Financial burdens and barriers to care among nonelderly adults: The role of functional limitations and chronic conditions.

BACKGROUND: People with functional limitations and chronic conditions account for the greatest resource use within the health care system. OBJECTIVE: To examine financial burdens and barriers to care among nonelderly adults, focusing on the role of functional limitations and chronic conditions. METHODS: High financial burden is defined as medical spending exceeding 20 percent of family income. Financial barriers are defined as delaying care/being unable to get care for financial reasons, and reporting that delaying care/going without was a big problem. Data are from the Medical Expenditure Panel Survey (2008-2012). RESULTS: Functional limitations are associated with increased prevalence of financial burdens. Among single adults, the frequency of high burdens is 20.3% for those with functional limitations, versus 7.8% for those without. Among those with functional limitations, those with 3 or more chronic conditions are twice as likely to have high burdens compared to those without chronic conditions (22.2% versus 11.1%, respectively). Similar patterns occur among persons in multi-person families whose members have functional limitations and chronic conditions. Having functional limitations and chronic conditions is also strongly associated with financial barriers to care: 40.2% among the uninsured, 21.9% among those with public coverage, and 13.6% among those with private group insurance were unable to get care. CONCLUSIONS: Functional limitations and chronic conditions are associated with increased prevalence of burdens and financial barriers in all insurance categories, with the exception that an association between functional limitations and the prevalence of burdens was not observed for public coverage.

Evaluating direct medical expenditures estimation methods of adults using the medical expenditure panel survey: an example focusing on head and neck cancer.

OBJECTIVE: To inform policymakers of the importance of evaluating various methods for estimating the direct medical expenditures for a low-incidence condition, head and neck cancer (HNC). METHODS: Four methods of estimation have been identified: 1) summing all health care expenditures, 2) estimating disease-specific expenditures consistent with an attribution approach, 3) estimating disease-specific expenditures by matching, and 4) estimating disease-specific expenditures by using a regression-based approach. A literature review of studies (2005-2012) that used the Medical Expenditure Panel Survey (MEPS) was undertaken to establish the most popular expenditure estimation methods. These methods were then applied to a sample of 120 respondents with HNC, derived from pooled data (2003-2008). RESULTS: The literature review shows that varying expenditure estimation methods have been used with MEPS but no study compared and contrasted all four methods. Our estimates are reflective of the national treated prevalence of HNC. The upper-bound estimate of annual direct medical expenditures of adult respondents with HNC between 2003 and 2008 was $3.18 billion (in 2008 dollars). Comparable estimates arising from methods focusing on disease-specific and incremental expenditures were all lower in magnitude. Attribution yielded annual expenditures of $1.41 billion, matching method of $1.56 billion, and regression method of $1.09 billion. CONCLUSIONS: This research demonstrates that variation exists across and within expenditure estimation methods applied to MEPS data. Despite concerns regarding aspects of reliability and consistency, reporting a combination of the four methods offers a degree of transparency and validity to estimating the likely range of annual direct medical expenditures of a condition.

The impact of health information technology and e-health on the future demand for physician services.

Arguably, few factors will change the future face of the American health care workforce as widely and dramatically as health information technology (IT) and electronic health (e-health) applications. We explore how such applications designed for providers and patients will affect the future demand for physicians. We performed what we believe to be the most comprehensive review of the literature to date, including previously published systematic reviews and relevant individual studies. We estimate that if health IT were fully implemented in 30 percent of community-based physicians' offices, the demand for physicians would be reduced by about 4-9 percent. Delegation of care to nurse practitioners and physician assistants supported by health IT could reduce the future demand for physicians by 4-7 percent. Similarly, IT-supported delegation from specialist physicians to generalists could reduce the demand for specialists by 2-5 percent. The use of health IT could also help address regional shortages of physicians by potentially enabling 12 percent of care to be delivered remotely or asynchronously. These estimated impacts could more than double if comprehensive health IT systems were adopted by 70 percent of US ambulatory care delivery settings. Future predictions of physician supply adequacy should take these likely changes into account.

Age-dependent cost-utility of pediatric cochlear implantation.

OBJECTIVES: Cochlear implantation (CI) has become the mainstay of treatment for children with severe-to-profound sensorineural hearing loss (SNHL). Yet, despite mounting evidence of the clinical benefits of early implantation, little data are available on the long-term societal benefits and comparative effectiveness of this procedure across various ages of implantation-a choice parameter for parents and clinicians with high prognostic value for clinical outcome. As such, the aim of the present study is to evaluate a model of the consequences of the timing of this intervention from a societal economic perspective. Average cost utility of pediatric CI by age at intervention will be analyzed. DESIGN: Prospective, longitudinal assessment of health utility and educational placement outcomes in 175 children recruited from six U.S. centers between November 2002 and December 2004, who had severe-to-profound SNHL onset within 1 year of age, underwent CI before 5 years of age, and had up to 6 years of postimplant follow-up that ended in November 2008 to December 2011. Costs of care were collected retrospectively and stratified by preoperative, operative, and postoperative expenditures. Incremental costs and benefits of implantation were compared among the three age groups and relative to a nonimplantation baseline. RESULTS: Children implanted at <18 months of age gained an average of 10.7 quality-adjusted life years (QALYs) over their projected lifetime as compared with 9.0 and 8.4 QALYs for those implanted between 18 and 36 months and at >36 months of age, respectively. Medical and surgical complication rates were not significantly different among the three age groups. In addition, mean lifetime costs of implantation were similar among the three groups, at approximately $2000/child/year (77.5-year life expectancy), yielding costs of $14,996, $17,849, and $19,173 per QALY for the youngest, middle, and oldest implant age groups, respectively. Full mainstream classroom integration rate was significantly higher in the youngest group at 81% as compared with 57 and 63% for the middle and oldest groups, respectively (p < 0.05) after 6 years of follow-up. After incorporating lifetime educational cost savings, CI led to net societal savings of $31,252, $10,217, and $6,680 for the youngest, middle, and oldest groups at CI, respectively, over the child's projected lifetime. CONCLUSIONS: Even without considering improvements in lifetime earnings, the overall cost-utility results indicate highly favorable ratios. Early (<18 months) intervention with CI was associated with greater and longer quality-of-life improvements, similar direct costs of implantation, and economically valuable improved classroom placement, without a greater incidence of medical and surgical complications when compared to CI at older ages.

Human and methodological sources of variability in the measurement of urinary 8-oxo-7,8-dihydro-2'-deoxyguanosine.

AIMS: Urinary 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) is a widely used biomarker of oxidative stress. However, variability between chromatographic and ELISA methods hampers interpretation of data, and this variability may increase should urine composition differ between individuals, leading to assay interference. Furthermore, optimal urine sampling conditions are not well defined. We performed inter-laboratory comparisons of 8-oxodG measurement between mass spectrometric-, electrochemical- and ELISA-based methods, using common within-technique calibrants to analyze 8-oxodG-spiked phosphate-buffered saline and urine samples. We also investigated human subject- and sample collection-related variables, as potential sources of variability. RESULTS: Chromatographic assays showed high agreement across urines from different subjects, whereas ELISAs showed far more inter-laboratory variation and generally overestimated levels, compared to the chromatographic assays. Excretion rates in timed 'spot' samples showed strong correlations with 24 h excretion (the 'gold' standard) of urinary 8-oxodG (rp 0.67-0.90), although the associations were weaker for 8-oxodG adjusted for creatinine or specific gravity (SG). The within-individual excretion of 8-oxodG varied only moderately between days (CV 17% for 24 h excretion and 20% for first void, creatinine-corrected samples). INNOVATION: This is the first comprehensive study of both human and methodological factors influencing 8-oxodG measurement, providing key information for future studies with this important biomarker. CONCLUSION: ELISA variability is greater than chromatographic assay variability, and cannot determine absolute levels of 8-oxodG. Use of standardized calibrants greatly improves intra-technique agreement and, for the chromatographic assays, importantly allows integration of results for pooled analyses. If 24 h samples are not feasible, creatinine- or SG-adjusted first morning samples are recommended.

Synthesis of new 7-chloroquinolinyl thioureas and their biological investigation as potential antimalarial and anticancer agents.

New 7-chloroquinolinyl thiourea derivatives derived from the corresponding 4,7-dichloroquinoline isothiocyanate were synthesized and evaluated for in vitro antimalarial and anticancer activity. The most active compound from the series displayed an inhibitory IC(50) value of 1.2 microM against the D10 strain of Plasmodium falciparum. Lack of cytotoxicity towards HeLa cells indicates selectivity towards parasites.

Dual-acting diamine antiplasmodial and chloroquine resistance modulating agents.

On the basis of structural features known to be critical for the antimalarial activity, accumulation and uptake of chloroquine (CQ), as well as chemosensitization of CQ resistant Plasmodium falciparum, an exploratory novel series of potential dual acting antiplasmodial and chemosensitizing agents was designed and synthesized for biological evaluation. All four compounds contain a common alkyl side chain with two amino groups and differ only in the chemical nature of the hydrophobic aromatic moieties. Among them, N'-[4-(biphenyl-2-ylmethoxy)-benzyl]-N,N-dimethyl-propane-1,3-diamine (P7) displayed the greatest potential as a dual-acting antiplasmodial agent against CQ-resistant strains (IC50K1/RSA11<0.6 microM) and chemosensitizer (RMIK1=0.67; RMIRSA11=0.82) while displaying low in vitro cytotoxicity against a mammalian cell line (CHO). At 1 microM, P7 caused a 8.5 and 4-fold potentiation in CQ accumulation in resistant P. falciparum K1 and RSA11 strains, respectively. In a parallel experiment, 1 microM verapamil showed a 6.5 (K1) and 2 (RSA11)-fold increase in CQ accumulation. The preliminary studies point to structural features that may determine antiplasmodial and/or CQ resistance modulating activity in this new series of compounds. An additive effect was observed against both CQS (D10) and CQR (RSA11) strains when CQ and P7 were used at their corresponding IC50 concentrations in isobologram analysis.