AFG and PAK could reduce about 90% of CRS births by introducing RCV with current measles routine coverage and executing supplemental immunization activities (SIAs). However, COD, NGA, and ETH must increase their current routine vaccination coverage to reduce CRS incidence significantly. This study showcases the potential benefits of RCV introduction and reinforces the need for global action to strengthen immunization programs.

Associations between healthcare costs and care experiences among older adults with and without cancer

INTRODUCTION

Care coordination and patient-provider communication are important for older adults with cancer, as they likely have additional, non-cancer chronic conditions requiring consultation across multiple providers. Suboptimal care coordination and patient-provider communication can lead to costly and preventable adverse outcomes. This study examines Medicare expenditures associated with patient-reported care coordination and patient-provider communication among older adults with and without cancer.

MATERIALS AND METHODS

We explore SEER-CAHPS® (Surveillance, Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems) linked data for differences in health care expenditures by care coordination and patient-provider communication experiences for beneficiaries with and without cancer. The cancer cohort included beneficiaries with ten prevalent cancer types diagnosed 2011-2019 at least six months before completing a CAHPS survey. Medicare expenditures were abstracted from Medicare claims data. Care coordination and patient-provider communication composite scores (range 0-100, higher scores indicate better experiences) were patient-reported in the CAHPS® survey. We estimated expenditure differences per one-point change in composite scores for patients with and without cancer.

RESULTS

Our analysis included 16,778 matched beneficiaries with and without a previously diagnosed cancer (N = 33,556). Higher care coordination and patient-provider communication scores were inversely associated with Medicare expenditures among beneficiaries with and without cancer in the six months prior to survey response, ranging from -$83 (standard error [SE] = $7) to -$90 (SE = $6) per month. Six months post-survey, expenditures estimates ranging -$88 (SE = $6) to -$106 (SE = $8) were found.

DISCUSSION

We found that lower Medicare expenditures were associated with higher care coordination and patient-provider communication scores. As the number of survivors living longer both with and beyond their cancer grows, addressing their multifaceted care and improving outcomes will be critical.

Does access to free medication reduce health system costs? An evaluation of the Dispensary of Hope program

BACKGROUND: Cost-related medication nonadherence-when patients fail to take medication as prescribed because of the cost of the medication-has numerous consequences: more hospitalizations, avoidable deaths, and greater health care expenditures. Dispensary of Hope is a charitable medication access program that collects and distributes pharmaceuticals to pharmacies to dispense free of charge to patients with no insurance, low incomes, and chronic conditions. OBJECTIVE: To estimate the differences in medical costs and utilization of hospital patients enrolled in the Dispensary of Hope program relative to those who were not enrolled. METHODS: We used administrative claims data from 2 health systems participating in Dispensary of Hope to identify those in the program and a comparison group, respectively. Claims data included emergency department (ED) encounters, inpatient encounters, costs, and prescriptions. Health system 1 (HS1) data began July 1, 2016, and ended December 31, 2019; health system 2 (HS2) data ran from March 10, 2014, to December 31, 2019. Program enrollment dates (index dates) were identified via program registration or prescription fills. We propensity score weighted a comparison population from HS1 and HS2, respectively, to match program patient demographic and comorbidity characteristics. We estimated changes in costs, ED visits, inpatient stays, and primary care sensitive ED visits over time between the 2 groups (difference-indifference) over 18 months preenrollment and postenrollment. RESULTS: HS1 comparison (n = 6,714) and Dispensary of Hope (n = 880) groups were balanced on age, sex, race and ethnicity, and comorbidities; both populations were approximately 46 years old, 43% female, 64% White, with an average of 3.0 comorbidities. The HS2 samples were almost 50 years old and a majority female (56%) and Black (55%). Per-person annual costs at HS1 decreased by $3,161 (P < 0.05) more in the Dispensary of Hope group than in the comparison group from the preenrollment to the postenrollment period. Inpatient stays decreased by 200 stays per 1,000 patients per year (P = 0.02) and ED visits increased by 0.32 (P < 0.01) on a yearly basis relative to the comparison group. Primary care sensitive ED visits increased over the period. No results were statistically significant in HS2. CONCLUSIONS: We found substantial reductions in costs and inpatient stays for Dispensary of Hope HS1 participants, and we did not find significant results at HS2. Differences between the health systems or patient populations could explain these varying results. Our study represents a rigorous, multistate evaluation that highlights the impact of a charitable medication access program on hospital utilization for the medically underserved population. DISCLOSURES: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was funded and supported by Dispensary of Hope.

Diet quality, weight loss, and diabetes incidence in the Diabetes Prevention Program (DPP)

BACKGROUND

We evaluated whether diet quality is a predictor of weight loss and reduced diabetes risk, independent of caloric intake in the Diabetes Prevention Program (DPP) cohort, a randomized clinical trial of adults at risk for diabetes.

METHODS

This secondary analysis included 2914 participants with available data (964 intensive lifestyle (ILS), 977 metformin, 973 placebo). Dietary intake was assessed using a 117-item food frequency questionnaire. Diet quality was quantified using the Alternative Healthy Eating Index 2010 (AHEI). AHEI ranges from 0 to 110, with higher scores corresponding to higher quality diets. ILS participants had greater improvement (p < 0.001) in AHEI over 1-year (4.2 ± 9.0) compared to metformin (1.2 ± 8.5) and placebo (1.4 ± 8.4). We examined the association between AHEI change and weight change from baseline to 1-year using linear regression, and that between 1-year AHEI change and incident diabetes, using hazard models over an average 3 years follow-up. Models were evaluated within treatment group and adjusted for relevant characteristics including caloric intake, physical activity, BMI and AHEI. Models testing incident diabetes were further adjusted for baseline fasting and 2 h glucose.

RESULTS

An increase in AHEI score was associated with weight loss in ILS [β per 10-point increase (SE) -1.2 kg (0.3, p < 0.001)], metformin [- 0. 90 kg (0.2, p < 0.001)] and placebo [- 0.55 kg (0.2, p = 0.01)]. However, AHEI change was not associated with incident diabetes in any group before or after adjustment for weight change.

CONCLUSIONS

Controlling for weight, diet quality was not associated with diabetes incidence but helps achieve weight loss, an important factor in diabetes prevention.

Assessing costs of a hypertension management program: An application of the HEARTS costing tool in a program planning workshop in Thailand

The HEARTS technical package, a part of the Global Hearts Initiative to improve cardiovascular health globally, is a strategic approach for cardiovascular disease prevention and control at the primary care level. To support the evaluation of costs associated with HEARTS program components, a costing tool was developed to evaluate the incremental cost of program implementation. This report documents an application of the HEARTS costing tool during a costing workshop prior to the initiation of a HEARTS pilot program in Thailand's Phothong District, 2019‐2020. During the workshop, a mock exercise was conducted to estimate the expected costs of the pilot study. The workshop application of the tool underscored its applicability to the HEARTS program planning process by identifying cost drivers associated with individual program elements. It further illustrated that by supporting disaggregation of costs into fixed and variable categories, the tool can inform the scalability of pilot projects to larger populations. Lessons learned during the initial development and application of the costing tool can inform future HEARTS evaluation efforts.

Cost-effectiveness of patient navigation for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program

OBJECTIVES

Patient navigation (PN) services have been shown to improve cancer screening in disparate populations. This study estimates the cost-effectiveness of implementing PN services within the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

We adapted a breast cancer simulation model to estimate a population cohort of women aged 40-64 years from the NBCCEDP through their lifetime. We incorporated their screening frequency and screening and diagnostic costs.

RESULTS

Within the NBCCEDP, Program with PN (vs. No PN) resulted in a greater number of mammograms per woman (4.23 vs. 4.14), lower lifetime mortality from breast cancer (3.53% vs. 3.61%), and fewer missed diagnostic resolution per woman (0.017 vs. 0.025). The estimated incremental cost-effectiveness ratios for a Program with PN was $32,531 per quality-adjusted life-years relative to Program with No PN.

CONCLUSIONS

Incorporating PN services within the NBCCEDP may be a cost-effective way of improving adherence to screening and diagnostic resolution for women who have abnormal results from screening mammography. Our study highlights the value of supportive services such as PN in improving the quality of care offered within the NBCCEDP.

Cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program

PURPOSE

To estimate the cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

Using a modified CISNET breast cancer simulation model, we estimated outcomes for women aged 40-64 years associated with three scenarios: breast cancer screening within the NBCCEDP, screening in the absence of the NBCCEDP (no program), and no screening through any program. We report screening outcomes, cost, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and sensitivity analyses results.

RESULTS

Compared with no program and no screening, the NBCCEDP lowers breast cancer mortality and improves QALYs, but raises health care costs. Base-case ICER for the program was $51,754/QALY versus no program and $50,223/QALY versus no screening. Probabilistic sensitivity analysis ICER for the program was $56,615/QALY [95% CI $24,069, $134,230/QALY] versus no program and $51,096/QALY gained [95% CI $26,423, $97,315/QALY] versus no screening.

CONCLUSIONS

On average, breast cancer screening in the NBCCEDP was cost-effective compared with no program or no screening.

Prediction of incident vertebral fracture using CT-based finite element analysis

Prior studies show vertebral strength from computed tomography-based finite element analysis may be associated with vertebral fracture risk. We found vertebral strength had a strong association with new vertebral fractures, suggesting that vertebral strength measures identify those at risk for vertebral fracture and may be a useful clinical tool.

INTRODUCTION

We aimed to determine the association between vertebral strength by quantitative computed tomography (CT)-based finite element analysis (FEA) and incident vertebral fracture (VF). In addition, we examined sensitivity and specificity of previously proposed diagnostic thresholds for fragile bone strength and low BMD in predicting VF.

METHODS

In a case-control study, 26 incident VF cases (13 men, 13 women) and 62 age- and sex-matched controls aged 50 to 85 years were selected from the Framingham multi-detector computed tomography cohort. Vertebral compressive strength, integral vBMD, trabecular vBMD, CT-based BMC, and CT-based aBMD were measured from CT scans of the lumbar spine.

RESULTS

Lower vertebral strength at baseline was associated with an increased risk of new or worsening VF after adjusting for age, BMI, and prevalent VF status (odds ratio (OR) = 5.2 per 1 SD decrease, 95% CI 1.3-19.8). Area under receiver operating characteristic (ROC) curve comparisons revealed that vertebral strength better predicted incident VF than CT-based aBMD (AUC = 0.804 vs. 0.715, p = 0.05) but was not better than integral vBMD (AUC = 0.815) or CT-based BMC (AUC = 0.794). Additionally, proposed fragile bone strength thresholds trended toward better sensitivity for identifying VF than that of aBMD-classified osteoporosis (0.46 vs. 0.23, p = 0.09).

CONCLUSION

This study shows an association between vertebral strength measures and incident vertebral fracture in men and women. Though limited by a small sample size, our findings also suggest that bone strength estimates by CT-based FEA provide equivalent or better ability to predict incident vertebral fracture compared to CT-based aBMD. Our study confirms that CT-based estimates of vertebral strength from FEA are useful for identifying patients who are at high risk for vertebral fracture.

Estimation of Breast Cancer Incident Cases and Medical Care Costs Attributable to Alcohol Consumption Among Insured Women Aged <45 Years in the U.S

INTRODUCTION

This study estimated the percentage of breast cancer cases, total number of incident cases, and total annual medical care costs attributable to alcohol consumption among insured younger women (aged 18-44 years) by type of insurance and stage at diagnosis.

METHODS

The study used the 2012-2013 National Survey on Drug Use and Health, cancer incidence data from two national registry programs, and published relative risk measures to estimate the: (1) alcohol-attributable fraction of breast cancer cases among younger women by insurance type; (2) total number of breast cancer incident cases attributable to alcohol consumption by stage at diagnosis and insurance type among younger women; and (3) total annual medical care costs of treating breast cancer incident cases attributable to alcohol consumption among younger women. Analyses were conducted in 2016; costs were expressed in 2014 U.S. dollars.

RESULTS

Among younger women enrolled in Medicaid, private insurance, and both groups, 8.7% (95% CI=7.4%, 10.0%), 13.8% (95% CI=13.3%, 14.4%), and 12.3% (95% CI=11.4%, 13.1%) of all breast cancer cases, respectively, were attributable to alcohol consumption. Localized stage was the largest proportion of estimated attributable incident cases. The estimated total number of breast cancer incident alcohol-attributable cases was 1,636 (95% CI=1,570, 1,703) and accounted for estimated total annual medical care costs of $148.4 million (95% CI=$140.6 million, $156.1 million).

CONCLUSIONS

Alcohol-attributable breast cancer has estimated medical care costs of nearly $150 million per year. The current findings could be used to support evidence-based interventions to reduce alcohol consumption in younger women.

Can Medicaid Claims Validly Ascertain Foster Care Status?

Medicaid claims have been used to identify populations of children in foster care in the current literature; however, the ability of such an approach to validly ascertain a foster care population is unknown. This study linked children in the National Survey of Child and Adolescent Well-Being-I to their Medicaid claims from 36 states using their Social Security numbers. Using this match, we examined discordance between caregiver report of foster care placement and the foster care eligibility code contained in the child's Medicaid claims. Only 73% of youth placed in foster care for at least a year displayed a Medicaid code for foster care eligibility. Half of all youth coming into contact with child welfare displayed discordance between caregiver report and Medicaid claims. Children with emergency department utilization, and those in primary care case management health insurance arrangements, had the highest odds of accurate ascertainment. The use of Medicaid claims to identify a cohort of children in foster care results in high rates of underascertainment. Supplementing administrative data with survey data is one way to enhance validity of ascertainment.

Breast cancer treatment costs in younger, privately insured women

PURPOSE

Younger women (under age 45 years) diagnosed with breast cancer often face more aggressive tumors, higher treatment intensity, lower survival rates, and greater financial hardship. The purpose of this study was to estimate breast cancer costs by stage at diagnosis during the first 18 months of treatment for privately insured younger women.

METHODS

We analyzed North Carolina cancer registry data linked to claims data from private insurers from 2003 to 2010. Breast cancer patients were split into two cohorts: a younger and older group aged 21-44 and 45-64 years, respectively. We conducted a cohort study and matched women with and without breast cancer using age, ZIP, and Charlson Comorbidity Index. We calculated mean excess costs between breast cancer and non-breast cancer patients at 6, 12, and 18 months.

RESULTS

For younger women, AJCC 6th edition stage II cancer was the most common at diagnosis (40%), followed by stage I (34%). On the other hand, older women had more stage I (46%) cancer followed by stage II (34%). The excess costs for younger and older women at 12 months were $97,486 (95% confidence interval [CI] $93,631-101,341) and $75,737 (95% CI $73,962-77,512), respectively. Younger breast cancer patients had both a higher prevalence of later-stage disease and higher within-stage costs.

CONCLUSIONS

The study reports high costs of treatment for both younger and older women than a non-cancer comparison group; however, the estimated excess cost was significantly higher for younger women. The financial implications of breast cancer treatment costs for younger women need to be explored in future studies.

Who Wants Long-Term Care Insurance? A Stated Preference Survey of Attitudes, Beliefs, and Characteristics

Approximately half of people turning 65 years between 2015 and 2019 are projected to need long-term support and services. Yet the long-term care insurance (LTCI) market is depressed, with only 7.4 million people owning policies. The objective of this study was to provide an analysis of potential LTCI purchasers. We investigate (1) who wants to purchase LTCI, (2) what are the attitudes and beliefs among those who have a preference for LTCI, and (3) who would prefer a law mandating the purchase of LTCI and how that view relates to willingness to purchase LTC. We combine a discrete choice experiment with a survey on attitudes toward LTCI. We estimate odds ratio for choosing a plan based on sociodemographic characteristics, attitudes, and beliefs. Our sample consists of a population of 12 936 people who completed an Internet panel survey. Female respondents were substantially less likely to choose an LTCI plan (OR = 0.74). Income and assets over $100 000 were strong predictors of LTCI uptake (OR = 1.27 and OR = 1.48, respectively). Having adult children live close by was not associated with preference for LTCI. People who support almost any government intervention are more likely to purchase private insurance (OR = 1.12-1.33). Minorities expressed a preference for mandatory enrollment relative to whites. There is a relationship between attitudes toward long-term care financing reform and preference for LTCI, but it is not limited to supporters of private sector initiatives. While support for mandatory LTCI is low overall, it is strongest among racial/ethnic minorities and people with health problems, who potentially have the most to gain.

Associations Between Magnitude of Child Maltreatment and Medicaid Expenditures for Psychotropic Medications

OBJECTIVE

This study examined relationships between various measures of the severity of child maltreatment and expenditures on psychotropic drugs among children in the welfare system.

METHODS

Child participants (N=4,453) in the first National Survey of Child and Adolescent Well-Being (NSCAW) were linked to their Medicaid claims from 36 states. Three specifications for severity of maltreatment were developed. A two-part regression of logistic and generalized linear models of expenditures on psychotropic medications was estimated for each specification.

RESULTS

Physically abused children had higher odds (odds ratio [OR]=1.34) and neglected children had lower odds (OR=.76) of incurring psychotropic drug expenditures. Children who experienced the most severe level of harm had higher odds (OR=1.33) of medication use, compared with children without appreciable harm. No maltreatment specifications were associated with increased expenditures on psychotropic drugs.

CONCLUSIONS

The magnitude of maltreatment affected odds of use of psychotropic drugs but had no effect on Medicaid expenditures for these drugs.

Morbid Obesity and Use of Second Generation Antipsychotics among Adolescents in Foster Care: Evidence from Medicaid

BACKGROUND

Many adolescents enter foster care with high body mass index (BMI), and patterns of treatment further exacerbate the risk of morbid obesity. A principal risk factor for such exacerbation is the use of second generation antipsychotics (SGAs). We examine the association between receiving a morbid obesity diagnosis and SGA prescriptions among adolescents in foster care.

METHODS

We analyzed claims from 36 states' Medicaid Analytic Extract (MAX) files for 2000 through 2003. Obesity diagnoses were ascertained through a primary or secondary diagnosis claim of morbid obesity. Covariates included gender, race/ethnicity. age, insurance status, state obesity rate, and state fixed effects. We calculated relative risks of a diagnosis based upon four SGAs (clozapine, olanzapine, quetiapine, and risperidone) associated with obesity and a polypharmacy indicator.

RESULTS

Of the 1,261,806 foster care adolescent-years in the MAX files, 6,517 were diagnosed with morbid obesity, an annual prevalence of 0.5%. The risk of a morbid obesity diagnosis is much higher for female and non-white adolescents. The risk increases with age. Quetiapine and clozapine increased the risk of a morbid obesity diagnosis more than 2.5 times, and two or more psychotropic drugs (polypharmacy) increased the risk fivefold.

CONCLUSIONS

Adolescents in foster care are much more likely to be on SGA medications, and therefore may be more susceptible to weight gain and obesity. Given that SGA prescribing for younger populations has only expanded since these data were released, our study may actually understate the magnitude of the problem. Care is needed when prescribing SGAs for foster care adolescents.

Medicaid Disenrollment Patterns Among Children Coming into Contact with Child Welfare Agencies

Objectives To examine retention of Medicaid coverage over time for children in the child welfare system. Methods We linked a national survey of children with histories of abuse and neglect to their Medicaid claims files from 36 states, and followed these children over a 4 year period. We estimated a Cox proportional hazards model on time to first disenrollment from Medicaid. Results Half of our sample (50 %) retained Medicaid coverage across 4 years of follow up. Most disenrollments occurred in year 4. Being 3-5 years of age and rural residence were associated with increased hazard of insurance loss. Fee-for-service Medicaid and other non-managed insurance arrangements were associated with a lower hazard of insurance loss. Conclusions for Practice A considerable number of children entering child environments seem to retain Medicaid coverage over multiple years. Finding ways to promote entry of child welfare-involved children into health insurance coverage will be critical to assure services for this highly vulnerable population.

Medical Care Costs of Breast Cancer in Privately Insured Women Aged 18-44 Years

INTRODUCTION

Breast cancer in women aged 18-44 years accounts for approximately 27,000 newly diagnosed cases and 3,000 deaths annually. When tumors are diagnosed, they are usually aggressive, resulting in expensive treatment costs. The purpose of this study is to estimate the prevalent medical costs attributable to breast cancer treatment among privately insured younger women.

METHODS

Data from the 2006 MarketScan database representing claims for privately insured younger women were used. Costs for younger breast cancer patients were compared with a matched sample of younger women without breast cancer, overall and for an active treatment subsample. Analyses were conducted in 2013 with medical care costs expressed in 2012 U.S. dollars.

RESULTS

Younger women with breast cancer incurred an estimated $19,435 (SE=$415) in additional direct medical care costs per person per year compared with younger women without breast cancer. Outpatient expenditures comprised 94% of the total estimated costs ($18,344 [SE=$396]). Inpatient costs were $43 (SE=$10) higher and prescription drug costs were $1,048 (SE=$64) higher for younger women with breast cancer than in younger women without breast cancer. For women in active treatment, the burden was more than twice as high ($52,542 [SE=$977]).

CONCLUSIONS

These estimates suggest that breast cancer is a costly illness to treat among younger, privately insured women. This underscores the potential financial vulnerability of women in this age group and the importance of health insurance during this time in life.

Treatment costs of breast cancer among younger women aged 19 to 44 years enrolled in Medicaid

74

Background: Breast cancer is the most common malignant tumor among women in the United States, accounting for about 30% of incident cancers. It is one of the most costly medical conditions to treat. Younger women aged 18-44 years account for 11% of new cases. These women tend to experience more aggressive types of breast cancer, requiring intensive and expensive treatment. In recent years, a few studies have examined the costs of breast cancer treatment in a Medicaid population at the state level. However, no study has estimated medical costs for breast cancer treatment at the national level for women aged 19-44 years enrolled in Medicaid. Methods: A sample of 5,542 younger women aged 19-44 years, fee-for-service Medicaid enrollees, and diagnosed with breast cancer in 2007 were compared with 4.3 million women aged 19-44 years, fee-for-service Medicaid enrollees, but without breast cancer. The study used linear and nonlinear regression methods to estimate treatment costs for younger women with breast cancer compared with those without breast cancer. Individual medical costs were estimated by race/ethnicity and by type of services. All medical treatment costs were adjusted to 2010 dollars. Results: The estimated annual direct medical costs for breast cancer treatment among younger women enrolled in Medicaid ranged from nearly $25,000 to $42,000 per woman. Non-Hispanic black women had the highest annual total medical costs, followed by Hispanic women, while non-Hispanic women of other race had the lowest. The cost estimates ranged from $14,600 to $18,800 for outpatient service, $4,600 to $5,700 for inpatient service, and $3,500 to $4,800 for prescription drugs. Conclusions: The cost estimates demonstrate the substantial medical costs associated with breast cancer treatment for younger Medicaid beneficiaries. As the Medicaid program continues to evolve, the treatment cost estimates could serve as important inputs in decision-making regarding planning for treatment of invasive breast cancer in this population.

Challenges in using medicaid claims to ascertain child maltreatment

Medicaid data contain International Classification of Diseases, Clinical Modification (ICD-9-CM) codes indicating maltreatment, yet there is a little information on how valid these codes are for the purposes of identifying maltreatment from health, as opposed to child welfare, data. This study assessed the validity of Medicaid codes in identifying maltreatment. Participants (n = 2,136) in the first National Survey of Child and Adolescent Well-Being were linked to their Medicaid claims obtained from 36 states. Caseworker determinations of maltreatment were compared with eight sets of ICD-9-CM codes. Of the 1,921 children identified by caseworkers as being maltreated, 15.2% had any relevant ICD-9-CM code in any of their Medicaid files across 4 years of observation. Maltreated boys and those of African American race had lower odds of displaying a maltreatment code. Using only Medicaid claims to identify maltreated children creates validity problems. Medicaid data linkage with other types of administrative data is required to better identify maltreated children.

Psychotropic drug use among preschool children in the Medicaid program from 36 states

OBJECTIVES

We determined the prevalence of and indications for psychotropic medication among preschool children in Medicaid.

METHODS

We obtained 2000 to 2003 Medicaid Analytic Extract data from 36 states. We followed children in 2 cohorts, born in 1999 and 2000, up to age 4 years. We used logistic regression to model odds of receiving medications for (1) attention-deficit disorder/attention-deficit hyperactivity disorder, (2) depression or anxiety, and (3) psychotic illness or bipolar.

RESULTS

Overall, 1.19% of children received at least 1 psychotropic drug. Medications for attention-deficit disorder/attention-deficit hyperactivity disorder treatment were most common (0.61% of all children), followed by depression or anxiety (0.59%) and psychotic illness or bipolar (0.24%). Among children, boys, those of other or unknown race compared with White, and those with other insurance compared with fee for service-only had higher odds of receiving a prescription (odds ratio [OR]=1.80 [95% confidence interval (CI)=1.74, 1.86], 1.75 [corrected] [1.66, 1.85], and 1.14 [1.01, 1.28], respectively), whereas Black and Hispanic children had lower odds (OR=0.51 [95% CI=0.48, 0.53] and 0.37 [0.34, 0.39], respectively).

CONCLUSIONS

Preschoolers are receiving psychotropic medications despite limited evidence supporting safety or efficacy. Future research should focus on implementing medication use practice parameters in infant and toddler clinics, and expanding psychosocial interventions for young children with behavioral problems.

Medicaid expenditures on psychotropic medications for maltreated children: a study of 36 States

OBJECTIVE

Children with histories of abuse or neglect are the most expensive child population to insure for their mental health needs. This study aimed to quantify the magnitude of Medicaid expenditures incurred in the purchase of psychotropic drugs for these children.

METHODS

Children (N=4,445) participating in the National Survey of Child and Adolescent Well-Being (NSCAW) and from households under investigation for suspected child abuse and neglect were linked to their Medicaid claims from 36 states. Expenditures on psychotropic medications between the NSCAW sample and a propensity score-matched comparison sample of Medicaid-enrolled children were compared in a two-part regression of logistic and generalized linear models.

RESULTS

Children in the NSCAW sample had twice the odds of psychotropic drug use and $190 higher mean annual expenditures on psychotropic drugs than children in the comparison sample. Increased expenditures on antidepressants and antimanic drugs were the primary drivers of these increased expenditures. Male gender and white race-ethnicity were associated with significantly increased expenditures. Children in primary care case management had $325 lower expenditures than those in fee-for-service Medicaid. Among NSCAW children alone, male gender, older age, being in poorer health, and scoring in the clinical range of the Child Behavior Checklist (CBCL) all increased expenditures on psychotropic drugs.

CONCLUSIONS

Medicaid agencies should focus their cost containment strategies on antidepressants and antimanic drugs, consider expanding primary care case management arrangements, and expand use of instruments such as the CBCL to identify and treat high-need children.

The effect of friend selection on social influences in obesity

We present an agent-based model of weight choice and peer selection that simulates the effect of peer selection on social multipliers for weight loss interventions. The model generates social clustering around weight through two mechanisms: a causal link from others' weight to an individual's weight and the propensity to select peers based on weight. We simulated weight loss interventions and tried to identify intervention targets that maximized the spillover of weight loss from intervention participants to nonparticipants. Social multipliers increase with the number of intervention participants' friends. For example, when friend selection was based on a variable exogenous to weight, the weight lost among non-participants increased by 23% (14.3lb vs. 11.6lb) when targeting the most popular obese. Holding constant the number of participants' friends, multipliers increase with increased weight clustering due to selection, up to a point. For example, among the most popular obese, social multipliers when matching on a characteristic correlated with weight (1.189) were higher than when matching on the exogenous characteristic (1.168) and when matching on weight (1.180). Increased weight clustering also implies more obese "friends of friends" of participants, who reduce social multipliers.

Racial/ethnic differences in Medicaid expenditures on psychotropic medications among maltreated children

This study quantifies racial/ethnic differences in Medicaid expenditures on psychotropic drugs among a national sample of children with suspected maltreatment. We linked 4,445 child participants in the National Survey of Child and Adolescent Well-Being (NSCAW) - consisting of children investigated for suspected abuse and neglect - to their Medicaid claims obtained from 36 states. We used propensity score matching to construct a comparison group of children without known child welfare involvement, and estimated two-part generalized linear models to examine differences in annual psychotropic drug expenditures per child between children of different races/ethnicities. When compared to a matched sample of children, African American and Latino children incur $292 and $144 less expenditures on psychotropic drugs, respectively, than white children. Among NSCAW children alone, African American children display $614 less spending on psychotropic drugs when compared to white children. Racial/ethnic differences in expenditures on psychotropic drugs occur among all children on Medicaid, but the differences are especially pronounced among African American children in contact with the child welfare system. These findings demonstrate that policymakers will need to pay special attention to the needs of children of color as Medicaid expansions proceed nationwide.

Associations between Infant Feeding Practices and Length, Weight, and Disease in Developing Countries

The health benefits of exclusive breastfeeding are well-known, but the relative detrimental impacts of other foods on infant health are unknown. Because infants in developing countries are fed a wide range of food, quantifying the burden of these diverse feeding practices on infant health is essential for public health policy. We used data from the Demographic Health Survey from 20 developing countries over multiple years to examine the independent association of six different types of food (exclusive breastfeeding, non-exclusive breastfeeding, infant formula, milk liquids, non-milk liquids, and solid foods) with five measures of infant health (length, weight, diarrhea, fever, and cough). We estimated associations with regression analysis, controlling for confounding factors with infant, mother, and household factors and community-year fixed effects. We used these estimates in a simulation model to quantify the burden of different combinations of food on infant health. We show that for an infant younger than 6 months old, following current guidelines and exclusively breastfeeding instead of giving the infant solid foods may increase length by 0.75 cm and weight by 0.25 kg and decrease diarrhea, fever, and cough prevalence by 8, 12, and 11%, respectively. We found that the burden on infant health of some feeding practices is less than others. Although all other feeding practices are associated with worse health outcomes than exclusive breastfeeding, breastfeeding supplemented with liquids has a lower burden on infant health than solid foods and infant formula has a lower burden than milk or non-milk liquids as measured by four of five health metrics. Providing specific quantified burden estimates of these practices can help inform public health policy related to infant feeding practices.

Incorporating indirect costs into a cost-benefit analysis of laparoscopic adjustable gastric banding

OBJECTIVES

The objective of this study was to estimate the time to breakeven and 5-year net costs of laparoscopic adjustable gastric banding (LAGB) taking both direct and indirect costs and cost savings into account.

METHODS

Estimates of direct cost savings from LAGB were available from the literature. Although longitudinal data on indirect cost savings were not available, these estimates were generated by quantifying the relationship between medical expenditures and absenteeism and between medical expenditures and presenteeism (reduced on-the-job productivity) and combining these elasticity estimates with estimates of the direct cost savings to generate total savings. These savings were then combined with the direct and indirect costs of the procedure to quantify net savings.

RESULTS

By including indirect costs, the time to breakeven was reduced by half a year, from 16 to 14 quarters. After 5 years, net savings in medical expenditures from a gastric banding procedure were estimated to be $4970 (±$3090). Including absenteeism increased savings to $6180 (±$3550). Savings were further increased to $10,960 (±$5864) when both absenteeism and presenteeism estimates were included.

CONCLUSIONS

This study presented a novel approach for including absenteeism and presenteeism estimates in cost-benefit analyses. Application of the approach to gastric banding among surgery-eligible obese employees revealed that the inclusion of indirect costs and cost savings improves the business case for the procedure. This approach can easily be extended to other populations and treatments.

Training providers in hypertension guidelines: cost-effectiveness evaluation of a continuing medical education program in South Carolina

BACKGROUND

Translation of published guidelines to clinical practice through continuing medical education (CME) can be effective at changing provider practice patterns and patient outcomes. Yet, cost-effectiveness analyses of CME interventions are rare. This study analyzed the cost-effectiveness of a CME program for improving patient hypertension outcomes relative to usual care.

METHODS

A CME, conducted by the Carolinas and Georgia chapter of the American Society of Hypertension, the Medical University of South Carolina, and the Heart Disease and Stroke Prevention Division of the South Carolina Department of Health and Environmental Control, trained primary care providers in evidence-based guidelines for hypertension prevention and control. A cost-effectiveness simulation model was created with inputs from primary data collection of program costs and secondary data analysis of the Hypertension Initiative Database for years 2000 through 2008. The data analysis consisted of a convenience sample of 8,183 patients in the Hypertension Initiative Database who saw a CME-trained provider at least once before and after the provider's training. Control patients saw providers who did not attend a CME program and were matched to CME patients using propensity score matching.

RESULTS

Incremental life-years gained (LYG) for CME compared with no intervention were 0.003 per patient. The incremental cost-effectiveness ratio was $39,494 ($19,184-$73,864) per LYG under optimistic assumptions and $54,755 ($32,423-$95,728) per LYG under pessimistic assumptions. These results were most sensitive to changes in the effectiveness of the intervention on systolic blood pressure.

CONCLUSIONS

The intervention is likely a cost-effective strategy to address hypertension in a real-world setting and can serve as a model for future innovations in hypertension prevention.

Individual and aggregate years-of-life-lost associated with overweight and obesity

This study presents nationally representative estimates of individual and aggregate years-of-life-lost (YLLs) associated with overweight and three categories of obesity separately by age, race, smoking status, and gender strata. Using proportional hazards analysis and data from the National Health Interview Survey (NHIS) Linked Mortality Files, we estimated life expectancies for each BMI strata and quantified YLLs by comparing differences between each strata and the normal BMI reference group. Our results provide further evidence that overweight and mild obesity are not associated with a reduction in life expectancy. However, higher BMI categories are associated with lower expected survival. In aggregate, excess BMI is responsible for approximately 95 million YLLs. White females account for more than two-thirds of the aggregate YLLs. Unless something is done to reduce the rising prevalence of those with BMIs >35, or to mitigate the impact of obesity or its correlates on YLLs, expected life expectancy for US adults may decrease in the future.

The lifetime medical cost burden of overweight and obesity: implications for obesity prevention

This study quantifies age-specific and lifetime costs for overweight (BMI: 25-29.9), obese I (BMI: 30-34.9), and obese II/III (BMI: >35) adults separately by race/gender strata. We use these results to demonstrate why private sector firms are likely to underinvest in obesity prevention efforts. Not only does the existence of Medicare reduce the economic burden that obesity imposes on private payers, but, from the perspective of a 20-year-old obese adult, the short-term costs of obesity are small. This suggests that legislation that subsidizes wellness programs and/or mandates coverage for obesity treatments might make all firms better off. Ironically, Medicare has a greater incentive to prevent obesity because when an obese 65 year old enters the program, his/her costs are immediate and higher than costs for normal weight individuals.