Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients.

STUDY OBJECTIVES: To examine the effect of untreated obstructive sleep apnea (OSA) on health care utilization (HCU) and costs among a nationally representative sample of Medicare beneficiaries. METHODS: Our data source was a random 5% sample of Medicare administrative claims data for years 2006-2013. OSA was operationalized as (1) receipt of one or more International Classification of Disease, Version 9, Clinical Modification diagnostic codes for OSA in combination with (2) initiation of OSA treatment with either continuous positive airway pressure or oral appliance (OA) therapy. First, HCU and costs were assessed during the 12 months prior to treatment initiation. Next, these HCU and costs were compared between beneficiaries with OSA and matched control patients without sleep-disordered breathing using generalized linear models. RESULTS: The final sample (n = 287,191) included 10,317 beneficiaries with OSA and 276,874 control patients. In fully adjusted models, during the year prior to OSA diagnosis and relative to matched control patients, beneficiaries with OSA demonstrated increased HCU and higher mean total annual costs ($19,566, 95% confidence interval [CI] $13,239, $25,894) as well as higher mean annual costs across all individual points of service. Inpatient care was associated with the highest incremental costs (ie, greater than control patients; $15,482, 95% CI $8,521, $22,443) and prescriptions were associated with the lowest incremental costs (ie, greater than control patients; $431, 95% CI $339, $522). CONCLUSIONS: In this randomly selected and nationally representative sample of Medicare beneficiaries and relative to matched control patients, individuals with untreated OSA demonstrated increased HCU and costs across all points of service.

The Impact of Treatments for OSA on Monetized Health Economic Outcomes: A Systematic Review.

OBJECTIVE: To review systematically the published literature regarding the impact of treatment for OSA on monetized health economic outcomes. METHODS: Customized structured searches were performed in PubMed, Embase (Embase.com), and the Cochrane Central Register of Controlled Trials (Wiley) databases. Reference lists of eligible studies were also analyzed. Titles and abstracts were examined, and articles were identified for full-text review. Studies that met inclusion criteria were evaluated in detail, and study characteristics were extracted using a standardized template. Quantitative characteristics of the studies were summarized, and a qualitative synthesis was performed. RESULTS: Literature searches identified 2,017 nonredundant abstracts, and 196 full-text articles were selected for review. Seventeen studies met inclusion criteria and were included in the final synthesis. Seven studies included formal cost-effectiveness or cost-utility analyses. Ten studies employed cohort designs, and four studies employed randomized controlled trial or quasi-experimental designs. Positive airway pressure was the most common treatment modality, but oral appliances and surgical approaches were also included. The most common health economic outcomes were health-care use (HCU) and quality-adjusted life years (QALYs). Follow-ups ranged from 6 weeks to 5 years. Overall, 15 of 18 comparisons found that treatment of OSA resulted in a positive economic impact. Treatment adherence and OSA severity were positively associated with cost-effectiveness. CONCLUSIONS: Although study methodologies varied widely, evidence consistently suggested that treatment of OSA was associated with favorable economic outcomes, including QALYs, within accepted ranges of cost-effectiveness, reduced HCU, and reduced monetized costs.

The appropriate role of cost-effectiveness in determining device coverage: a case study of drug-eluting stents.

The use of incremental cost-effectiveness ratios based on quality-adjusted life-years (QALYs) as a critical determinant of what should be covered by a health system is a growing trend. This presents challenges when applied to rapidly evolving technologies. The case study here focuses on the example of drug-eluting stents and the four-year change in cost-effectiveness as determined by the U.K. National Institute for Health and Clinical Excellence (NICE). We contend that classic cost-effectiveness as a blunt instrument for determining what should be covered may lead to erroneous conclusions when a broader perspective and the impact on health outcomes and costs are considered.

Growth of intensive care unit resource use and its estimated cost in Medicare.

OBJECTIVE: The past 10-15 yrs brought significant changes in the United States healthcare system. Effects on Medicare intensive care unit use and costs are unknown. Intensive care unit costs are estimated using the Russell equation with a ratio of intensive care unit to floor cost per day, or "R value," of 3, which may no longer be valid. We sought to determine contemporary Medicare intensive care unit resource use, costs, and R values; whether these vary by patient and hospital characteristics; and the impact of updated values on estimated intensive care unit costs. DESIGN: Retrospective analysis of Medicare Inpatient Prospective Payment System hospitalizations from 1994 to 2004 using Medicare Provider Analysis and Review files. SETTING: All nonfederal acute care US hospitals paid through the Inpatient Prospective Payment System. SUBJECTS: Inpatient prospective payment system hospitalizations from 1994 to 2004 (n = 121,747, 260). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined resource use and costs (adjusted to y2004$), calculating intensive care unit and floor costs directly and using these to generate year-specific R values. By 2004, 33% of Medicare hospitalizations had intensive care unit or coronary care unit care, with more than half of the increase in total hospitalizations because of additional intensive care unit hospitalizations. Adjusted intensive care unit cost per day remained stable ($2,616 vs. $2,575; 1994 vs 2004), yet adjusted floor cost per day rose substantially ($1,027 vs. $1,488) driven by decreased floor length of stay. Annual adjusted Medicare intensive care unit costs increased 36% to $32.3B, largely because of increased utilization. R values decreased progressively from 2.55 to 1.73, were lower for surgical vs. medical admissions and survivors vs. nonsurvivors, but varied little by hospital characteristics. An R value of 3 overestimated Medicare intensive care unit costs by 17.6% ($5.7 billion) in 2004. CONCLUSIONS: Medicare intensive care unit use is rising rapidly and will likely continue to do so. Despite significant healthcare system changes, adjusted daily critical care costs remained stable, yet care outside the intensive care unit became more expensive. To track intensive care unit cost over time, year-specific R values should be used.

Cost-effectiveness of drug-eluting stents: real-world scrutiny of the BASKET trial of real-world usage.

This editorial examines incremental cost-effectiveness analysis as a decision-making tool to guide the allocation of scarce financial resources. BASKET (Basel Stent Kosten Effektivitats Trial) evaluated the cost-effectiveness of drug-eluting stents in a real-world setting. Results of this study are examined in relation to similar assessments and alternative plausible assumptions are explored and presented in the context of real-world sensitivity analysis.

Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care.

INTRODUCTION: Infection is an important complication in cancer patients, which frequently leads to or prolongs hospitalization, and can also lead to acute organ dysfunction (severe sepsis) and eventually death. While cancer patients are known to be at higher risk for infection and subsequent complications, there is no national estimate of the magnitude of this problem. Our objective was to identify cancer patients with severe sepsis and to project these numbers to national levels. METHODS: Data for all 1999 hospitalizations from six states (Florida, Massachusetts, New Jersey, New York, Virginia, and Washington) were merged with US Census data, Centers for Disease Control vital statistics and National Cancer Institute, Surveillance, Epidemiology, and End Results initiative cancer prevalence data. Malignant neoplasms were identified by International Classification of Disease (ninth revision, clinical modification) (ICD-9-CM) codes (140-208), and infection and acute organ failure were identified from ICD-9-CM codes following Angus and colleagues. Cases were identified as a function of age and were projected to national levels. RESULTS: There were 606,176 cancer hospitalizations identified, with severe sepsis present in 29,795 (4.9%). Projecting national estimates for the US population, cancer patients account for 126,209 severe sepsis cases annually, or 16.4 cases per 1000 people with cancer per year. The inhospital mortality for cancer patients with severe sepsis was 37.8%. Compared with the overall population, cancer patients are much more likely to be hospitalized (relative risk, 2.77; 95% confidence interval, 2.77-2.78) and to be hospitalized with severe sepsis (relative risk, 3.96; 95% confidence interval, 3.94-3.99). Overall, severe sepsis is associated with 8.5% (46,729) of all cancer deaths at a cost of 3.4 billion dollars per year. CONCLUSION: Severe sepsis is a common, deadly, and costly complication in cancer patients.

Medicare intensive care unit use: analysis of incidence, cost, and payment.

OBJECTIVE: To determine the incidence, cost, and payment for intensive care unit services among Medicare beneficiaries. DESIGN: Retrospective observational database cohort study. SETTING: All nonfederal hospitals with intensive care unit beds (n = 5003) paid through the inpatient prospective payment system (IPPS). PATIENTS: We used all fiscal year 2000 Medicare IPPS hospitalizations with consistent payment information (n = 10,657,587). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined the distribution of cost and payments overall, by hospital type, and by diagnosis related group. Intensive care was used in 2,353,208 cases (21.1%). The overall incidence was 59.8 cases per thousand beneficiaries in the aged (65+) population, increasing with age from 36.2 (65-69) to 91.6 (85+). Intensive care unit patients cost nearly three times floor patients (4,135 dollars vs. 5,571 dollars), with two thirds of costs associated with the intensive care unit portion of the stay, 2,278 dollars per intensive care unit day. However, intensive care unit cases were paid at a rate only twice floor cases (11,704 dollars vs. 5,835 dollars). Only 83% of costs were paid for intensive care unit patients, compared with 105% for floor patients, generating a 5.8 billion dollars loss to hospitals when intensive care unit care is required. There was a linear association between the percent intensive care unit in a diagnosis related group and the percent paid, with payment >90% of cost only in diagnosis related groups with >/=60% intensive care unit cases. We found that teaching hospitals were better paid than nonteaching hospitals (87% vs. 78% of costs, respectively), but this was only due to indirect medical education payments. CONCLUSIONS: Intensive care is common, expensive, and poorly paid in the Medicare population. Few diagnosis related groups have a large enough intensive care unit population to ensure adequate payment. Additional diagnosis related groups for conditions common to the intensive care unit would improve payment and enable incentives for efficiency.

Impact of drotrecogin alfa (activated) on resource use and implications for reimbursement.

Selecting therapies in health care requires rigorous review of clinical and economic data. The financial implications of new clinical treatment options are an important component. The preferred method for evaluating the costs and effects of therapies is cost-effectiveness analysis along with an estimation of utility associated with the life-years gained. Preliminary reports suggest patients receiving drotrecogin alfa (activated) for severe sepsis have a faster resolution of cardiovascular and pulmonary dysfunction with minimal additional financial burden despite additional survivors. Furthermore, the reported cost/quality-adjusted life-year of $48,800 is consistent with many other common life-saving measures. Recently approved new technology payments for hospitals treating patients with drotrecogin alfa (activated) minimize financial impact. Clinicians and administrators should work collaboratively to optimize the therapy of patients with severe sepsis, minimize the financial impact on the health care system, and maximize the utility of drotrecogin alfa (activated).