Additional stroke-related and non-stroke-related cardiovascular costs and hospitalizations in managed-care patients after ischemic stroke.

BACKGROUND AND PURPOSE: Prior stroke confers an increased risk of future cardiovascular events. Because the incremental economic impact of this added risk is unknown, we assessed the additional cardiovascular costs and hospitalizations associated with ischemic stroke. METHODS: Patients hospitalized for ischemic stroke during 2002 to 2005 were identified from a large US managed-care plan and matched to control patients hospitalized for a noncardiovascular acute event. Cumulative stroke-related and non-stroke-related cardiovascular medical costs were determined for each group. Stroke and nonstroke cardiovascular hospitalization rates were calculated with the Kaplan-Meier method; risk of hospitalization was estimated with a Cox regression model. RESULTS: Stroke patients and matched controls (N=11 883) were identified (mean age approximately 58 years; 47.8% female). Compared with controls, patients hospitalized for ischemic stroke had higher stroke and nonstroke cardiovascular medical costs at 6 months (stroke: $1756 vs $50, P<0.01; nonstroke cardiovascular: $1437 vs $658, P<0.01) and 12 months (stroke: $2109 vs $68, P<0.01; nonstroke cardiovascular: $2203 vs $1167, P<0.01) of follow-up. Among stroke patients, cumulative stroke and nonstroke cardiovascular hospitalization rates were 9.06% and 5.63% at 6 months, respectively, and 21.09% and 22.05% at 36 months, respectively. Stroke patients were at significantly increased risk of repeat stroke hospitalization (hazard ratio=12.55; 95% CI, 10.50 to 15.01) and nonstroke cardiovascular hospitalization (hazard ratio=1.95; 95% CI, 1.77 to 2.14). CONCLUSIONS: After ischemic stroke, patients have significantly greater stroke and nonstroke cardiovascular costs and hospitalizations than do matched controls. Attention to total cardiovascular risk reduction in this population could potentially reduce downstream costs.

Resource use and cost of diagnostic workup of women with suspected breast cancer.

We estimated resource use and costs associated with a diagnostic workup for suspected breast cancer among Medicare beneficiaries. Using Medicare claims data, we found that the average cost of a diagnostic workup for suspected breast cancer--whether it eventuated in a breast cancer diagnosis or not--was $361, and did not vary by presentation (signs/symptoms or screening mammography). In the aggregate, we estimate that Medicare spends approximately $679 million annually on diagnostic workups for women with suspected breast cancer, and that false positive mammograms result in diagnostic costs of approximately $250 million.

Treatment interruptions and non-adherence with imatinib and associated healthcare costs: a retrospective analysis among managed care patients with chronic myelogenous leukaemia.

OBJECTIVES: Identify treatment interruptions and non-adherence with imatinib; examine the clinical and patient characteristics related to treatment interruptions and non-adherence; and estimate the association between treatment interruptions and non-adherence with imatinib and healthcare costs for US managed care patients with chronic myeloid leukaemia (CML). METHODS: This retrospective analysis utilised electronic healthcare claims data from a US managed care provider. Adult patients with CML (as determined by International Classification of Diseases, ninth revision, Clinical Modification [ICD-9-CM] diagnosis code) were identified who began treatment with imatinib from 1 June 2001 through 31 March 2004. Treatment interruptions (i.e. failure to refill imatinib within 30 days from the run-out date of the prior prescription) were identified during the 12-month follow-up period. Medication possession ratio (MPR), calculated as total days' supply of imatinib divided by 365, was also examined. Healthcare costs (i.e. paid amounts for all prescription medications and medical services received, including health plan and patient liability) were examined in three ways: (i) total healthcare costs; (ii) total healthcare costs exclusive of imatinib costs; and (iii) total medical costs. All costs were converted to US dollars (2004 values) using the medical component of the Consumer Price Index. MPR was modelled using ordinary least squares regression. Presence of treatment interruptions was modelled using logistic regression. The association between MPR and healthcare costs was estimated using a generalised linear model specified with a gamma error distribution and a log link. All models included adjustment for age, gender, number of concomitant medications, starting dose of imatinib and cancer complexity. RESULTS: A total of 267 patients were identified. Average age was approximately 50 years, and 43% were women. Mean MPR was 77.7%, with 31% of patients having a treatment interruption. However, all of these patients resumed imatinib within the study period. In this population, MPR decreased as the number of concomitant medications increased (p = 0.002), and was lower among women (p = 0.003), patients with high cancer complexity (p = 0.003) and patients with a higher starting dose of imatinib (p = 0.04). Women were approximately twice as likely as men to have a treatment interruption (p = 0.009), as were patients with a high cancer complexity (p = 0.03). After adjusting for the aforementioned covariates, MPR was found to be inversely associated with healthcare costs excluding imatinib (p < 0.001) and medical costs (p < 0.001). A 10% point difference in MPR was associated with a 14% difference in healthcare costs excluding imatinib and a 15% difference in medical costs. For example, patients with an MPR of 75% incur an additional 4072 US dollars in medical costs annually compared with patients with an MPR of 85%. CONCLUSIONS: Treatment interruptions and non-adherence with imatinib, both of which could lead to undesired clinical and economic outcomes, appear to be prevalent. Physicians and pharmacists should educate patients and closely monitor adherence to therapy, as improving adherence and limiting treatment interruptions may not only optimise clinical outcomes but also reduce the economic burden of CML.

Treatment of hypertension and dyslipidemia or their combination among US managed-care patients.

The authors examined treatment rates in managed-care patients with hypertension (HTN) only or dyslipidemia (DYS) only compared with patients who had both (HTN+DYS). A retrospective, cross-sectional claims analysis was performed in a 2002 US national managed-care database of 1.23 million continuously eligible members aged 18 years or older. Median age was 44.0 years, 8.8% were aged 65 years or older, and 53.2% were women. Study criteria identified 354,324 patients, 32.9% with HTN only, 34.7% with DYS only, and 32.4% with HTN+DYS. Overall, 49.7% of HTN patients had DYS and 48.3% of DYS patients had HTN. Patients with HTN+DYS were significantly older, more likely to have cardiovascular comorbidities, and more likely to use medications and hospital facilities than were patients with HTN only or DYS only (P<.01). About two-thirds of patients with HTN only received 1 or more prescription for an antihypertensive medication, compared with three-quarters of those with HTN+DYS. Fewer than half of patients with DYS only and approximately two-thirds with HTN+DYS received a cholesterol-lowering agent.

Health care resource utilization and the impact of anemia management in patients with chronic kidney disease.

BACKGROUND: Limited information exists on resource utilization patterns and overall patient management of chronic kidney disease (CKD) before the initiation of dialysis therapy. METHODS: A retrospective claims analysis from January 1997 to December 1999 was conducted using a managed care database on 1,936 incident dialysis patients, examining the 12 months preceding dialysis initiation to evaluate whether managed care patients with CKD are receiving expected interventions and appropriate management of CKD. RESULTS: Mean age was 66.8 years, 46% were women, 91.2% had claims for facility services, 97.6% had claims for professional services, and 95.7% had claims for outpatient pharmacy, with mean costs per patient of $26,204, $9,623, and $1,503, respectively. Sixty-two percent of patients were hospitalized, averaging 1.3 admissions annually ($14,818/admission; average, 7.8 d/admission). Despite high overall resource use, treatments for preparation for dialysis therapy, appropriate tests, and nutritional supplements (eg, phosphate binders, B-complex combinations, and vitamins with iron) were administered infrequently. Comorbid conditions, such as anemia (47.4%) and diabetes (53%), were appropriately addressed with erythropoietin (10.5%) and angiotensin-converting enzyme inhibitors (38%) in only a minority of cases. In preparation for dialysis therapy, only 20.8% underwent a vascular access procedure. CONCLUSION: Although patients consumed significant amounts of resources during the 12 months before dialysis initiation, many were not using expected resources for the appropriate management of CKD. A number of opportunities exist to improve predialysis care through better management of these conditions.

Estimating angina prevalence in a managed care population.

Estimations of angina prevalence were calculated using managed care administrative data and applying 3 angina-related definitions. The definitions comprised angina pectoris diagnosis codes, diagnosis and procedure codes signifying the broader condition of coronary artery disease (CAD), including angina pectoris, and diagnosis codes for the symptom of chest pain. Prevalence rates were calculated in 2000, 2001, and the combined period of 2000 and 2001 for each definition based on the number of members with at least 1 day of eligibility in each period. Results were compared with published estimates and projected to the US population. The prevalence rates per 1000 people for angina pectoris in 2000, 2001, and 2000--2001 were 12.3, 14.0, and 17.5, respectively. The prevalence rate is higher in the combined 2-year period primarily because there is little duplication in patients with angina who appear in both years, but there is significant overlap in the overall (denominator) population eligible in both years. For CAD the rates were 52.2, 59.9, and 65.4, respectively, and for chest pain they were 63.4, 75.8, and 93.4, respectively. Rates were higher in men versus women and in each successive age group. These gender and age results were observed in the projections to the US population. By comparison, the American Heart Association (AHA) estimates angina pectoris prevalence to be 35 per 1000 in 2001. The lower managed care rate for angina pectoris may reflect differences in data capture (ie, self-reported data for AHA vs claims submitted for reimbursement for managed care). AHA estimates are higher for women versus men while the managed care estimates show the opposite trend. Prevalence of angina in the United States is substantial. With the aging of the US population, numbers of patients with angina presenting to the healthcare system can be expected to increase, further adding to the cost burdens facing managed care.

Exploring the methodological challenges of investigating comparison groups with different underlying characteristics: a case study.

OBJECTIVE: To examine challenges in forming accurate conclusions from claims data when comparing different patient groups, and to stress the need to adjust for confounding variables through application of statistical methods. METHODS: Patients who were 60 or older and began amlodipine or felodipine in 1997 or 1998 were identified from a proprietary managed care claims database. Patients had 6 months of medical and outpatient pharmacy benefits coverage before and after initiating therapy. They were stratified on varying degrees of hypertension severity and on all-condition clinical complexity, and quantified with a proprietary Burden of Illness (BOI) score, defined as the expected resource use for the patient.s combined conditions during the 6 months before therapy. RESULTS: Of the 17,667 patients, 10,469 (59.3%) were female. The 12,389 amlodipine users were similar in age to felodipine users (n=5,278), 73 versus 74, respectively. More amlodipine users were assigned to the 2 most clinically complex quintiles of the BOI distribution (45.5% to 26.9%), with 24.3% of patients in the top quintile (9.7% for felodipine) and twice the prevalence of ischemic heart disease/angina (42.4% versus 19.4%). High-severity hypertension was found among 33.6% of amlodipine users, contrasted with 17.9% for felodipine. A significant difference in the mean average daily dose (ADD) between the amlodipine (5.93 mg) and felodipine (5.8 mg) groups (P=0.0007) was noted. CONCLUSION: These results stress the importance of assessing the impact of potentially confounding variables and the need to address differing patient characteristics through either risk adjustment or stratification in making head-to-head comparisons.

Examination of resource use and clinical interventions associated with chronic kidney disease in a managed care population.

BACKGROUND: The management of chronic kidney disease (CKD) is multifaceted, including monitoring, early diagnosis, and treatment of comorbidities such as diabetes, hypoalbuminemia, and anemia, and initiating timely procedures in preparation for dialysis such as vascular access placement. Presumably, optimal care provided to patients during the predialysis phase will produce a significant impact on morbidity and mortality outcomes. OBJECTIVE: A retrospective analysis was conducted to assess specific factors that may be associated with optimal quality of care for CKD patients during the predialysis phase. METHODS: Health care resource utilization and the occurrence of interventions associated with optimal predialysis care were evaluated with claims data. Predialysis erythropoietin (EPO) therapy, nephrology referrals, and nutritional supplement administration were all examined during the 12 months prior to dialysis. RESULTS: Medical and pharmacy claims from a managed care database were analyzed for 1,936 incident dialysis patients. Of these, 48.7% did not have any interventions associated with optimal care. Only a minority of patients received prescription iron preparations (6.8%), vitamin D (4.0%), and phosphate binders (7.7%). A total of 20.8% patients had a vascular access placement, and 29.8% were in the care of a nephrologist during this same time period. Only 10.5% received predialysis EPO, yet more than 40% were diagnosed with anemia. Of the EPO users, however, 72.4% were also receiving other interventions to appropriately manage CKD. CONCLUSION: These claims-documented results suggest that the lack of EPO use in predialysis patients in a managed care plan may predict overall suboptimal treatment of these patients. There is an apparent need for the proactive management of CKD in a managed care plan to potentially redistribute or reduce health care resource utilization while improving patient outcomes.

Impact of anemia on hospitalization time, charges, and mortality in patients with heart failure.

OBJECTIVES: Although anemia is known to influence clinical outcomes in heart failure (HF) patients, little is known about its impact on economic outcomes. A retrospective analysis was performed to determine the impact of hemoglobin (Hb) level on hospital length of stay (LOS), total charges, and hospital mortality in HF patients. METHODS: Claims data were drawn from 21 teaching and nonteaching hospitals for patients hospitalized between October 1, 2000 and September 30, 2001. The impact of Hb on LOS, charges, and hospital mortality was determined using multivariate analyses. Two-stage least squares regression methods were used to assess the potential endogeneity of the economic outcomes (LOS and total charges) and Hb level. RESULTS: Of the 8569 patients in the analysis, 40.2% had Hb < 12 g/dl and 73.8% were > or = 70 years of age. Hemoglobin had significant independent effects on all three outcomes. A 1 g/dl increase in Hb was associated with a 5.1% reduction in LOS (P < 0.001), a 4.3% decrease in charges (P < 0.001), and an 8.7% reduction in mortality risk (P < 0.001). The impact of Hb on all outcomes was greatest in younger HF patients. CONCLUSIONS: This analysis demonstrates that higher Hb is associated with reductions in LOS, charges, and mortality in hospitalized HF patients. Further clinical studies are necessary to validate the cost effectiveness of pharmacologic intervention in anemic HF patients and its impact on patient care.