Impact of rural hospital closures on hospitalizations and associated outcomes for ambulatory and emergency care sensitive conditions

PURPOSE

The purpose of this paper is to examine the impact of rural hospital closures on age-adjusted hospitalization rates for ambulatory care sensitive condition (ACSC) and emergency care sensitive condition (ECSC) and associated outcomes, such as length of stay and in-hospital mortality in hospital service areas (HSAs) that utilized the closed hospital.

METHODS

We used the State Inpatient Data from the Healthcare Cost and Utilization Project for 9 states from 2010 to 2017 and classified admissions as ACSC or ECSC. We compared age-adjusted admission rates and length of stay (LOS) for ACSC and ECSC rates and age adjusted in-hospital mortality rate for ECSC among rural ZIP codes in HSAs with a closure to rural ZIP codes in HSAs without closures. We used propensity score-weighted regression analysis and event study design.

FINDINGS

Findings suggest that ACSC admission rates started to increase right before the closure. However, this increase levels off 2 years after closure. LOS for ACSC significantly decreased almost a year after closure. ECSC admissions showed a significant decrease for a few quarters 1 year before the closure.

CONCLUSIONS

Rural hospital closures were associated with increase in ACSC admissions right before closure and for nearly 2 years post closure as well as decrease in ECSC admissions before closure. As rural hospitals continue to close, efforts to ensure communities affected by these closures maintain access to primary health care may help eliminate increases in costly preventable hospital admissions for ACSC while ensuring access for emergency care services.

Preventing Leading Causes of Death: Systematic Review of Cost-Utility Literature

INTRODUCTION

Heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke are the 5 leading causes of death in the U.S. The objective of this review is to examine the economic value of prevention interventions addressing these 5 conditions.

METHODS

Tufts Medical Center Cost-Effectiveness Analysis Registry data were queried from 2010 to 2018 for interventions that addressed any of the 5 conditions in the U.S. Results were stratified by condition, prevention stage, type of intervention, study sponsorship, and study perspective. The analyses were conducted in 2020, and all costs were reported in 2019 dollars.

RESULTS

In total, 549 cost-effectiveness analysis studies examined interventions addressing these 5 conditions in the U.S. Tertiary prevention interventions were assessed in 61.4%, whereas primary prevention was assessed in 8.6% of the studies. Primary prevention studies were predominantly funded by government, whereas industry sources funded more tertiary prevention studies, especially those dealing with pharmaceutical interventions. The median incremental cost-effectiveness ratio for the 5 conditions combined was $68,500 per quality-adjusted life year. Median incremental cost-effectiveness ratios were lowest for primary prevention and highest for tertiary prevention.

DISCUSSION

Primary prevention may be more cost effective than secondary and tertiary prevention interventions; however, research investments in primary prevention interventions, especially by industry, lag in comparison. These findings help to highlight the gaps in the cost-effectiveness analysis literature related to the 5 leading causes of death and identify understudied interventions and prevention stages for each condition.

Trends in State-Level Pharmacy-Based Naloxone Dispensing Rates, 2012-2019

INTRODUCTION

Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia.

METHODS

Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020.

RESULTS

Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states.

CONCLUSIONS

Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.

Estimated economic burden of cancer associated with suboptimal diet in the United States

PURPOSE

Suboptimal diet is a preventable cause of cancer. We aimed to estimate the economic burden of diet-associated cancer among US adults.

METHODS

We used a Comparative Risk Assessment model to quantify the number of new cancer cases attributable to seven dietary factors among US adults ages 20 + years. A Markov cohort model estimated the 5-year medical costs for 15 diet-associated cancers diagnosed in 2015. We obtained dietary intake from 2013 to 2016 National Health and Nutrition Examination Survey, cancer incidence, and survival from 2008 to 2014 Surveillance, Epidemiology, and End Results (SEER) program, and medical costs from 2007 to 2013 linked SEER-Medicare data.

RESULTS

The estimated 5-year medical costs of new diet-associated cancer cases diagnosed in 2015 were $7.44 (2018 US$). Colorectal cancer had the largest diet-related 5-year medical costs of $5.32B. Suboptimal consumption of whole grains ($2.76B), dairy ($1.82B), and high consumption of processed meats ($1.5B) accounted for the highest medical costs. Per-person medical costs attributable to suboptimal diet vary by gender, race, and age group.

CONCLUSIONS

Suboptimal diet contributes substantially to the economic burden of diet-associated cancers among US adults. This study highlights the need to implement population-based strategies to improve diet and reduce cancer burden in the US.

Late-Stage Diagnosis and Cost of Colorectal Cancer Treatment in Two State Medicaid Programs

INTRODUCTION

To assess timing of Medicaid enrollment with late-stage colorectal cancer (CRC) diagnosis and estimate treatment costs by stage at diagnosis.

METHODS

We analyzed 2000-2009 California and Texas Medicaid data linked with cancer registry data. We assessed the association of Medicaid enrollment timing with late-stage colorectal cancer and estimated total and incremental 6-month treatment costs to Medicaid by stage using a noncancer comparison group matched on age group and sex.

RESULTS

Compared with Medicaid enrollment before diagnosis, enrolling after diagnosis was associated with late-stage diagnosis. Incremental per-person treatment costs were $31,063, $39,834, and $47,161 for localized, regional, and distant stage in California, respectively; and $28,701, $38,212, and $49,634 in Texas, respectively.

DISCUSSION

In California and Texas, Medicaid enrollment after CRC diagnosis was associated with later-stage disease and higher treatment costs. Facilitating timely and continuous Medicaid enrollment may lead to earlier stage at diagnosis, reduced costs, and improved outcomes.

Awareness of breast cancer risk related to a positive family history and alcohol consumption among women aged 15-44 years in United States

Awareness of the link between breast cancer and risk factors such as family history of breast cancer and alcohol consumption may help modify health behaviors. To reduce risk factors for breast cancer among young women, it is important to understand overall levels of risk awareness and socioeconomic differences in awareness. Data from the National Survey of Family Growth 2011-2015 were used to examine awareness of two risk factors for breast cancer, positive family history and alcohol consumption, among women aged 15-44 years (n = 10,940) in the United States by presence of risk factors and by socioeconomic characteristics. Prevalence of positive family history, non-binge, and binge drinking was 30%, 29%, and 31%, respectively among women aged 15-44. Awareness of positive family history of breast cancer as a risk factor for breast cancer was 88%, whereas for alcohol consumption it was 25%. Awareness of family history as a risk factor was higher among women with positive family history of breast cancer compared to those without. Current drinkers were more likely to believe that alcohol was not a risk factor for breast cancer compared to those who did not drink. Racial/ethnic minority women and those with lower education and income had lower awareness of family history as a risk factor. Awareness of alcohol consumption as a risk factor for breast cancer was low across all socioeconomic groups. Evidence-based interventions to increase risk awareness and decrease excessive alcohol use among young women are needed to reduce the risk of developing breast cancer.

Utilization and Cost of Mammography Screening Among Commercially Insured Women 50 to 64 Years of Age in the United States, 2012-2016

Background: In recent years, most insurance plans eliminated cost-sharing for breast cancer screening and recommended screening intervals changed, and newer modalities-digital mammography and breast tomosynthesis-became more widely available. The objectives of this study are to examine how these changes affected utilization, frequency, and costs of breast cancer screening among commercially insured women, and to understand factors associated with utilization and frequency of screening. Materials and Methods: This study used commercial insurance claims data for women 50 to 64 years of age, continuously enrolled in commercial insurance plans during 2012-2016. Results: Of the 685,737 eligible women, 20% were not screened, 40% received annual screening, 24% received biennial screening, and 16% were screened less frequently than recommended during the time period examined. Sociodemographic factors such as age <60 years, rurality, and fee-for-service insurance were associated with low screening utilization. Patients who received annual screening incurred ∼1.78 times higher costs compared to those who received biennial screening during the study period. Digital mammography was the most costly and commonly used modality along with computer-aided detection. Conclusions: Evidence-based interventions to promote screening among women who are screened less frequently are needed along with interventions to move toward biennial screening rather than annual screening. Increasing provider awareness regarding breast cancer screening rates and frequency among various sociodemographic groups is essential to guide provider recommendations and shared decision making. The results of this study can guide targeted public health interventions to reduce barriers to screening, and can also serve as inputs for economic analyses of screening interventions and programs.

Systematic review of healthcare costs related to mental health conditions among cancer survivors

INTRODUCTION

This systematic review examines healthcare costs associated with mental health conditions among cancer survivors in the United States.

AREAS COVERED

Ten published studies were identified. Studies varied substantially in terms of population, mental health conditions examined, data collection methods, and type of cost reported. Cancer survivors with mental health conditions incurred significantly higher total medical costs and costs of most service types compared to cancer survivors without a mental health condition. Additionally, the total healthcare expenditure related to mental health was higher among cancer survivors compared with people without history of cancer.

EXPERT COMMENTARY

Mental health conditions are associated with increased healthcare costs among cancer survivors. Future examination of other components of economic burden, including patient out-of-pocket costs, nonmedical costs, such as transportation, childcare, and productivity losses for patients and their caregivers, will be important. Additionally, evaluation of economic burden by cancer site, stage at diagnosis, duration of survivorship, and treatment(s) will increase understanding of the overall impact of mental health conditions on cancer survivors and on the healthcare system.

Abstract C08: Multilevel determinants of disparities in breast reconstruction: A systematic review

Context and Objectives: Breast reconstruction has been shown to yield important psycho-social and quality of life benefits for patients with breast cancer who have undergone mastectomy. However, a number of studies have demonstrated significant disparities in access to breast reconstruction. The Women's Health and Cancer Rights Act, which mandated insurance coverage of post mastectomy breast reconstruction in 1999 sought to improve access and reduce disparities but disparities continue to persist in spite of legislative action. Previous studies have established the presence of racial, income, insurance and geographic variation in breast reconstruction. However, no systematic review of these multiple disparities has been conducted. This study has two aims: 1) To conduct a quantitative assessment of the magnitude of multiple disparities in breast reconstruction and 2) To conduct a qualitative and quantitative assessment of multi-level determinants of these disparities.

Methods: 43 relevant articles published from 1999 to 2015 were obtained through electronic database searches (PubMed) and manual searches of reference lists. English-language studies from United States were included if study objectives included examination of non-clinical patient level, provider level, institution level or geographic level determinants of Breast Reconstruction surgery after Mastectomy. Both qualitative and quantitative studies were included. Data were extracted and rated for study quality by one reviewer.

Findings: Reconstruction rates varied from 6% to 53% in the studies reviewed based on the population assessed and the data used. Implants were more likely to be performed than autologous reconstruction. African Americans and Hispanics, patients with Medicare and Medicaid and patients residing in areas with median income in the lowest quartile were less likely to receive reconstructions. A consistent association was seen between increasing patient age and decreasing likelihood of reconstruction. Another significant and consistent association was between African American race and autologous versus implant reconstruction.

Conclusions: Socioeconomic disparities in breast reconstruction remain pervasive in spite of legislation such as the Women's Health and Cancer Rights Act (WHCRA) and the Affordable Care Act, with substantial variation by racial or ethnic subgroup, median income of area of residence and payer. Factors explaining these disparities include variation in access to early diagnosis (later stage patients are less likely to get reconstruction), access to information regarding reconstruction (due to language barriers or provider bias) and in access to providers and institutions with high volumes of reconstruction. Other non-clinical patient level factors that influence reconstruction include patient preferences (religious preferences, body image perception, importance of feeling whole again, etc.), marital status, education, employment status, etc. Plastic surgeon characteristics include age and years in practice. Institutional characteristics include setting, teaching status, region, affiliation with an oncology group or national cancer centers, presence of residents, etc. Future reviews should focus on identifying interventions to successfully reduce these disparities in breast reconstruction.

New Contribution: Although there have been two systematic reviews which look at socioeconomic and other determinants of breast reconstruction, neither of them focus only on United States nor do they include sufficient number of studies conducted after the Affordable Care Act in order to determine its impact on socioeconomic disparities. Additionally, neither of the two studies look at multi-level determinants of breast reconstruction and the type of reconstruction nor do they rate the quality of the studies included in the review. Thus, this review will address these gaps and make a significant and new contribution to literature.

Citation Format: Jaya S. Khushalani. Multilevel determinants of disparities in breast reconstruction: A systematic review. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C08.