Budget Impact of a Steroid-Eluting Sinus Implant Versus Sinus Surgery for Adult Chronic Sinusitis Patients with Nasal Polyps

BACKGROUND

A corticosteroid-eluting sinus implant was recently approved by the FDA as a drug to treat adult patients with nasal polyps who have undergone previous endoscopic sinus surgery (ESS) of the ethmoid sinuses. ESS is performed in an operating room under general anesthesia, whereby diseased tissue and bone are removed to provide improved drainage. ESS typically involves dissection of 1 or more of the 4 paired sinus cavities (maxillary, ethmoid, sphenoid, or frontal). The implant, containing 1,350 mcg of mometasone furoate, is inserted by a physician in an office setting and offers controlled localized release of corticosteroid to the polypoid sinus tissue. The implant has demonstrated significant improvements in clinical testing; however, little research has been conducted on its economic impact.

OBJECTIVE

To evaluate and quantify the budget impact to a commercial payer of using this implant instead of ESS in patients with nasal polyps after a previous ESS. Since essentially all patients with recurrent nasal polyps after ESS are patients with chronic sinusitis (CS) diagnosis, this study also identified patients with CS with nasal polyposis (CSwNP) for consistency with the patient population studied in clinical trials evaluating the implant.

METHODS

A budget impact analysis was conducted from a U.S. commercial payer perspective over a 1-year time horizon with patients who received the implant or revision ESS. Primary outcomes of interest were annual total and per-member per-month (PMPM) direct health care costs. Costs were estimated using a decision analysis model, assuming 50% implant utilization as an alternative to revision ESS in eligible patients, with other levels (25%, 75%) also considered. The model utilized the results of a recently published analysis of 86,052 patients in the Blue Health Intelligence database, results from published clinical trials evaluating the implant, a literature review, and published Medicare national payment amounts.

RESULTS

A commercial health plan with 1 million members could anticipate 1,000 CSwNP patients as candidates for receiving the implant or revision ESS. Estimated direct treatment costs for refractory CSwNP using only revision ESS are $11.03 million ($0.92 PMPM). If the implant replaced surgery in 50% of cases and if 63% those patients received a second treatment with the implant during the year, the estimated total cost savings would be $2.56 million ($0.21 PMPM). Cost savings associated with using the implant changed to $0.11 PMPM and $0.32 PMPM with implant adoption of 25% and 75%, respectively.

CONCLUSIONS

In a large commercially insured U.S. population, annual revision ESS costs are substantial. Using the implant instead of revision ESS could result in considerable cost savings for payers at various levels of adoption.

DISCLOSURES

This study was sponsored by Intersect ENT, which was involved in study design and manuscript review. Ernst and Imhoff are employed by CTI Clinical Trial and Consulting Services, which contracted with Intersect ENT to conduct this study. Ernst and Imhoff also report other financial support from Intersect ENT during the conduct of the study. DeConde reports personal fees from Intersect ENT during the conduct of the study, as well as personal fees from Optinose, Stryker Endoscopy, and Olympus, outside the submitted work. Manes reports grants from Intersect ENT during the conduct of the study, as well as grants from Optinose and Sanofi outside the submitted work.

Health Economics and Outcomes of Surfactant Treatments for Respiratory Distress Syndrome Among Preterm Infants in US Level III/IV Neonatal Intensive Care Units

OBJECTIVE

To compare length of stay (LOS), costs, mechanical ventilation (MV), and mortality in preterm infants treated in the Neonatal Intensive Care Unit (NICU) with beractant (BE), calfactant (CA), and poractant alfa (PA) for Respiratory Distress Syndrome (RDS).

METHODS

This study evaluated preterm infants born between 2010 and 2013 with RDS diagnosis, gestational age of 25 to 36 weeks, birthweight of ≥500 g, and age of ≤2 days on first surfactant administration. Multivariable regression was used to evaluate all NICU outcomes.

RESULTS

Of 13,240 infants meeting the study criteria, 4136 (31.2%) received BE, 2502 (18.9%) received CA, and 6602 (49.9%) received PA. Adjusted analyses estimated similar mean LOS (BE 26.7 days, CA 27.8 days, and PA 26.2 days) and hospital costs (BE: $50,929; CA: $50,785; and PA: $50,212). Compared to PA, BE and CA were associated with greater odds of MV use on day 3 (OR = 1.56 and 1.60, respectively) and day 7 (OR = 1.39 and 1.28, respectively; all p < 0.05). Adjusted NICU mortality was significantly higher only with CA vs PA (OR = 1.51; p = 0.015).

CONCLUSION

Adjusted NICU LOS and costs were similar among BE, CA, and PA. Infants receiving PA were less likely to be on MV at 3 and 7 days, and PA treatment was associated with lower odds of NICU mortality when compared to CA.

Relapse outcomes, safety, and treatment patterns in patients diagnosed with relapsing-remitting multiple sclerosis and initiated on subcutaneous interferon β-1a or dimethyl fumarate: a real-world study

OBJECTIVE

To estimate real-world treatment patterns, safety, and relapse outcomes of subcutaneous (sc) interferon (IFN) β-1a (Rebif) vs dimethyl fumarate (DMF; Tecfidera), to treat relapsing-remitting multiple sclerosis (RRMS).

METHODS

A US retrospective chart review of 450 randomly selected adults newly diagnosed with RRMS who received sc IFN β-1a (n = 143) or DMF (n = 307) was conducted. Patients were either (a) treatment-naïve, initiating first-line treatment with sc IFN β-1a or DMF, or (b) previously treated, switching to sc IFN β-1a or DMF. Two years' follow-up data were captured. Patient characteristics, persistence, and adverse events between treatment groups were compared using t-tests or Chi-square tests. Kaplan-Meier curves with log-rank tests and Cox proportional hazards models were used to compare time to, and risk of non-persistence. Annualized Relapse Rates (ARR) were calculated using a robust variance Poisson model adjusting for covariates. Propensity scores were used to address possible selection bias.

RESULTS

One hundred and twelve patients became non-persistent, most commonly due to an adverse event (n = 37). No difference was observed in time to overall non-persistence between sc IFN β-1a and DMF patients. Among treatment-naïve patients, those receiving DMF had 2.4-times the risk (HR = 2.439, 95% CI = 1.007-5.917, p = .0483) of experiencing a discontinuation than patients receiving sc IFN β-1a. Non-persistent patients receiving DMF had 2.3-times the risk (HR = 2.311, 95% CI = 1.350-3.958, p = .0023) of experiencing an adverse event at a given time point than patients prescribed sc IFN β-1a. No differences in relapse risk or ARR between sc IFN β-1a- and DMF-treated patients were observed.

CONCLUSIONS

sc IFN β-1a-treated patients had comparable persistence and relapse outcomes, and better safety outcomes vs DMF-treated patients across 2 years.

Barriers to MACRA among a cohort of community oncologists

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Background: Value Based Care (VBC) initiatives specifically the Medicare and CHIP Reauthorization Act (MACRA), which includes Medicare Incentive Payment System (MIPS) and Alternative Payment Models (APMs), present challenges for community oncologists. Understanding barriers associated with implementation and compliance are essential for optimal execution. Methods: Using audience response technology, 52 community oncologists and 26 practice managers (PMs) of diverse geography, practice type and affiliations were surveyed in November 2016. Results: Of the attendees, 43% were participating in commercial payer VBC while 33% were participating in the Oncology Care Model (OCM), an APM. Reasons for non-participation: Cost of drugs 58%; data transparency 42%; human resources 33%; technology 29%. The majority of attendees stated limited awareness of MACRA reporting requirements. Once reporting was explained, the stated challenges to MACRA implementation included: inability to measure and track costs 76%; problematic quality improvement activities 56%; lack of patient engagement tools 52%; concern about interpreting CMS reports 52%; meeting meaningful use requirements 33%. In regard to preparation: 52% had survivorship or palliative care plans, 39% made infrastructure investments, and 23% were utilizing clinical pathways. Although 54% stated use of data analytics to maximize efficiency and profitability, half of these were not satisfied with ease of data extraction or output. One third opined that patient satisfaction was irrelevant to quality of care. In the end, nearly half stated reporting requirements could be managed; but 98% stated they were unwilling to assume downside financial risks for hospital and emergency room visits. Conclusions: Identifying and eliminating barriers to MACRA (MIPS/APMs) implementation may be critical to program success. The main reasons for OCM non-participation were costs of drugs and data transparency. There is significant dissatisfaction with available reporting and data extraction tools. Willingness to assume 2-sided risk for total cost of care was identified as the greatest risk to APM adoption.

Retrospective Study of Patients Switched from Tablet Formulations to a Gel Cap Formulation of Levothyroxine: Results of the CONTROL Switch Study

INTRODUCTION

Medication changes involving levothyroxine-either dose titrations or switching formulations-occur frequently in patients with erratic thyroid-stimulating hormone (TSH) levels and persistent hypothyroid symptoms. We investigated whether switching patients from levothyroxine tablets to a gel cap formulation of levothyroxine might reduce dose adjustments and improve tolerability and efficacy outcomes.

OBJECTIVES

Primary study objectives included quantifying the percentage of patients achieving TSH levels within a pre-specified range, median dose changes experienced, and the percentage of patients with improved hypothyroid symptom control after switching from levothyroxine tablets to levothyroxine gel caps.

METHODS

A retrospective medical chart review was conducted among 99 randomly selected hypothyroid patients who were switched from a tablet to a gel cap formulation of levothyroxine. Patients were required to have been on levothyroxine monotherapy for ≥1 year prior to the medication switch. Data was collected for 6 months pre-switch and up to 6 months post-switch.

RESULTS

Of the 99 patients studied, the majority (51.5%) experienced no documented change in TSH status after the switch (P < 0.0001). However, there was a decrease in the mean number of dose changes experienced (1.61 ± 0.96 vs. 0.73 ± 0.96; P < 0.0001). Improved hypothyroid symptom control was reported among 61.6% of patients (61 of 99; P < 0.0001).

CONCLUSION

The results of CONTROL Switch support a strategy of switching patients who may experience tolerability or efficacy problems with standard levothyroxine tablets to the levothyroxine gel cap formulation.

Assessment of treatment patterns associated with injectable disease-modifying therapy among relapsing-remitting multiple sclerosis patients

Background

Availability of oral disease-modifying therapy (DMT) for relapsing–remitting multiple sclerosis (RRMS) may affect injectable DMT (iDMT) treatment patterns.

Objective

The objective of this paper is to evaluate iDMT persistency, reasons for persistency lapses, and outcomes among newly diagnosed RRMS patients.

Methods

Medical records of 300 RRMS patients initiated on iDMT between 2008 and 2013 were abstracted from 18 US-based neurology clinics. Eligible patients had ≥3 visits: pre-iDMT initiation, iDMT initiation (index), and ≥1 visit within 24 months post-index. MS-related symptoms, relapses, iDMT treatment patterns (i.e. persistency, discontinuation, switching, and restart), and reasons for non-persistency were tracked for 24 months.

Results

At 24 months, iDMT persistency was 61.0%; 28.0% of patients switched to another DMT, 8.0% discontinued, and 3.0% stopped and restarted the same iDMT. The most commonly identified reasons for non-persistency were perceived lack of efficacy (22.2%), adverse events (18.8%), and fear of needles/self-injecting (9.4%). At 24 months, 38.0% of patients had experienced a relapse and 11.0% had changes in MRI lesion counts. Patients without MS-related symptoms at index reported increases in the incidence of these symptoms at 24 months.

Conclusions

Non-persistency with iDMT remains an issue in the oral DMT age. Many patients still experienced relapses and disease progression, and should consider switching to more effective therapies.

The Economic Impact of Levothyroxine Dose Adjustments: the CONTROL HE Study

Background

In general, hypothyroidism can be adequately treated with a consistent daily dose of levothyroxine. However, the need for levothyroxine dose adjustments is frequent in clinical practice. The extent to which levothyroxine dose adjustments increase the utilization of healthcare resources has not previously been described in the clinical literature.

Objective

The primary objective of our study was to measure the effect of levothyroxine dose adjustments in terms of their utilization of healthcare resources including direct and indirect costs. A secondary goal was to identify any differences in patient characteristics that may be responsible for levothyroxine dose adjustments.

Methods

A retrospective medical chart review was conducted among patients of selected healthcare providers in the USA. Patients who were recently started on levothyroxine therapy (<6 months) were excluded to avoid situations that were more likely attributable to treatment initiation than inadequate therapeutic effect. Trained nurses extracted data from patient charts and electronic medical record systems for review. We analyzed the cost of resources consumed by the frequency of levothyroxine dose changes over 24 months: 0 dose changes (no dose adjustment group); one dose change, two dose changes, three or more dose changes (≥1 dose adjustment group).

Results

The study included 454 patients. Overall estimated resource utilization was higher per patient in the ≥1 dose adjustment group (US$5824) vs. the no dose adjustment group (US$3166) during the 24-month study period. When direct and indirect costs were combined, overall costs of care were greatest in patients requiring three or more dose adjustments (US$8220/patient). Patients in this cohort incurred 2.5-fold greater total costs compared with patients requiring no dose adjustments (US$8220 vs. US$3166). Among the 58 patients in the group requiring three or more dose adjustments, mean direct medical costs were significantly higher than in the patients requiring no dose adjustments (US$6387 vs. US$2182). Patients with at least one dose adjustment experienced a 40.3% increase in lost productivity vs. patients who had no dose adjustments (US$1381 vs. US$984). Loss of productivity was highest among patients with three or more levothyroxine dose adjustments. Among this cohort, there was an 86.4% increase in lost productivity vs. patients who had no levothyroxine dose adjustments (US$1833 vs. US$984).

Conclusions

Patients experiencing multiple levothyroxine dose adjustments were shown to consume more healthcare resources, resulting in higher costs than those who required no dose adjustments. Each care episode contributed to lost time and wages with total estimated lost productivity escalating with increasing levothyroxine dose adjustments over a 24-month period.

Electronic supplementary material

The online version of this article (doi:10.1007/s40261-016-0462-3) contains supplementary material, which is available to authorized users.

Value of Propensity Score Matching for Equalizing Comparator Groups in Observational Database Studies: A Case Study in Anti-infectives

PURPOSE

Propensity score methodologies can reduce bias and confounding in nonrandomized studies, including pharmaceutical comparative effectiveness studies. An observational case study was developed to demonstrate the impact of propensity score adjustments on outcomes (ie, discharge status) of patients hospitalized for complicated intra-abdominal infections.

METHODS

Two cohorts were examined: intensive care unit (ICU) (vs non-ICU) patients and tigecycline-treated patients (vs patients receiving other antibiotics). Discharge status was captured before propensity scoring.

FINDINGS

The impact of propensity scoring on discharge outcome was greater when comparing ICU patients versus non-ICU patients than when comparing tigecycline recipients versus nonrecipients.

IMPLICATIONS

Propensity scoring should be examined carefully to optimize its effects. Moreover, propensity scoring only addresses bias and confounding in nonrandomized studies that are attributable to variables contained within the dataset (ie, so called "observables") and not to other variables that may influence the relationship between outcomes and other independent variables.

Treatment for Multiple Acute Cardiopulmonary Conditions in Older Adults Hospitalized with Pneumonia, Chronic Obstructive Pulmonary Disease, or Heart Failure

OBJECTIVES

To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions.

DESIGN

Retrospective cohort study.

SETTING

368 U.S. hospitals in the Premier research database.

PARTICIPANTS

Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010.

MEASUREMENTS

Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days.

RESULTS

Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both).

CONCLUSION

Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.

Analysis of Diagnoses Associated with Multiple Sclerosis-Related In-Hospital Mortality Using the Premier Hospital Database

BACKGROUND

We sought to compare mortality rates and related diagnoses in hospitalized patients with multiple sclerosis (MS), those with diabetes mellitus (DM), and the general hospitalized population (GHP).

METHODS

Patients who died between 2007 and 2011 were identified in the US hospital-based Premier Healthcare Database. Demographic information was collected, mortality rates calculated, and principal diagnoses categorized.

RESULTS

Of 55,152 unique patients with MS identified, 1518 died. Mean age at death was 10 years younger for the MS group (63.4 years) than for the DM (73.3 years) and GHP (73.1 years) groups. Age-adjusted mortality rates, based on the 2000 US Standard Million Population, were 1077, 1248, and 1133 per 100,000, respectively. Infection was the most common principal diagnosis at the hospital stay during which the patient died in the MS cohort (43.1% vs. 26.3% and 24.0% in the DM and GHP groups, respectively). Other common principal diagnoses in the MS group included pulmonary (17.5%) and cardiovascular (12.1%) disease. Septicemia/sepsis/septic shock was a secondary diagnosis for 50.7% of patients with MS versus 36.0% and 31.0% of patients in the DM and GHP cohorts, respectively.

CONCLUSIONS

Patients with MS had a shorter life span than patients with DM or the GHP and were more likely to have a principal diagnosis of infection at their final hospital stay. However, the database was limited to codes recorded in the hospital; diagnoses received outside the hospital were not captured.

Evaluation of Tigecycline Efficacy and Post-Discharge Outcomes in a Clinical Practice Population with Complicated Intra-Abdominal Infection: A Propensity Score-Matched Analysis

Background: The utility of tigecycline as compared with other antibiotic therapies in the treatment of patients with complicated intra-abdominal infection (cIAI) and the short- and long-term outcomes of a large cohort of severely ill patients were examined. We provide the first published data on post-discharge events for these patients.

Methods: Retrospective data for the cIAI cohort were obtained from a large clinical database. Patients aged ≥18 y were selected for inclusion based on hospitalization with a relevant diagnosis code and procedure code, and guideline-compliant antimicrobial therapy. Propensity scoring was used to reduce treatment-selection bias introduced by the use of observational data. Tigecycline patients were placed into quintiles based on propensity score and were matched 1:3.

Results: The final model based on propensity score matching included 2,424 patients: Tigecycline (n = 606) and other antibiotic therapy (n = 1,818). Treatment was successful in 426 (70.3%) tigecycline-treated patients and in 1,294 (71.2%) patients receiving other antibiotics. Similar treatment success occurred across all infection sites. Among survivors, treatment failure was associated with a greater need for all-cause re-hospitalization at 30 d and 180 d. No differences in cIAI-related re-hospitalization and discharge status were observed.

Conclusions: Using propensity scores to match populations, similar outcomes were demonstrated between treatment with tigecycline and other antibiotics as expressed by treatment success, the need for re-admission, similar 30-d discharge status, and the need for re-admission at 180 d.

Comparative resource utilization and costs for patients with acute coronary syndrome managed with percutaneous coronary intervention and treated with clopidogrel or prasugrel

PURPOSE

Results of a study of bleeding events and other inhospital outcomes with the use of clopidogrel versus prasugrel in patients with acute coronary syndrome (ACS) managed with percutaneous coronary intervention (PCI) are reported.

METHODS

Demographic and clinical data on adults hospitalized for ACS, managed with PCI, and treated with clopidogrel or prasugrel during a two-year period were extracted from a large hospital claims database. Bleeding rates, hospital length of stay (LOS), and total hospital costs during the index hospitalization were evaluated.

RESULTS

The study sample consisted of 75,297 patients who received clopidogrel and 9,477 who received prasugrel. The unadjusted bleeding rates were 5.7% with clopidogrel use and 3.2% with prasugrel use (p < 0.0001). After propensity score stratification to adjust for selection bias, rates of bleeding events were not significantly different between clopidogrel- and prasugrel-treated patients (odds ratio, 0.90; 95% confidence interval [CI], 0.80-1.02; p = 0.0949). The adjusted mean ± S.D. hospital LOS was 0.22 day lower (95% CI, 0.15-0.28; p < 0.001) with the use of prasugrel versus clopidogrel, and adjusted total mean hospital costs were $375 less for prasugrel-treated patients (p = 0.003).

CONCLUSION

After adjustments for demographic and clinical characteristics, rates of inhospital bleeding in patients who received prasugrel and those who received clopidogrel were not significantly different. The adjusted analyses showed that the mean hospital LOS was shorter and total mean hospital costs were lower for patients treated with prasugrel.

Opioid Medication Practices Observed in Chronic Pain Patients Presenting for All-Causes to Emergency Departments: Prevalence and Impact on Health Care Outcomes

BACKGROUND

Chronic pain is a significant health problem that affects an estimated 100 million American adults (aged ≥ 18 years). Chronic pain affects more individuals than heart disease, stroke, diabetes, and cancer combined. Chronic pain sufferers cost up to $635 billion annually in medical treatment and lost productivity. Opioids are commonly used to treat chronic pain, but their metabolic interactions with concurrently prescribed medications for concomitant disease burdens can affect potency and efficacy of pain therapy. Additionally, misuse of short-acting opioids (SAOs) for chronic pain versus breakthrough pain can create gaps in pain relief. These potentially suboptimal prescribing practices may contribute to the high economic impact associated with chronic pain. 

OBJECTIVE

To examine the prevalence of suboptimal opioid therapy and the associated health care costs resulting from these prescribing practices in real-world patients presenting for all-causes to the emergency department (ED). 

METHODS

This retrospective observational database cohort analysis used the linked Premier-Optum database and included patients with ED visits from 2006 to 2010 having ≥ 60 days supply of opioids in the 75 days prior to the visit. Suboptimal prescribing practices were identified as patients with (a) drug-drug exposures (DDEs), defined as cytochrome P-450 (CYP-450)-metabolized opioids prescribed concurrently with CYP-450 inhibitors or inducers and/or (b) monotherapy with SAOs. Comorbid conditions and principal diagnoses were documented. Readmission rates to the ED and hospital within 72 hours as well as ≤ 30, ≤ 45, ≤ 60, and ≤ 90 days were computed. Total costs for health care were calculated, and reimbursement rates were normalized using 2011 Medicare severity diagnosis-related group (MS-DRG) and CPT-4 information. Nonparametric bootstrapping to adjust for patient comorbidities was applied to cost data.

RESULTS

Of the 9,214 patients identified with chronic pain, potentially suboptimal medication practices prior to the index ED visit were found for 8,539 (92.6%) patients. These appeared to be corrected in 345 (4.0%) patients before leaving the ED. Of 675 (7.3%) patients without prior DDE or exclusive use of SAOs, 345 (51.1%) patients were discharged with one of these. Of the 8,352 patients who left the ED with DDE or exclusive use of SAOs, 1,525 (18.3%) left with a DDE without exclusive SAO use; 4,812 (57.6%) left with both DDE and exclusive SAO use; and 2,015 (24.1%) left with only exclusive SAO use. Only 862 (9.3%) patients from the entire cohort left the ED without DDE or exclusive SAO use. Patients identified with suboptimal opioid use were aged 50 ± 13.5 years and were predominantly female (64.0%). Hypertension (44.0%), fluid and electrolyte disorders (32.7%), chronic pulmonary disease (22.8%), depression (19.6%), diabetes without chronic complications (16.2%), and drug abuse (15.6%) were the most prevalent comorbid conditions identified. The most prevalent principal diagnoses involved symptoms and signs of ill-defined conditions (36.5%), injury and poisoning (18.2%), and diseases of the musculoskeletal system (13.2%). The majority of revisits to the ED and hospital admissions occurred within 72 hours (73.6%) of the index visit and within 30 days (70%), respectively. When adjusted total costs were compared for all patients whose opioid use included DDE versus those without, a significantly greater cost (P  less than  0.05) was observed at every time period except ≤ 72 hours. Respective mean increases in costs were $581, $689, $773, and $1,275 at 30, 45, 60, and 90 days. Exclusive SAO use with or without DDE resulted in a significant increase (P  less than  0.05) in mean costs at all times: $214 at 72 hours; $836 at 30 days; $1,023 at 45 days; $1,022 at 60 days; and $1,536 at 90 days. 

CONCLUSIONS

This study identified potentially suboptimal opioid prescribing practices in a real-world population presenting for all-causes to the ED. The observed rate of ED revisits and inpatient admissions in these patients was associated with increased health care costs. These findings suggest that the ED has the future potential to serve as an ideal setting to identify and correct such practices, thereby improving patient care and reducing resource use and beneficiary costs.

Abstract 12: Do “Drip and Ship” Cases Incur Higher Costs to Warrant CMS MS-DRG Reassignment?

Background: Telestroke networks enable acute stroke patients to receive r-tPA at a remote hospital (ie, spoke) emergency department and are subsequently transferred to another hospital (ie, hub) for additional care - commonly referred to as “drip and ship” (D&S). While hub hospitals do not administer r-tPA in D&S cases, they handle all subsequent care for these patients upon arrival. It is hypothesized that current CMS reimbursement rates do not reflect the higher cost to hospitals that receive D&S patients.

Objective: Compare hospital costs and reimbursement rates for Medicare patients with AIS who received r-tPA, did not receive r-tPA, and were treated and sent to hub hospitals.

Methods: The study included Medicare-covered patients hospitalized with a primary diagnosis of AIS (ICD-9 codes 433.x1, 434.x1, 436) admitted between 6/9/2007 and 12/30/2012 from 5 hub hospitals in the Premier research database with telestroke implementation ranging from 10/2009 - 12/2011. Treatment arms were defined as r-tPA (billing data), D&S (ICD-9 =V45.88), or none. Costs were reported from the hospital perspective and compared with CMS reimbursements based on MS-DRG assignment. Median costs were compared using the Wilcoxon ranked sum test.

Results: 4122 patients were included in the study, with 84 (2%) receiving r-tPA treatment and 233 (6%) having D&S treatment. Total costs and reimbursement rates are summarized in Table 1.

Conclusions: Results from the study demonstrate D&S cases were associated with higher costs than untreated cases, despite not administering r-tPA; however, they were reimbursed similarly. Future reassignment of MS-DRG to these cases may be warranted.

Real-world observations with prasugrel compared to clopidogrel in acute coronary syndrome patients treated with percutaneous coronary intervention in the United States

OBJECTIVES

To compare 30 and 90 day real-world acute myocardial infarction (AMI) and bleeding related rehospitalization rates in acute coronary syndrome (ACS) patients receiving percutaneous coronary intervention (PCI; ACS-PCI) treated with clopidogrel or prasugrel.

RESEARCH DESIGN AND METHODS

Using the Premier hospital database, ACS-PCI patients receiving a drug-eluting (DES) or bare-metal (BMS) stent and clopidogrel or prasugrel from July 2009 to June 2011 were analyzed. Patients were included based on the prasugrel US prescribing information (USPI), excluding patients with a history of transient ischemic attack/stroke and patients ≥75 years without diabetes or prior MI. The primary endpoint was 30 day adjusted AMI rehospitalization rate. Secondary endpoints included 90 day AMI and 30 and 90 day bleeding-related rehospitalization rates. Treatment comparisons were adjusted using propensity score stratification.

RESULTS

At the index event, prasugrel patients (N = 9404) differed from clopidogrel patients (N = 74,163) by having a lower risk of comorbid conditions associated with bleeding, being more likely younger and male, having ST-elevation MI and receiving a DES. For clopidogrel and prasugrel, respectively, the observed AMI-related rehospitalization rates were 4.7% and 3.9% at 30 days (p < 0.0001) and 6.3% and 5.1% at 90 days (p < 0.0001). After adjustment, prasugrel was associated with ∼10% lower odds of AMI-related rehospitalization (30 days: OR = 0.892 [95% CI: 0.798, 0.998]; 90 days, OR = 0.901 [95% CI: 0.817, 0.994]). Adjusted bleeding-related rehospitalization rates were similar to each other (OR = 1.035 at 30 days [95% CI: 0.765, 1.399]; OR = 0.922 at 90 days [95% CI: 0.725, 1.172]).

STUDY LIMITATIONS

Treatment adherence was not assessed. Bleeding events not resulting in a hospitalization (e.g. office, outpatient, or emergency room visits), deaths outside the hospital, or readmissions to a hospital outside of the Premier alliance were not captured in the database.

CONCLUSIONS

The different patient characteristics between prasugrel- and clopidogrel-treated patients suggest physicians are more selective in choosing patients for prasugrel than recommended in the prasugrel USPI. However, after adjustment for these differences, 30 and 90 day AMI rehospitalization rates were lower for prasugrel-treated patients compared to clopidogrel-treated patients, with no difference in adjusted bleeding-related rehospitalization rates.

Patient Outcomes on Day 4 of Intravenous Antibiotic Therapy in Non-Intensive Care Unit Hospitalized Adults With Community-Acquired Bacterial Pneumonia

BACKGROUND

Community-acquired bacterial pneumonia (CABP) is a leading cause of morbidity and mortality especially in hospitalized patients. In place of clinical end points traditionally used to evaluate antimicrobial efficacy for its treatment, Food and Drug Administration guidelines now require all registration trials to assess clinical response at day 4. The primary objective of this study was to assess health outcomes (length of stay [LOS] and hospital charges) between responders and nonresponders at this time point.

METHODS

The Premier database was used to identify adult patients from 4 participating hospitals with a principal diagnosis of CABP (International Classification of Diseases, Ninth Revision, Clinical Modification, codes 481, 482.0, 483.8, 484.3, 484.5, 485, 486, or 487.0) hospitalized between July 1, 2010, and June 30, 2011. Only non-intensive care unit patients with hospital stays exceeding 2 days and receiving intravenous antibiotic agents within 24 hours of admission were included. After institutional review board approvals, a retrospective chart review extracted data for patient demographics, clinical efficacy variables at day 4, LOS, and total hospital charges. Data analysis included multivariable gamma regression models to control for patient demographics and clinical differences between responders and nonresponders.

RESULTS

A total of 666 patients met study the criteria. Mean (SD) age was 70.7 (17.9) years, and 42.5% were males. Among these patients, 277 (41.6%) achieved clinical response by day 4 of initial antibiotic therapy. The unadjusted mean (SD) LOS was 6.3 (2.8) days for responders and 7.4 (5.6) days for nonresponders (P = 0.0009). Respective unadjusted total hospital charges were $22,827 (SD, $17,724) and $26,403 ($36,882) (P = 0.0031). Adjusted for demographics and clinical factors, nonresponders compared with responders had an increased LOS of 0.9 days (8.4 vs 7.5 days; P = 0.0008), resulting in associated charges of approximately $2500 ($34,139 vs $36,629; P = 0.0768).

CONCLUSIONS

In this real-world chart study, less than half of hospitalized patients with CABP achieved clinical response at day 4 of initial intravenous antibiotic therapy. The observed clinical response was associated with a significantly shorter hospital stay and trended toward lower total hospital charges. These findings corroborate the Food and Drug Administration guidance for assessing antimicrobial therapy at day 4 because responder is associated with improved health outcomes.

Differences in resource utilization between patients with diabetes receiving glycemia-targeted specialized nutrition vs standard nutrition formulas in U.S. hospitals

OBJECTIVES

The purpose of the study was to compare patient outcomes and costs for patients with diabetes mellitus (DM) receiving glycemia-targeted specialized nutrition (GTSN) with similar patients receiving standard nutrition (STDN) formulas during acute care hospitalizations.

RESEARCH DESIGN AND METHODS

The study was designed as a retrospective analysis over a 10-year period (2000-2009) of clinical and cost data from 125,000 hospital inpatient episodes in the Premier Research Database. Patients received either GTSN or STDN, by tube or orally, as a component of comprehensive care for hyperglycemia in patients with DM. To adjust for potential cohort imbalances, GTSN patients were matched with STDN patients on the basis of propensity scores, adjusting for many characteristics, including age, sex, race, All Patient Refined Diagnosis-Related Group (APR-DRG) illness severity, APR-DRG mortality risk, and comorbidities.

RESULTS

Tube-fed patients with DM who were provided GTSN had a 0.88-day (95% confidence interval [CI], 0.73-1.02) shorter length of hospital stay (LOS) on average compared with those patients provided STDN. Orally fed patients with DM who were provided GTSN had a 0.17-day (95% CI, 0.14-0.21) shorter LOS than did those patients provided STDN. The shorter LOS associated with GTSN contributed to a cost savings of $2586 for tube-fed patients and $1356 for orally fed patients.

CONCLUSIONS

The use of GTSN feeding formulas for patients with DM in acute care hospital settings was associated with reduced LOS and inpatient hospital episode cost in comparison to STDN.

Comparison of hospital length of stay, costs, and readmissions of alteplase versus catheter replacement among patients with occluded central venous catheters

BACKGROUND

Central venous catheter (CVC) occlusion is common, affecting 30% of all CVCs.

OBJECTIVE

To compare length of stay (LOS), costs, and readmissions associated with the use of alteplase to clear catheter blockage to outcomes associated with catheter replacement.

DESIGN

Retrospective observational study utilizing a large hospital database.

PARTICIPANTS

Hospitalized patients treated for catheter occlusion from January 2006 to December 2011.

MAIN MEASURES

Univariate analyses of patient characteristics and treatment patterns and multivariable regression analyses of postocclusion hospital costs, LOS, and 30- and 90-day readmissions were conducted.

KEY RESULTS

We included 34,579 patients treated for a CVC occlusion by replacement (N=1028) or by alteplase (2 mg) administration (N=33,551). Patients receiving alteplase were somewhat younger than those having catheter replacement (60 ± 19 vs 62 ± 20 years old, P=0.0002). After adjusting for patient and hospital factors via regression modeling, average daily postocclusion costs were $317 lower for alteplase recipients than for catheter replacement patients (95% confidence interval [CI]: 238.22-392.24; P<0.0001). Adjusted total postocclusion costs were $1419 lower for alteplase recipients versus patients receiving catheter replacement (95% CI: 307.27-2458.12; P=0.0121). Postocclusion operating room/surgery, radiology, and supply costs were significantly lower for alteplase recipients (P<0.001). Average adjusted postocclusion LOS was similar for both groups (P>0.05). Odds of readmission were not significantly different at 30 or 90 days.

CONCLUSIONS

Among patients treated for an occluded CVC, alteplase-treated patients had lower daily and total postocclusion costs than patients receiving catheter replacement. Cost differences were mainly driven by lower operating room/surgery, radiology, and supplier costs.

Abstract W P184: Comparison of Thrombolytic Treatment for Acute Ischemic Stroke Pre- and Post -Telemedicine Implementation in the Spoke Hospital Setting

Background: Stroke telemedicine enables “Hub” hospitals with stroke expertise to interact with smaller “Spoke” hospitals in an effort to improve capabilities of accurate diagnosis and treatment of patients suffering from an acute stroke event. Administration of recombinant tissue plasminogen activator (rtPA) for treatment for acute ischemic stroke (AIS) patients is time dependent, and telemedicine has the potential to increase AIS patient thrombolytic treatment rate.

Objective: To compare treatment rates of AIS patients in the Spoke hospital setting before and after implementation of telemedicine.

Methods: The study included patients (age≥18) hospitalized with a primary diagnosis of AIS (ICD-9 codes 433.x1, 434.x1, 436) admitted to the hospital between January 1, 2006 and December 30, 2012 from 13 pre-specified Spoke hospitals in the Premier research database with telemedicine implementation ranging from October 2009 through December 2011. Evidence of MRI or CT scan during the hospital stay was required for study inclusion. Treatment of rtPA was identified using ICD-9 procedure code 99.10 and/or charge master data indicating rtPA use.

Results: A total of 9,629 and 5,228 patients were included in the study population pre- and post- telemedicine implementation respectively. Mean age and gender distribution were similar for pre- and post- implementation (72.0 vs. 71.3 years; 53.1% vs. 51.9% female, respectively). The percentage of patients treated with rtPA increased from 4.4% during pre- to 6.9% during post-implementation (p <0.0001) time period, a 56.8% increase. Increase in treatment percentages were seen in hospitals with <200 beds (1.1% vs. 7.3% p<0.0001) and hospitals with >= 200 beds (5.2% vs. 6.8% p=0.0003).

Conclusions: Results from the study demonstrate that the percent of patients treated with rtPA with telemedicine increased more than 50% as compared to the pre-telemedicine time period. Smaller hospitals showed the most significant increase in rtPA treatment rate. This finding supports previous findings that telemedicine improves appropriate use of thrombolytic treatment for AIS patients and highlights the impact in smaller hospital settings.

Hospital readmissions following initiation of nebulized arformoterol tartrate or nebulized short-acting beta-agonists among inpatients treated for COPD

BACKGROUND

Inpatient admissions for chronic obstructive pulmonary disease (COPD) represent a significant economic burden, accounting for over half of direct medical costs. Reducing 30-day readmissions could save health care resources while improving patient care. Recently, the Patient Protection and Affordable Care Act authorized reduced Medicare payments to hospitals with excess readmissions for acute myocardial infarction, heart failure, and pneumonia. Starting in October 2014, hospitals will also be penalized for excess COPD readmissions. This retrospective database study investigated whether use of arformoterol, a nebulized long-acting beta agonist, during an inpatient admission, had different 30-day all-cause readmission rates compared with treatment using nebulized short-acting beta agonists (SABAs, albuterol, or levalbuterol).

METHODS

A US nationally representative hospital database was used to study adults aged ≥40 years, discharged between January, 2006 and March, 2010, and with a diagnosis of COPD. Patients receiving arformoterol on ≥80% of days following treatment initiation were compared with patients receiving a nebulized SABA during hospitalization. Arformoterol and nebulized SABA patients were matched (1:2) for age, sex, severity of inpatient admission, and primary/secondary COPD diagnosis. Logistic regression compared the odds of readmission while adjusting for age, sex, race, admission type, severity, primary/secondary diagnosis, other respiratory medication use, respiratory therapy use, oxygen use, hospital size, and teaching status.

RESULTS

This retrospective study compared 812 arformoterol patients and 1,651 nebulized SABA patients who were discharged from their initial COPD hospital admission. An intensive care unit stay was more common among arformoterol patients (32.1% versus 18.4%, P<0.001), suggesting more severe symptoms during the initial admission. The observed readmission rate was significantly lower for arformoterol patients than for nebulized SABA patients (8.7% versus 11.9%, P=0.017), as were the adjusted odds of readmission (odds ratio 0.69, 95% confidence interval 0.51-0.92).

CONCLUSION

All-cause 30-day readmission rates were significantly lower for arformoterol patients than nebulized SABA patients, both before and after adjusting for patient and hospital characteristics.

Mortality in preterm infants with respiratory distress syndrome treated with poractant alfa, calfactant or beractant: a retrospective study

OBJECTIVE

The objective of this study is to compare all-cause in-hospital mortality in preterm infants with respiratory distress syndrome (RDS) treated with poractant alfa, calfactant or beractant.

STUDY DESIGN

A retrospective cohort study of 14 173 preterm infants with RDS, treated with one of three surfactants between 2005 and 2009, using the Premier Database was done. Multilevel, multivariable logistic regression modeling, adjusting for patient- and hospital-level factors was performed.

RESULT

Calfactant treatment was associated with a 49.6% greater likelihood of death than poractant alfa (odds ratio (OR): 1.496, 95% confidence interval (CI): 1.014-2.209, P=0.043). Beractant treatment was associated with a non-significant 37% increase in mortality, compared with poractant alfa (OR: 1.370, 95% CI: 0.996-1.885, P=0.053). No differences in mortality were observed between calfactant and beractant treatment (OR: 1.092, 95% CI: 0.765-1.559, P=0.626).

CONCLUSION

Poractant alfa treatment for RDS was associated with a significantly reduced likelihood of death when compared with calfactant and a trend toward reduced mortality when compared with beractant.

A retrospective study of the clinical and economic burden during hospitalizations among cancer patients with febrile neutropenia

OBJECTIVE

The objective of this study was to provide up-to-date estimates of the clinical and economic burden that occurs during inpatient treatment of cancer patients with febrile neutropenia (FN).

METHODS

A retrospective cohort study was conducted using 2007-2010 hospital discharge data from the Premier database. The study population included adult patients with discharge diagnoses of neutropenia (ICD-9 code 288.0x) with fever or infection and receipt of intravenous antibiotics and female breast cancer, lung cancer, colorectal cancer, ovarian cancer, non-Hodgkin lymphoma (NHL), or Hodgkin lymphoma. Primary study outcomes were inpatient mortality, hospital length of stay (LOS), and total hospitalization cost for each patient's first FN-related hospitalization. Logistic regressions (for mortality) and multivariate linear regressions (for LOS and cost) were conducted to assess the effect of comorbidities and infection types on study outcomes, adjusting for other patient and hospital characteristics.

RESULTS

Among 16,273 cancer patients hospitalized with FN, the inpatient case fatality rate was 10.6%, mean LOS was 8.6 days, and mean total hospitalization cost was $18,880. Lung cancer patients had the highest inpatient case fatality rate (15.7%), and NHL patients had the longest LOS (10.1 days) and the highest cost ($24,218). Multivariate analyses showed that most comorbidities were associated with a greater risk of mortality, longer LOS, and higher cost. Septicemia/bacteremia and pneumonia were associated with a greater risk of mortality, and most types of infection were associated with a longer LOS and higher cost.

LIMITATIONS

The total burden of FN may be under-estimated in this study because outpatient treatment and any patient deaths or costs that occurred outside of Premier hospitals could not be captured.

CONCLUSIONS

FN-related hospitalizations among cancer patients are costly and accompanied by considerable mortality risk. Substantial differences in the clinical and economic burden of FN exist depending on cancer types, comorbidities, and infection types.

Pediatric vancomycin use in 421 hospitals in the United States, 2008

BACKGROUND

Recommendations to prevent the spread of vancomycin resistance have been in place since 1995 and include guidelines for inpatient pediatric use of vancomycin. The emergence of large databases allows us to describe variation in pediatric vancomycin across hospitals. We analyzed a database with hospitalizations for children under 18 at 421 hospitals in 2008.

METHODOLOGY/PRINCIPAL FINDINGS

The Premier hospital 2008 database, consisting of records for 877,201 pediatric hospitalizations in 421 hospitals, was analyzed. Stratified analyses and logistic mixed effects models were used to calculate the probability of vancomycin use while considering random effects of hospital variation, hospital fixed effects and patient effects, and the hierarchical structure of the data. Most hospitals (221) had fewer than 10 hospitalizations with vancomycin use in the study period, and 47 hospitals reported no vancomycin use in 17,271 pediatric hospitalizations. At the other end of the continuum, 21 hospitals (5.6% of hospitals) each had over 200 hospitalizations with vancomycin use, and together, accounted for more than 50% of the pediatric hospitalizations with vancomycin use. The mixed effects modeling showed hospital variation in the probability of vancomycin use that was statistically significant after controlling for teaching status, urban or rural location, size, region of the country, patient ethnic group, payor status, and APR-mortality and severity codes.

CONCLUSIONS/SIGNIFICANCE

The number and percentage of pediatric hospitalizations with vancomycin use varied greatly across hospitals and was not explained by hospital or patient characteristics in our logistic models. Public health efforts to reduce vancomycin use should be intensified at hospitals with highest use.

Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures

PURPOSE.: We performed an analysis of hospitalizations involving thoracentesis procedures to determine whether the use of ultrasonographic (US) guidance is associated with differences in complications or hospital costs as compared with not using US guidance. METHODS.: We used the Premier hospital database to identify patients with ICD-9 coded thoracentesis in 2008. Use of US guidance was identified using CPT-4 codes. We performed univariate and multivariable analyses of cost data and adjusted for patient demographics, hospital characteristics, patient morbidity severity, and mortality. Logistic regression models were developed for pneumothorax and hemorrhage adverse events, controlling for patient demographics, morbidity severity, mortality, and hospital size. RESULTS.: Of 19,339 thoracentesis procedures, 46% were performed with US guidance. Mean total hospitalization costs were $11,786 (±$10,535) and $12,408 (±$13,157) for patients with and without US guidance, respectively (p < 0.001). Unadjusted risk of pneumothorax or hemorrhage was lower with US guidance (p = 0.019 and 0.078, respectively). Logistic regression analyses demonstrate that US is associated with a 16.3% reduction likelihood of pneumothorax (adjusted odds ratio 0.837, 95% CI: 0.73-0.96; p= 0.014), and 38.7% reduction in likelihood of hemorrhage (adjusted odds ratio 0.613, 95% CI: 0.36-1.04; p = 0.071). CONCLUSIONS.: US-guided thoracentesis is associated with lower total hospital stay costs and lower incidence of pneumothorax and hemorrhage. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011.

Economic impact of ventilator-associated pneumonia in a large matched cohort

OBJECTIVE

To evaluate the economic impact of ventilator-associated pneumonia (VAP) on length of stay and hospital costs. Design. Retrospective matched cohort study.

SETTING

Premier database of hospitals in the United States.

PATIENTS

Eligible patients were admitted to intensive care units (ICUs), received mechanical ventilation for ≥2 calendar-days, and were discharged between October 1, 2008, and December 31, 2009.

METHODS

VAP was defined by International Classification of Diseases, Ninth Revision (ICD-9), code 997.31 and ventilation charges for ≥2 calendar-days. We matched patients with VAP to patients without VAP by propensity score on the basis of demographics, administrative data, and severity of illness. Cost was based on provider perspective and procedural cost accounting methods.

RESULTS

Of 88,689 eligible patients, 2,238 (2.5%) had VAP; the incidence rate was 1.27 per 1,000 ventilation-days. In the matched cohort, patients with VAP ([Formula: see text]) had longer mean durations of mechanical ventilation (21.8 vs 10.3 days), ICU stay (20.5 vs 11.6 days), and hospitalization (32.6 vs 19.5 days; all [Formula: see text]) than patients without VAP ([Formula: see text]). Mean hospitalization costs were $99,598 for patients with VAP and $59,770 for patients without VAP ([Formula: see text]), resulting in an absolute difference of $39,828. Patients with VAP had a lower in-hospital mortality rate than patients without VAP (482/2,144 [22.5%] vs 630/2,144 [29.4%]; [Formula: see text]).

CONCLUSIONS

Our findings suggest that VAP continues to occur as defined by the new specific ICD-9 code and is associated with a statistically significant resource utilization burden, which underscores the need for cost-effective interventions to minimize the occurrence of this complication.

Evaluation of hospital complications and costs associated with using ultrasound guidance during abdominal paracentesis procedures

OBJECTIVE

Abdominal paracentesis is commonly performed for diagnostic, therapeutic, and palliative indications, but the use of ultrasound guidance for these procedures is relatively recent, variable, and not well documented. A retrospective database analysis of abdominal paracentesis procedures was performed to determine whether ultrasound guidance was associated with differences in adverse events (AEs) or hospital costs, compared to procedures without ultrasound guidance.

METHODS

The hospital database maintained by Premier was used to identify patients with abdominal paracentesis International Classification of Diseases - 9th Revision - Clinical Modification (ICD-9 code 54.9, Common Procedural Terminology CPT-4 codes 49080, 49081) in 2008. Use of ultrasound guidance was determined via patient billing data. The incidence of selected AEs and patients' hospitalization costs were calculated for two groups: procedures with ultrasound guidance and those without. Univariate and multivariable analyses were performed to evaluate differences between groups.

RESULTS

This study identified 1297 abdominal paracentesis procedures, 723 (56%) with ultrasound and 574 (44%) without. The indications for paracentesis were similar between the two groups. The incidence of AEs was lower in ultrasound-guided procedures: all AEs (1.4% vs 4.7%, p = 0.01), post-paracentesis infection (0.41% vs 2.44%, p = 0.01), hematoma (0.0% vs 0.87%, p = 0.01), and seroma (0.14% vs 1.05%, p = 0.03). Analyses adjusted for patient and hospital covariates revealed significant reductions in AEs (OR = 0.349, 95% CI = 0.165, 0.739, p = 0.0059) and hospitalization costs ($8761 ± $5956 vs $9848 ± $6581, p < 0.001) for procedures with ultrasound guidance vs those without.

LIMITATIONS

There are several limitations to using claims data for clinical analyses; causality cannot be determined, the possibility of miscoded or missing data, and the inability to control for elements not captured in claims data that may influence clinical outcomes.

CONCLUSIONS

The use of ultrasound guidance in abdominal paracentesis procedures is associated with fewer AEs and lower hospitalization costs than procedures where ultrasound is not used.

The 3-year clinical and functional course of schizophrenia among individuals with and without diabetes at study entry

OBJECTIVE

This prospective observational study compared the 3-year clinical and functional course of schizophrenia among individuals with and without diabetes at study entry.

METHOD

Data were drawn from a large, 3-year, multisite, prospective, naturalistic study of treatment for schizophrenia-related disorders. The study was conducted in the United States between July 1997 and September 2003 and represented treatment practices in diverse systems of care. Participants were diagnosed with schizophrenia or schizoaffective or schizophreniform disorders based on DSM-IV criteria. Clinical and functional outcomes were assessed at study enrollment and at 12-month intervals using standard psychiatric measures, medical records, and a validated patient-reported questionnaire. Diabetes status was determined by participant interview at enrollment. Statistical analyses used mixed models with repeated measures.

RESULTS

Of 594 participants queried about comorbid medical conditions at enrollment, 76 (12.8%) reported having diabetes. Other comor-bid conditions were reported by 79% of the diabetes group (N = 60) and 50% of the nondiabetes group (N = 259). Across the 3-year study, participants with diabetes differed significantly from participants without diabetes on 2 of 36 outcome measures: more contacts with nonpsychiatrist physicians (p < .001) and poorer physical health (p = .015). Groups did not differ significantly on mental health symptomatology, mental health resource utilization, legal and safety issues, substance use, productivity, activities and relationships, or quality of life.

CONCLUSIONS

In this 3-year, prospective, naturalistic study, the course of schizophrenia did not differ significantly between participants with and without diabetes, although persons with diabetes did have poorer physical health and more contacts with nonpsychiatrist physicians. Findings highlight the need for better medical treatment for people with schizophrenia, both with and without comorbid diabetes.

Effect of early clopidogrel discontinuation on rehospitalization in acute coronary syndrome: results from two distinct patient populations

PURPOSE

Results of a study of the association between early discontinuation of clopidogrel therapy and rehospitalization rates among patients with acute coronary syndrome (ACS) are reported.

SUMMARY

In a retrospective observational study, analyses of two nationally representative cohorts of adults hospitalized for acute myocardial infarction (AMI) or coronary stent insertion were conducted to assess risk factors for ACS-related adverse outcomes (rehospitalization for AMI or coronary revascularization) during the 12 months after completion of an initial 28-day course of clopidogrel therapy. Case data were sourced from a commercial insurance claims database, a pharmacy administrative claims database, and a combined dataset that linked hospital discharge and outpatient service data; a time-varying method was used to differentiate adverse events occurring "on" and "off" clopidogrel therapy. One cohort analysis (n = 42,757) indicated that patients who discontinued clopidogrel early (i.e., within 12 months of index discharge) were at significantly increased risk for ACS-related rehospitalization during the 12-month study period (hazard ratio [HR] = 1.11; 95% confidence interval [CI], 1.02-1.20; p < 0.05). In the other cohort analysis (n = 3,171), early clopidogrel discontinuation was associated with an increased risk of rehospitalization or inpatient death (HR = 1.75; 95% CI, 1.59-1.91; p < 0.0001).

CONCLUSION

Observational evidence from analyses of data on two large cohorts of patients with primarily employer-sponsored health insurance suggests that early discontinuation of clopidogrel therapy after hospitalization for AMI or coronary stent insertion is associated with a significant increase in the risk of ACS-related rehospitalization within the 12-month postdischarge period.

Cost and resource utilization associated with fluconazole as first-line therapy for invasive candidiasis: a retrospective database analysis

BACKGROUND

Fluconazole is a standard first-line therapy for candidemia/invasive candidiasis (C/IC), based on its efficacy, safety profile, and comparatively low acquisition cost. However, little is known about the total costs associated with fluconazole treatment for this indication, particularly in cases of clinical failure.

OBJECTIVE

The aim of this study was to examine overall costs, resource use, and treatment outcomes associated with fluconazole as first-line therapy for invasive Candida infections in the United States.

METHODS

A retrospective analysis of data from a US hospital-based (>500 hospitals), service-level database was performed. All patients aged >16 years with primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification codes for IC or septicemia, receiving intravenous fluconazole treatment, and discharged between October 1, 2004 and September 30, 2005 were selected. Costs and resource use were calculated from the start of antifungal therapy until discharge. Two groups were analyzed: patients who received fluconazole only and those who required a second-line antifungal. Separate analyses for the survivor subpopulations were also conducted.

RESULTS

A total of 7170 patients met the inclusion criteria; 21.2% required an additional antifungal agent. Overall mortality was 27.1%, and total mean treatment cost for all patients was $44,482 (in 2005 US dollars). Patients treated with fluconazole alone incurred mean costs of $36,319. Mean hospital and intensive care unit stays in the fluconazole monotherapy group were 17.9 days and 7.1 days, respectively. Patients requiring additional therapy had a mortality rate of 34.5% and a mean treatment cost of $76,329; in this group, the mean hospital and intensive care unit stays were 31.7 days and 14.8 days, respectively.

CONCLUSIONS

The overall resource use associated with fluconazole as first-line treatment for C/IC was high, especially in patients who required additional antifungal therapy. Future studies should examine the patterns of care and costs associated with alternative treatment options as first-line C/IC therapy.

Managing severe sepsis: a national survey of current practices

PURPOSE

Current practices for managing severe sepsis in U.S. hospitals were studied.

METHODS

A questionnaire was distributed to nurse managers who were members of the Association of Critical Care Nurses to assess current practices associated with the management of severe sepsis, including assessment of sepsis management priority, patient identification and screening process for sepsis, current treatment practices, process measures and outcomes measurements, and hospital demographics. Differences among small (<200 beds), medium (200-399 beds), and large (>/=400 beds) hospitals were identified using chi-square analysis and Student's t test.

RESULTS

A total of 414 surveys were completed, received, and analyzed. As hospital bed size increased, so did the percentage of hospitals with an active severe sepsis program (p = 0.002). Hospitals rated the effect of severe sepsis on mortality as the paramount issue influencing severe sepsis prioritization. Screening for severe sepsis most commonly occurred upon deterioration of laboratory test values, regardless of hospital size. Of 17 Surviving Sepsis Campaign (SSC) treatment guidelines, hospitals most frequently reported adherence to ordering cultures within 6 hours of onset of acute organ dysfunction (71.3%). The least followed guideline was initiation of drotrecogin alfa (activated) within 24 hours of acute organ dysfunction (37.9%).

CONCLUSION

A survey of critical care nurses revealed that of the 17 SSC treatment guidelines, hospitals most frequently reported adherence to those concerning prompt ordering of cultures, prompt administration of broad-spectrum antibiotics, and prompt initiation of deep venous thrombosis prophylaxis. Deterioration of laboratory test values was the most common identifier of severe sepsis, regardless of hospital size. Among all hospitals, the least followed guideline was prompt initiation of drotrecogin alfa (activated) therapy.

Simplified pharmacoeconomics of critical care and severe sepsis

Understanding pharmacoeconomic evaluation can empower clinicians to be stronger decision makers. However, cost-effectiveness analyses (CEAs) in critical care are sometimes not easy to understand and often not placed in context with other interventions. The purpose of this article is to clarify and simplify the CEA process using examples from critical care and severe sepsis. First discussed is cost-effectiveness as a framework for clinical decision making and how it compares to other types of economic evaluations. Then important considerations when conducting or reviewing CEAs are explored, such as perspective, discounting, sensitivity analysis, and grading of CEAs, as well as shortcomings and resistance to using CEAs. Next, applications of CEA in critical care and severe sepsis are reviewed. Included is the Food and Drug Administration-approved drug for severe sepsis, drotrecogin alfa (activated), as an example of a recently new critical care intervention that resulted in significant interest in understanding cost-effectiveness. Finally, CEAs of other medical and nonmedical interventions are placed in context with CEAs from critical care. Understanding pharmacoeconomic evaluation can empower clinicians to be stronger decision makers. CEAs provide decision makers a quantitative measure of the value of therapeutic options that can guide clinicians toward balancing the cost burdens of therapy with their profound effects and choosing between options that compete for funding.

Timing of drotrecogin alfa (activated) initiation in treatment of severe sepsis: a database cohort study of hospital mortality, length of stay, and costs

INTRODUCTION

For patients with critical conditions including severe sepsis, minimizing the time from presentation to treatment is important to improving outcomes. Understanding the factors influencing high hospital mortality and resource utilization in severe sepsis continues to interest clinicians and researchers. This study examined the associations between timing of drotrecogin alfa (activated) (DrotAA) initiation and hospital mortality, length-of-stay, and costs.

METHODS

We conducted a cohort study of adult patients (N = 1179) with intensive care unit stays from November 2001 to June 2003 who received DrotAA in US hospitals with data in the Solucient ACTracker database. We defined evident severe sepsis (ESS) as concurrent antibiotic plus ventilator and/or vasopressor use. We characterized the interval between ESS and DrotAA initiation as Same-day, Next-day, or Day 2+. We compared group characteristics and created multivariate models of hospital mortality, length-of-stay, and costs.

RESULTS

Forty-three percent of patients received Same-day DrotAA, 30% Next-day, and 27% Day 2+. Same-day and Next-day patients had more organ dysfunctions at ICU admission than Day 2+ patients (1.1 +/- 0.9 and 1.2 +/- 0.8 vs. 1.0 +/- 0.8; p = 0.021 and p < 0.001, respectively), but from ESS to DrotAA initiation, organ dysfunctions for Day 2+ patients had increased more (+0.0 and +0.4 vs. +0.6, respectively; all p < 0.0001). Increased mortality was observed with administration later than Same-day, although only for the Day 2+ group did the association remain significant (p < 0.05) after adjusting for clinical and demographic factors. Only Next-day initiation was associated with significantly decreased costs (p = 0.0145).

CONCLUSIONS

Timing of DrotAA initiation is associated with clinical and economic outcomes in severe sepsis. The potential impact of this timing on hospital mortality, length-of-stay, and costs deserves further study.

Use of drotrecogin alfa (activated) in older patients with severe sepsis

Drotrecogin alfa (activated) has been approved by the United States Food and Drug Administration for treatment of patients at high risk of death from severe sepsis. Severe sepsis is common, and its occurrence increases dramatically with age. Clinical use data, however, suggest that drotrecogin alfa (activated) may be underused in older patients, possibly due to concern over the drug's anticoagulant effects and perceived high cost. In addition, clinicians often treat older patients less aggressively than younger patients. We reviewed a subgroup analysis of patients aged 75 years and older from a large clinical trial evaluating efficacy and safety of drotrecogin alfa (activated), as well as cost-effectiveness data from real-world clinical use of the drug in older patients. We also explored ethical dilemmas of treating older patients with sepsis. Drotrecogin alfa (activated) is safe, effective, and cost-effective in older patients with severe sepsis and should be considered for elderly intensive care patients who are high risk of death and who have no contraindications to treatment.

Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care

BACKGROUND

Relatively little is known about the relationships between medication adherence and long-term functional outcomes in the treatment of schizophrenia. To extend previous research, we prospectively examined the relationships between adherence with any antipsychotic medication and functional outcomes among schizophrenia patients treated over a 3-year period, assessed the stability of adherence over time, and examined whether adherence in the first year predicts changes in functional outcomes over the following 2 years.

METHOD

Analyses included 1906 participants with DSM-IV diagnoses of schizophrenia or schizoaffective or schizophreniform disorder in a multi-site, 3-year, prospective, naturalistic study conducted in the United States between July 1997 and September 2003. Outcome measures were assessed at 6-month intervals using systematic medical record abstraction and structured interview of patients. Adherence with antipsychotic regimen was assessed using patient-reported adherence and the medication possession ratio (percent days with prescription for any antipsychotic), dichotomized into adherence and non-adherence. Analyses employed generalized estimating equations and mixed models with repeated measures.

RESULTS

Nonadherence was associated with poorer functional outcomes, including greater risks of psychiatric hospitalizations, use of emergency psychiatric services, arrests, violence, victimizations, poorer mental functioning, poorer life satisfaction, greater substance use, and more alcohol-related problems (all p < .001). Adherence was relatively stable, with 77.3% of patients maintaining the same adherence status from the first year to the second year. Nonadherence in the first year predicted significantly poorer outcomes in the following 2 years.

CONCLUSIONS

Findings highlight the importance of adherence with antipsychotic medication in the long-term treatment of schizophrenia and its potential beneficial impact on the mental health and criminal justice delivery systems.

A comparison of olanzapine and risperidone on the risk of psychiatric hospitalization in the naturalistic treatment of patients with schizophrenia

Background

Decreasing hospital admissions is important for improving outcomes for people with schizophrenia and for reducing cost of hospitalization, the largest expenditure in treating this persistent and severe mental illness. This prospective observational study compared olanzapine and risperidone on one-year psychiatric hospitalization rate, duration, and time to hospitalization in the treatment of patients with schizophrenia in usual care.

Methods

We examined data of patients newly initiated on olanzapine (N = 159) or risperidone (N = 112) who continued on the index antipsychotic for at least one year following initiation. Patients were participants in a 3-year prospective, observational study of schizophrenia patients in the US. Outcome measures were percent of hospitalized patients, total days hospitalized per patient, and time to first hospitalization during the one-year post initiation. Analyses employed a generalized linear model with adjustments for demographic and clinical variables. A two-part model was used to confirm the findings. Time to hospitalization was measured by the Kaplan-Meier survival formula.

Results

Compared to risperidone, olanzapine-treated patients had significantly lower hospitalization rates, (24.1% vs. 14.4%, respectively, p = 0.040) and significantly fewer hospitalization days (14.5 days vs. 9.9 days, respectively, p = 0.035). The mean difference of 4.6 days translated to $2,502 in annual psychiatric hospitalization cost savings per olanzapine-treated patient, on average.

Conclusions

Consistent with prior clinical trial research, treatment-adherent schizophrenia patients who were treated in usual care with olanzapine had a lower risk of psychiatric hospitalization than risperidone-treated patients. Lower hospitalization costs appear to more than offset the higher medication acquisition cost of olanzapine.

Drug-related morbidity and mortality: updating the cost-of-illness model

OBJECTIVE

To update the 1995 estimate of $76.6 billion for the annual cost of drug-related morbidity and mortality resulting from drug-related problems (DRPs) in the ambulatory setting in the United States to reflect current treatment patterns and costs.

DESIGN

For this study, we employed the decision-analytic model developed by Johnson and Bootman. We used the model's original design and probability data, but used updated cost estimates derived from the current medical and pharmaceutical literature. Sensitivity analyses were performed on cost data and on probability estimates.

SETTING

Ambulatory care environment in the United States in the year 2000.

PATIENTS AND OTHER PARTICIPANTS

A hypothetical cohort of ambulatory patients.

MAIN OUTCOME MEASURES

Average cost of health care resources needed to manage DRPs.

RESULTS

As estimated using the decision-tree model, the mean cost for a treatment failure was $977. For a new medical problem, the mean cost was $1,105, and the cost of a combined treatment failure and resulting new medical problem was $1,488. Overall, the cost of drug-related morbidity and mortality exceeded $177.4 billion in 2000. Hospital admissions accounted for nearly 70% ($121.5 billion) of total costs, followed by long-term-care admissions, which accounted for 18% ($32.8 billion).

CONCLUSION

Since 1995, the costs associated with DRPs have more than doubled. Given the economic and medical burdens associated with DRPs, strategies for preventing drug-related morbidity and mortality are urgently needed.