Measuring the burden of illness for end-stage renal disease: some heavy lifting required

Estimates for the burden of illness (BOI) attributable to end-stage renal disease (ESRD) in Canada are presented in the article by Zelmer. This Commentary describes the methodology of BOI analysis, its role in formulating public policy, and the potential application to improving care for ESRD.

Observation unit treatment of heart failure with nesiritide: results from the proaction trial

This was a multicenter, randomized, double-blind, placebo-controlled pilot study, evaluating the safety and efficacy of a standard care treatment regimen with the addition of either nesiritide or placebo (SCP) in 237 Emergency Department (ED)/Observation Unit (OU) patients with decompensated heart failure (HF). Efficacy measures included initial admission, length of hospital stay (LOS), and inpatient rehospitalization through 30 days. Compared to the standard care group, patients who also received nesiritide had 11% fewer inpatient hospital admissions at the index ED visit (55% SCP, 49% nesiritide, p = 0.436), and 57% fewer inpatient hospitalizations within 30 days after discharge from the index hospitalization (23% SCP, 10% nesiritide, p = 0.058). The duration of rehospitalization was shorter for nesiritide patients (median LOS 2.5 vs. 6.5 days, p = 0.032). The incidence of symptomatic hypotension was low and did not differ between the groups. This study showed that nesiritide is safe when used in the emergency department, observation units, or similar settings.

Economic analysis of unrelated allogeneic bone marrow transplantation: results from the randomized clinical trial of T-cell depletion vs unmanipulated grafts for the prevention of graft-versus-host disease

Unrelated-donor marrow transplantation is a potential option for transplant candidates lacking a compatible related donor. The T-cell Depletion Study compared the 3-year disease-free survival for patients receiving T-cell-depleted (TCD) donor marrow (n = 203) vs unmanipulated donor marrow with methotrexate and cyclosporine (M/C) (n = 207). Hospital costs during index admission were documented with billing data, while hospital costs during subsequent 6-month follow-up were estimated from case report forms. Patients with index admission billing were included in the analysis (TCD = 119, M/C = 127). Total hospital length of stay (LOS) was similar across groups, with medians 47.0 days for TCD and 52.0 days for M/C (P = 0.72). Total hospital costs were comparable, 145,115 dollars vs 141,981 dollars (P = 0.63) for TCD and M/C, respectively. However, controlling for site and patient characteristics, TCD was associated with a 12.1% reduction in LOS for the index admission (95% CI -19.4%, -4.3%). Independent of treatment, HLA matching (6/6) was associated with an 8.6% (95% CI -17.4%, +1.2%) reduction in the index admission LOS, while cost was lower by 15.8% (95% CI -26.7%, -3.3%). Treatment costs were similar for TCD and M/C study groups. Savings on reduced cost for treating acute graft-versus-host disease were likely offset by increase in serious infections in the TCD arm.

Economic issues in the treatment and prevention of deep vein thrombosis from a managed care perspective

Treatment and prevention of deep vein thrombosis (DVT) raise a number of important economic issues. Economic burden of the disease is a primary concern. Enrollment trends indicate that the patient population mix in managed care health plans is changing. Health plans are enrolling a growing number of members who are at higher risk for DVT. Accordingly, managed care health plans will increasingly need to focus attention on the development of high-quality and cost-effective strategies for treatment and prevention of DVT. It is widely agreed that the use of low-molecular-weight heparin (LMWH) is safe and effective, and there is also good evidence that its use is cost effective in selected indications. The shift from inpatient to outpatient treatment that is made possible by substitution of LMWH for conventional unfractionated heparin brings with it a need to restructure healthcare delivery resources. This may have substantial economic impact on both providers and health plan members. Growing recognition of the DVT risk associated with various disease states, as well as the costly long-term sequelae of DVT, is spurring a trend to broader use of LMWH for prophylaxis. The relative cost effectiveness of prevention depends on the tradeoff between an expenditure that is made today and an uncertain future benefit. What is needed now is better evidence as a basis for decisions regarding DVT prophylaxis and clinical studies that track the long-term clinical and economic impact of DVT.

Cost for inpatient care of venous thrombosis: a trial of enoxaparin vs standard heparin

BACKGROUND

Enoxaparin, a low-molecular-weight heparin administered to hospitalized patients once or twice daily, has shown efficacy and safety equivalent to unfractionated heparin in the treatment of acute venous thromboembolic disease. Although the cost of either enoxaparin regimen is greater than that of unfractionated heparin, the overall cost of care for each of these 3 treatment strategies is unknown.

METHODS

A cost minimization analysis of a 3-month, partially blinded, randomized, controlled efficacy and safety trial of anticoagulant therapy for deep vein thrombosis. Three hundred thirty-nine hospitalized patients with symptomatic lower extremity deep vein thrombosis were randomly assigned to initial therapy with subcutaneous enoxaparin either once (n = 112) or twice (n = 123) daily, or with dose-adjusted intravenous unfractionated heparin (n = 104), followed by long-term oral anticoagulant therapy. Estimated 1997 total cost from a third-party payer perspective for the 3-month episode of care was calculated by assigning standard unit costs to counts of medical resources used by each patient in the clinical trial.

RESULTS

Average total cost for the 3-month episode of care was similar across all 3 treatment regimens: once-daily dose of enoxaparin, $12,166 (95% confidence interval [CI], $10,744-$13,588); twice-daily dose of enoxaparin, $11,558 (95% CI, $10,201-$12,915); and unfractionated heparin, $12,146 (95% CI, $10,670-$12,622). Bootstrapped estimates and sensitivity analyses did not significantly change findings.

CONCLUSIONS

There was no significant difference in the overall cost for the 3-month episode of care for patients treated with either enoxaparin or unfractionated heparin. Additional acquisition costs for anticoagulant medication among patients treated with enoxaparin were offset by savings associated with lower incidence of hospital readmission and shorter duration of venous thromboembolism-related readmissions.

Relationship of hemoglobin A1c, age of diabetes diagnosis, and ethnicity to clinical outcomes and medical costs in a computer-simulated cohort of persons with type 2 diabetes

OBJECTIVE

To project the impact of maintaining long-term glycemic control (i.e., a sustained reduction in glycosylated hemoglobin (hemoglobin A1c [HbA1c]) on the lifetime incidence and direct medical costs of complications in persons with type 2 diabetes.

STUDY DESIGN, PATIENTS, AND METHODS

Computer simulation of hypothetical patient cohorts using a published model developed by the National Institutes of Health.

RESULTS

Across all HbA1c levels, Hispanics had the highest and whites had the lowest complication rates. With lower maintained HbA1c, the absolute decrease in complication rates was greatest and the reduction in direct medical expenditures was highest among Hispanics (18% vs 15% for blacks and 12% for whites). Complication rates and costs were most dramatically reduced when lower levels of HbA1c were maintained among persons with a younger age at diagnosis.

CONCLUSIONS

Maintaining long-term glycemic control reduces complication rates and costs for medical care for all ethnic groups regardless of age at diagnosis. Relatively greater benefit is achieved by interventions targeting Hispanics and younger, newly diagnosed persons.

A prospective study of the cost-utility of the multichannel cochlear implant

CONTEXT

Prior clinical studies have indicated that cochlear implantation provides benefits to individuals with advanced sensorineural hearing loss who are unable to gain effective speech recognition with hearing aids.

OBJECTIVE

To determine the cost per quality-adjusted life-year (QALY) for adults receiving multichannel cochlear implants.

DESIGN

Prospective 12-month multicenter study using preference-based quality-of-life measures and total cost determinations, comparing profoundly hearing-impaired adult subjects with and without cochlear implants.

SETTING

Hospital-based and patient-resource clinics.

PATIENTS

Severely to profoundly hearing-impaired adult recipients of a cochlear implant and adults eligible for the device who had not yet received it.

MAIN OUTCOME MEASURE

Clinical assessment of implant participants included medical and audiologic (speech understanding) data at the time of enrollment, 6 months, and 12 months. All participants' health-utility was assessed at the time of enrollment, 6 months, and 12 months using the Health Utility Index. One-year medical resource utilization and cost data included bills related to implants, patient diaries, charge estimates from clinical sites, and published literature. A decision model was developed to determine cost per QALY.

RESULTS

Of the 84 enrolled adults, 62 (75%) completed the study. Mean health-utility scores at the time of enrollment were identical between groups. The marginal 12-month health-utility gain for implant recipients was 0.20; 90% of this improvement was achieved within 6 months. For patients with a mean 22-year life expectancy, the marginal cost per QALY was $14,670.

CONCLUSIONS

Overall, multichannel cochlear implants significantly improved recipients' performance on measures of speech understanding and ratings of health-utility within 6 months of implantation. The multichannel cochlear implant yielded a very favorable cost per QALY.

Strategic activity and financial performance of U.S. rural hospitals: a national study, 1983 to 1988

This study examines the effect of 13 strategic management activities on the financial performance of a national sample of 797 U.S. rural hospitals during the period of 1983-1988. Controlled for environment-market, geographic-region, and hospital-related variables, the results show almost no measurable effect of strategic adoption on rural hospital profitability and liquidity. Where statistically significant relationships existed, they were more often negative than positive. These findings were not expected; it was hypothesized that positive effects across a broad range of strategies would emerge, other things being equal. Discussed are possible explanations for these findings as well as their implication for a rural health policy relying on individual rural hospital strategic adaptation to environmental change.

Rural hospital administrators and strategic management activities

This study examines the association of characteristics of rural hospital administrators and the adoption of seven strategic activities in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Based on the premise that managerial activities can affect organizational change, we test five hypotheses relating head administrator characteristics to strategic adaptation, controlling for environment-market and hospital-related variables. Bivariate analysis of the strategic adoption showed a positive association with administrative turnover and a negative association with head administrator age. Multivariate logistic regression showed that only high levels of turnover were associated with strategic activities, net of control variables. The implications of these findings and the lack of predictive power of other rural hospital administrator characteristics--especially affiliation with the American College of Healthcare Executives--are discussed within the context of a "strategic management policy" for rural hospitals.

Horizontal and vertical integration-diversification in rural hospitals: a national study of strategic activity, 1983-1988

This study examines both the magnitude of and factors influencing the adoption of 13 horizontal and vertical integration and diversification strategies in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Using organization theory, hypotheses were posed relating environmental and market factors, geographic location, and hospital characteristics to the adoption of horizontal and vertical integration and diversification. Results indicate that only one of 13 strategies was adopted by more than 50 percent of all rural hospitals during the study period, and that most of the directional hypotheses were not confirmed using Cox's proportional hazards models. In particular, environmental and market factors were unrelated to the strategies studied. Issues of methodology and theory are discussed; however, during an historically turbulent period, both relatively low levels of rural hospital strategic activities and lack of predictive power of the theory suggest caution in relying heavily on a policy for rural hospital survival that is dependent on individual market-oriented strategic behavior.

A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy

BACKGROUND AND PURPOSE

Access to physical therapy in many states is contingent on prescription or referral by a physician. Other states have enacted direct access legislation enabling consumers to obtain physical therapy without a physician referral. Critics of direct access cite potential overutilization of services, increased costs, and inappropriate care.

METHODS AND RESULTS

Using paid claims data for the period 1989 to 1993 from Blue Cross-Blue Shield of Maryland, a direct access state, we compiled episodes of physical therapy for acute musculoskeletal disorders and categorized them as direct access (n = 252) or physician referral (n = 353) using algorithms devised by a clinician advisory panel. Relative to physician referral episodes, direct access episodes encompassed fewer numbers of services (7.6 versus 12.2 physical therapy office visits) and substantially less cost ($1,004 versus $2,236).

CONCLUSION AND DISCUSSION

Direct access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classified as physician referral episodes. There are several potential reasons why this may be the case, such as lower severity of the patient's condition, overutilization of services by physicians, and underutilization of services by physical therapists. Concern that direct access will result in overutilization of services or will increase costs appears to be unwarranted.

Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome

A decision analytic study was conducted using computer simulation to project the outcomes in a simulated cohort of patients whose treatment for back surgery had failed. The objective of this study was to estimate the direct cost of intrathecal morphine therapy (IMT) delivered via an implantable pump relative to alternative therapy (medical management) over a 60-month course of treatment. IMT administered by way of an implantable pump can provide effective pain relief for selected patients whose less invasive treatment modalities have failed. Previous research suggested that a pump implant is less costly than alternative methods providing comparable analgesia for treatment exceeding 12 to 18 months. However, those analyses did not include the cost of complications or pump replacement. Scenarios representing the course of IMT, devised by a panel of experts, were represented as treatment pathways in a Monte Carlo simulation. Adverse event rates were drawn from published data supplemented by expert judgment. Direct costs were based on a health insurer paid claims perspective (direct costs) discounted at a 5% annual rate. The cost-effectiveness of IMT was calculated based on a report of 65% to 81% "good to excellent" pain relief relative to alternative (medical) management. With both adverse event probabilities and costs set at most likely (base case) values, the expected total cost of IMT over 60 months was $82,893 (an average of $1382 per month). In a sensitivity analysis, the best case (low adverse event rate, low cost) estimate was $53,468 ($891/mo), whereas the worst case (high adverse event rate, high cost) estimate was $125,102 ($2085/mo). Cost-effectiveness estimates ranged from $7212 (best case) to $12,276 (worst case) per year of pain relief. Results from a computer simulation designed to collect the costs not included in previous empiric research indicate that IMT appears to be cost-effective when compared with alternative (medical) management for selected patients when the duration of therapy exceeds 12 to 22 months.

Complex decisions about an uncomplicated therapy: reimbursement for long-term oxygen therapy in Catalonia (Spain)

Therapies used in the management of chronic diseases cause specific problems regarding reimbursement policy. Oxygen therapy is an example of such treatments that receive little attention from health care policy makers, due to their low cost to the health care budget and to their little importance from a social point of view. In this paper, we analyze the problems posed by this therapy in the Catalan health care system, as an example of the several aspects implied in the reimbursement of such kind of therapies. A technology assessment of this therapy was carried out showing that a change in the reimbursement of long-term home oxygen therapy (LTOT) was needed. Slow diffusion of new oxygen delivery modalities and over-prescription of LTOT were among the problems observed. The new system proposed is presented, and some preliminary results and consequences of the role of technology assessment in health care policy-making are discussed.

The cost of a preventable disease: estimated U.S. national medical expenditures for congenital syphilis, 1990

Reported cases of congenital syphilis have increased rapidly in recent years. The purpose of this study was to estimate first-year medical care expenditures among 1990 incident cases of infants diagnosed with congenital syphilis. The authors used a synthetic estimation model to calculate expenditures for congenital syphilis as the number of treated cases multiplied by cost per case. The number of cases was derived from surveillance data adjusted for underreporting and presumptive (false-positive) treatment. Cost per case was based on expected hospital and physician charges applied to case treatment protocols appropriate to case severity. Base-case estimated first-year medical expenditure for 1990 treated cases (N = 4,400) in 1990 was +12.5 million. In sensitivity analysis, estimates ranged from +6.2 million to +47 million. Substantial reduction in congenital syphilis treatment costs could be achieved through targeted public health interventions consisting of prenatal maternal screening and contact tracing of males testing positive for syphilis. Physicians should be aggressive in presumptive treatment of newborns, since this usually prevents future disability but represents a small portion of total national expenditure for congenital syphilis. More precise data on severe cases resulting in long-term disability are needed to make reliable cost estimates.

The economic cost of migraine. Present state of knowledge

The costs of medical care and lost productivity associated with migraine headache impose an economic burden on society. Knowledge of the costs that can be attributed to migraine would provide a basis for evaluating alternative diagnosis and treatment strategies. The most widely used approaches to analyzing the cost of illness analysis are the willingness-to-pay and human capital methods. Using these as a framework, all recent published studies (from 1980 to the present) relevant to the economic cost of migraine were reviewed. The literature reviewed demonstrates that the economic burden of migraine headache is substantial. To estimate the cost of migraine to society more precisely, data are needed on incidence and prevalence among carefully selected samples representative of the underlying population. Use of medical care must be expressed as units of specific types of services rendered over known periods. Health insurance coverage, an important determinant of access to care, should also be known. Absenteeism and work losses must be linked to occupation and earnings levels.

The relationship of provider organizational status and erythropoietin dosing in end stage renal disease patients

Controversy exists as to whether provider organizational characteristics such as profit status and setting are associated with the content of medical care or efficiency with which care is rendered. Following FDA approval of human recombinant erythropoietin (EPO) for use in clinical practice, Medicare approved coverage for beneficiaries in its end stage renal disease program and established a fixed payment per dose. Because cost of EPO administration varied positively with dose, providers could realize larger profit with prescription of smaller doses. We used Medicare claims data to assess EPO use by renal dialysis providers one year after FDA approval (June 1990) as a function of provider ownership (for-profit, not-for-profit, government agency) and setting (hospital-based, free-standing). Mean dose of EPO was 236 units greater (P = 0.0001) for not-for-profit freestanding facilities, 593 units greater (P = 0.0001) for government facilities, and 555 units greater for not-for-profit hospitals (P = 0.0001) than among for-profit freestanding providers. With fixed payment per dose of EPO, for-profit, freestanding providers prescribed EPO more often and administered smaller doses than not-for-profit or government providers, behavior that is consistent with profit maximization.

Effect of recombinant erythropoietin on hospital admissions, readmissions, length of stay, and costs of dialysis patients

To examine the effects of recombinant human erythropoietin (rHuEPO) on hospital utilization, hospital costs, and Medicare reimbursements for hospital care, a longitudinal, matched cohort study was conducted using Medicare claims data of 23,806 Medicare-eligible, dialysis patients who received rHuEPO, did not have a transplant, and were alive for 18 mo or longer and 22,720 controls matched on age, sex, race, cause of ESRD, and dialysis modality. The relative odds (rHuEPO versus control) of admission for all causes and for specific causes over 9 mo, adjusted for admission in the prior 9 mo and the per patient change in total admissions, inpatient days, hospital costs, and Medicare hospital payments between the prior 9-mo period and the subsequent 9-mo period was examined. The adjusted relative odds (95% confidence interval) of admission (rHuEPO versus control) was: higher and statistically significant for all causes, 1.08 (1.03 to 1.14); seizure, 1.52 (1.28 to 1.75); vascular access revision, 1.11 (1.06 to 1.17), and heart failure, 1.17 (1.09 to 1.26); higher but not statistically significant for angina, 1.09 (0.99 to 1.20) and stroke, 1.08 (0.86 to 1.31); and lower but not statistically significant for myocardial infarction, 0.91 (0.72 to 1.10); peripheral vascular disease, 0.81 (0.60 to 1.02); anemia, 0.86 (0.56 to 1.17); and depression, 0.89 (0.37 to 1.40). The mean change per 1,000 patients in admissions was less by 38 (P = 0.03) because of fewer readmissions, and in days was 1,309 less (P < 0.001), for patients treated with rHuEPO versus controls. The mean change per patient in hospital costs was $371 less and was statistically significant (P = 0.03) and in Medicare hospital payments was $132 less but was not statistically significant (P = 0.43) for patients treated with rHuEPO versus controls. rHuEPO was associated with an increase in the probability of hospital admission (particularly admissions potentially related to adverse effects) but a decrease in readmissions, overall admissions, hospital days, and cost to hospitals in this cohort of patients surviving for 18 mo. Although not realized short term, Medicare savings from potential rHuEPO-related reductions in hospital care may be long term through future adjustments in diagnosis-related group-based hospital payment.

A review of the first year of Medicare coverage of erythropoietin

Recombinant human erythropoietin (rHuEPO) is a new drug for treating anemia associated with end stage renal disease (ESRD). In a study of rHuEPO diffusion, costs, and effectiveness, we analyze ESRD program data and all claims submitted to Medicare for reimbursement of rHuEPO administered to ESRD dialysis patients. Access to rHuEPO was rapid and extensive during the first year of Medicare coverage. Dosing of rHuEPO and achieved hematocrit were lower than expected based on the results of clinical trials. rHuEPO cost Medicare $144 million in its first year. The analysis of insurance claims data allowed effective monitoring of access, costs, and effectiveness of this new biotechnology.

Medicare payment policy and recombinant erythropoietin prescribing for dialysis patients

The Medicare payment policy for recombinant human erythropoietin (rHuEPO) treatment for dialysis patients changed in January 1991 from a relatively fixed payment per treatment (allowed charge of $40 per < or = 10,000 units injected) to a more variable payment based on the amount of rHuEPO administered with each treatment (allowed charge of $11 per 1,000 units injected). This change provided an opportunity to examine how payment policy can effect the use, cost, and health outcome of a biotechnology product used in the dialysis population. In cross-sectional (n = 71,880 Medicare-entitled dialysis patients) and longitudinal (n = 29,088 Medicare-entitled dialysis patients) study designs, we used Medicare end-stage renal disease program and claims data in bivariate and multivariate analyses to examine the effect of the change in payment policy for rHuEPO on access to the biotechnology, dosing, costs, and hematocrit, including the prescribing patterns at for-profit versus not-for-profit providers. The observation period included several months before (July 1989 to December 1990) and 6 months after (January to June 1991) the change in Medicare payment policy. The mean dose per treatment during the initial and fourth month of therapy was low (2,742 [95% confidence interval, 2,703 to 2,781] units and 2,632 [95% confidence interval, 2,598 to 2,667] units, respectively, in June 1990) and increased 3.4% and 5.0%, respectively, in the next 6 months prior to the change in Medicare payment policy compared with 14.6% and 14.8%, respectively, in the 6 months following the change in payment policy. The average monthly allowed charge for rHuEPO per dialysis patient receiving rHuEPO decreased from $455 before the policy change to $349 immediately following the policy change, because the allowed charge per unit of rHuEPO was lower when payment became more dependent on the amount of rHuEPO administered with each treatment than when the payment was fixed at $40 per treatment. The average monthly allowed charge for rHuEPO increased to $375 in the sixth month following the change in payment policy as a result of the increase in dose and the new variable payment. The unadjusted and adjusted changes in mean hematocrit 6 months after the payment change were positive but clinically very small (0.3 and 0.2 percentage points, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

Cost analysis of imipenem-cilastatin versus clindamycin with tobramycin in the treatment of acute intra-abdominal infection

Clinical effectiveness of imipenem/cilastatin (I/C) versus tobramycin with clindamycin (T + C) in treatment of patients presenting with suspected acute intra-abdominal infection was assessed in a multicentre randomised clinical trial conducted during 1985 to 1986. The principal finding was a lower incidence of treatment failure among patients in the I/C arm (p = 0.043). We now report results of retrospective analysis of hospital treatment costs during an episode of infection incurred by patients enrolled in the trial. Treatment costs (in 1989 US dollars) were calculated from a hospital perspective, using an intention-to-treat analysis. Among 161 patients with low illness severity (APACHE II less than or equal to 14) the mean cost for the episode of care was $US7038 in the I/C arm versus $US8404 for the T + C regimen; the difference was not statistically significant (p = 0.40). For 93 more severely ill patients (APACHE II score greater than 14) the mean cost for the I/C arm was $US19 985 versus $US16 582 for the T + C regimen; the difference was not statistically significant (p = 0.36). Multiple regression analysis, controlling for patient demographics and study site, showed that the cost of the episode was positively associated with the severity of illness (p less than 0.01) and presence of malnutrition (p < 0.01), but that the total cost of the episode of infection was not statistically different for the 2 drug regimens (p = 0.45).

Early dosing practices and effectiveness of recombinant human erythropoietin

In a national longitudinal-cohort study of 59,462 end-stage renal disease (ESRD) patients, we examined dosing and effectiveness of erythropoietin (EPO) during the first year of its use in clinical practice (July 1989 through June 1990). In unadjusted and multivariate analyses of Medicare claims data, the mean dose of EPO prescribed was: relatively small and similar for initial and maintenance therapy, 2752 (95% confidence interval 2740 to 2764) and 2668 (95% confidence interval 2654 to 2682) units, respectively; lower when initial therapy was started later (591 units lower in September 1989 and 760 units lower in November 1989 vs. July 1989, P < 0.0001); lower by 135 units during initial therapy and by 116 units during maintenance therapy for females (who weigh less) compared to males (P < 0.001); and lower by 400 units for patients treated in for-profit versus not-for-profit centers. In multivariate analysis: hematocrit response was less and mean maintenance dose was 298 units and 621 units greater for patients whose ESRD was due to multiple myeloma and sickle cell disease, respectively, compared to those with hypertension-related ESRD (P < 0.01); and hematocrit response was logarithmically related to dose [hematocrit = 0.97 ln (dose), P < 0.0001]. Forty-four percent of patients had a hematocrit > or = 30 after four months of therapy. The percent of patients transfused during three month periods before and after therapy decreased from 20% to 5%, respectively (P < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Razing a Tower of Babel: a taxonomy for managed care and health insurance plans

To many, the U.S. health care system has become an unintelligible alphabet soup of three-letter health plans. There is little agreement about which characteristics distinguish one type of plan from another. In this article we chip away at what has become a Tower of Babel of managed care and health insurance terminology. We review past and current trends in the market for nontraditional health benefit plans and propose a taxonomy, or system of classification, that will aid in understanding how managed care plans differ from conventional health insurance and from one another. Also included is a comprehensive glossary of terms.

Access to recombinant erythropoietin by Medicare-entitled dialysis patients in the first year after FDA approval

OBJECTIVE

Examine access to recombinant human erythropoietin (rHuEPO) by dialysis-dependent end-stage renal disease (ESRD) patients during the first year after FDA approval for use in clinical practice and Medicare coverage.

DESIGN

Longitudinal and cross-sectional claims data analyses.

SETTING

All US providers of outpatient dialysis treatment.

PATIENTS

126,201 Medicare-entitled dialysis patients (approximately 93% of all US dialysis patients).

OUTCOME MEASURES

Percentage of patients who received rHuEPO, odds of receiving rHuEPO according to patient characteristics, and cost of rHuEPO to Medicare.

RESULTS

One year after FDA approval, 52% of all dialysis and 60% of in-center hemodialysis patients who regularly had Medicare-paid dialysis services received rHuEPO at a monthly cost to Medicare of $19 million (18% of Medicare ESRD outpatient expenditures and 6% of all ESRD program expenditures). Blacks were less likely than whites to receive rHuEPO (odds ratio, 0.88; 95% confidence interval, 0.86 to 0.91). Home peritoneal and hemodialysis patients were less likely than in-center hemodialysis patients to receive rHuEPO (odds ratios, 0.17 and 0.22, respectively; 95% confidence intervals, 0.16 to 0.17 and 0.20 to 0.24, respectively). Use of rHuEPO varied across geographic regions. The odds of receiving rHuEPO were lower for patients of male vs female sex, of ages 35 through 64 years vs less than 35 years and greater than 65 years, with a longer history of ESRD, with polycystic kidney disease vs other causes of ESRD, and receiving care in nonprofit vs for-profit facilities. First-month hematocrits were slightly higher (1.2 percentage points) for patients starting rHuEPO in the 12th month than in the first month after FDA approval.

CONCLUSIONS

With prompt insurance coverage, the majority of Medicare-entitled dialysis patients received rHuEPO following widespread availability. Factors that may not be related to clinical need (race, setting of care, and geography) possibly influenced early patient access. More attention should be paid to monitoring the appropriate use of high-cost biotechnologic therapy.

Advanced home health care

Home health care in the United States is growing rapidly, as reflected in numbers of persons treated and national expenditures for care. Recent growth in this sector reflects the emergence of 'high-tech' care, such as intravenous infusion therapy, total parenteral nutrition and home dialysis. This focus on device-based therapy detracts from a larger issue, the efficient production of medical care subject to acceptable levels of cost and quality. The structure of payment and quality assurance mechanisms will shape the emergence of advanced home health care in the 1990's and beyond.

Patient selection in the Medicare End-Stage Renal Disease Program

Since the inception of the Medicare End-Stage Renal Disease (ESRD) Program in 1972, the number of persons qualifying for this benefit has increased every year, even when controlling for growth of the US population. At the same time, the profile of the typical dialysis patient has changed dramatically over the years, with new enrollees tending to be older and sicker. This study attempts to explain case mix through an economic model of a dialysis provider who certifies eligibility of Medicare ESRD beneficiaries and manages their care. The model was tested using administrative data from the Medicare ESRD program and other sources. Results demonstrated that dialysis patient case mix is influenced by local area demand for medical care and factors such as competition or payment levels that might affect a provider's supply decisions.