Healthcare and associated costs related to type 2 diabetes in youth and adolescence: the TODAY clinical trial experience.

The economic issues related to medical treatments in youth with type 2 diabetes (T2D) are rarely reported and thus not fully understood. The Treatment Options for type 2 Diabetes in Adolescents and Youth clinical trial of youth recently diagnosed with T2D collected healthcare and related cost information from the largest cohort studied to date. Costs related to medical treatments and expenses faced by caregivers were identified over a 2-year period from 496 participants. Data were collected by surveys and diaries to document frequency of use of diabetes care (excluding study laboratory tests), non-diabetes care services and treatments, caregiver time, and expenses related to exercise and dietary activities recommended for patients. Economic costs were derived by applying national cost values to the reported utilization frequency data. Annual medical costs in the first year varied by the treatment group, averaging $1798 in those assigned to metformin alone (M), $2971 to combination drug therapy with metformin + rosiglitazone (M + R), and $2092 to metformin + an intensive lifestyle and behavior change program (M + L). Differences were primarily due to costs related to combination drug therapy. Adult caregiver support costs were higher for participants in the lifestyle program, which was delivered in weekly sessions in the first 6 months. Expenses for purchases to enhance diet and exercise change did not vary by treatment assignment. In year 2, medication costs increased in M and M + L due to the initiation of insulin in subjects who failed to maintain glycemic control on the assigned treatment. Data are reported for use by researchers and those providing healthcare to this vulnerable patient population.

Neonatal outcomes after elective cesarean delivery.

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. LEVEL OF EVIDENCE: II.

Compensation costs of work-related back disorders among union carpenters, Washington State 1989-2003.

BACKGROUND: We measured resources used to provide medical care and to estimate lost productivity represented by payments for lost work time or impairment for work-related back injuries among a large cohort of union carpenters over 15 years. METHODS: Using administrative data we identified a cohort of carpenters, their hours worked, their workers' compensation claims and associated costs. After adjustment for inflation and discounting to 2006 dollars, yearly costs for injuries and payment rates based on hours worked were calculated. Using negative binomial regression, dollars paid per claim were modeled based on age, gender, union tenure, and predominant type of work of the carpenter and whether the injury resulted from overexertion or acute trauma. RESULTS: Workers' compensation costs for back injuries exceeded $128 million dollars between 1998 and 2003, representing payments of $0.97 for each hour of work. Costs per hour of work declined substantively over time due largely to declining overexertion injury rates. Traumatic injuries, though less common than overexertion injuries, were more expensive. Costs increased with the number of prior back injuries and with increasing age, beginning as early as age 30. CONCLUSIONS: Increasing costs even among relatively young carpenters likely reflect the heavy nature of their work rather than simply the effects of biological aging. Musculoskeletal back problems remain a common, and consequently costly, source of injury among these carpenters that needs to be addressed through engineering modifications; there are also clearly needs for prevention of the often more costly back injuries associated with acute trauma.

Injuries from slips and trips in construction.

Construction injuries preceded by a slip or trip were documented using data from the building of the Denver International Airport (Denver, Colorado, USA), the largest construction project in the world at the time. Slips and trips occurred at a rate of 5/200,000 h worked accounting for 18% of all injuries and 25% of workers' compensation payments, or more than $10 million. Slips contributed to the vast majority (85%) of same-level falls and over 30% of falls from height, as well as a significant number of musculoskeletal injures sustained after slipping or tripping but without falling. The injury burden would have been under-recognized in analyses of most coded compensation records. In contrast to other types of injuries, the most common contributing factors were environmental in nature including conditions of walking and working surfaces, terrain and weather. Due to the very dynamic nature of construction work, reducing slips and trips will require a focus on environmental and organizational solutions that evolve as the site changes and the construction project evolves.

Uncomplicated acute renal failure and hospital resource utilization: a retrospective multicenter analysis.

BACKGROUND: Although acute renal failure (ARF) complicating nonrenal organ dysfunction in the intensive care unit is associated with significant mortality and hospital costs, hospital resource utilization attributed to uncomplicated ARF is not well known. The goal of this study is to characterize the costs and lengths of stay (LOSs) incurred by hospitalized patients with uncomplicated ARF and their important determining factors. METHODS: We obtained hospital case-mix data sets from 23 Massachusetts hospitals for a 2-year period (1999 to 2000) from the Massachusetts Division of Health Care Finance and Policy. A total of 2,252 records of patients hospitalized with uncomplicated ARF were identified. Patient records of other common medical diagnoses were studied for comparison. RESULTS: Patients hospitalized with uncomplicated ARF incurred median direct hospital costs of 2,600 dollars, median hospital LOS of 5 days, and mortality of 8%. Dialysis was independently associated with significantly greater hospital costs and LOSs for patients with uncomplicated ARF (P < 0.05). Male sex and nonwhite race were associated with significantly lower hospital costs and LOSs, whereas type of hospital had opposing effects on these 2 resource utilization outcomes (P < 0.05). Unadjusted aggregate resource utilization associated with uncomplicated ARF exceeded that of many other common illnesses. CONCLUSION: Demographic and hospital factors, as well as dialysis therapy, are significant determinants of hospital resource utilization for patients with uncomplicated ARF. Uncomplicated ARF appears to incur greater hospital costs and longer LOSs compared with other common medical conditions. Greater focus should be directed toward further understanding of the factors influencing resource utilization for ARF.

Using an immunization registry: effect on practice costs and time.

INTRODUCTION: Immunization registries can consolidate immunization records scattered among different providers, allowing immunization documentation for legal purposes, generation of needed-immunization lists, inventory management, and outreach for underimmunized children. They have been endorsed by the Centers for Disease Control and Prevention and health professionals as a means of sustaining high immunization rates. However, some providers perceive the cost of registry use as a barrier to participation. We sought to determine the effects of registry use on cost and time. METHODS: We used a pre-post design and a cost-accounting approach to measure labor costs and time for immunization-related activities possibly affected by registry use before development of a regional registry in Colorado and after the registry was being fully used. Two rural family practices, 2 rural community health centers (CHCs), 3 urban pediatric practices, and 2 rural public health agencies participated in both periods. RESULTS: Cost per shot increased slightly in the postregistry period for private practices and CHCs ($0.56 per shot in 2001 dollars) and public health agencies ($0.38). Since costs can increase for several reasons, including salary increases above inflation, we analyzed time spent per shot and found that staff time decreased for private practices and CHCs but increased substantially for public health agencies. CONCLUSIONS: The study findings suggest to private practices that registry participation can provide a net benefit by making the vaccination process more efficient and, absent above-average salary increases, less costly. Public health agencies, however, would have to rely exclusively on the registry and eschew the use of paper vaccination records to realize efficiencies seen by other practice types.

Primary-care visits and hospitalizations for ambulatory-care-sensitive conditions in an inner-city health care system.

OBJECTIVE: Hospitalizations for ambulatory-care-sensitive conditions (ACSCs) are a marker for access barriers for children and a possible outcome measure for primary-care interventions. We assessed the relationship between primary-care utilization and subsequent ACSC hospitalization among inner-city children. METHODOLOGY: We conducted a nested, case-control study of children born in 1993 in Denver Health (DH), a "safety-net" delivery system in Denver, Colo. Utilization of preventive care and other primary-care services was compared between children hospitalized for ACSCs and nonhospitalized children, who were matched by age and duration of care. Comparisons were adjusted for demographics, payer, and chronic health conditions. RESULTS: Of 2531 children, 115 (4.5%) were hospitalized for ACSCs. Sixty-eight percent were Hispanic, and 78% were enrolled in Medicaid. Children with ACSC hospitalization and nonhospitalized children made a similar number of preventive-care visits (2.7 +/- 2.0 vs 3.0 +/- 2.1 visits, P =.30) and other primary-care visits (4.4 +/- 4.6 vs 3.6 +/- 4.6, P =.16) between birth and hospitalization (for cases) or the same time period (for controls). After multivariate adjustment, each additional preventive-care visit (odds ratio = 0.87; 95% confidence interval: 0.67-1.12) was associated with a nonsignificant reduction in the risk of hospitalization for ACSC. CONCLUSIONS: Because ACSC hospitalizations are uncommon and the association between primary care and subsequent hospitalization is weak, a reduction in ACSC hospitalizations may not be a feasible outcome measure for interventions to increase the rate of preventive- or primary-care visits for underserved children within individual delivery systems.

Effectiveness and cost of immunization recall at school-based health centers.

BACKGROUND AND OBJECTIVE: Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs. METHODS: During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥ 1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices. RESULTS: At the end of the demonstration study, 77% of girls had received ≥ 1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥ 1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized. CONCLUSIONS: SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings.

Effectiveness and net cost of reminder/recall for adolescent immunizations.

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

Cost of vaccine administration among pediatric practices.

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations. METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by > or = 2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments. RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged $11.51, calculated from the following categories: nursing time, $1.71; billing services, $2.67; nonroutine services, $1.64; registry use, $0.96; physician time, $4.05; supplies, $0.36; medical waste disposal, $0.12. Nonroutine activities primarily included performing vaccine inventory and ordering, providing vaccination records to requesters, and answering parent telephone questions about vaccinations. With the use of a simulation model to compensate for the small number of participating practices, the calculated total variable cost per injection was $11.83. When 2 vaccines were administered, we compared the sum of the 2 payments with the sum of the 2 variable costs ($23.02). More than one third of the payment agreements (13 of 37 agreements) paid the practices less than the combined variable costs for 2 immunizations. CONCLUSION: This study shows that the variable costs of vaccine administration exceeded reimbursement from some insurers and health plans.

Who is paying the bills? Health care costs for musculoskeletal back disorders, Washington State Union Carpenters, 1989-2003.

OBJECTIVE: Factors associated with private health insurance payment rates for musculoskeletal back disorders were examined among a 15-year cohort of union carpenters. Payment patterns were contrasted with work-related back injury rates over time. METHODS: Negative binomial regression was used to assess payment rates; generalized estimated equations accounted for multiple observations per person and cost correlation within subjects. RESULTS: Payment rates increased after work-related injury and with the number of injuries. Increasing private payments and deductibles (inflation-adjusted and discounted) were observed in contrast with a marked decline in reported work-related injuries. CONCLUSIONS: Private insurance payments do not appear to be independent of work-related back injury. Findings suggest cost-shifting from workers' compensation to the union-provided health insurance and to the worker; they also provide a warning regarding reliance on workers' compensation statistics for surveillance of work-related disorders or disease.

"Get smart Colorado": impact of a mass media campaign to improve community antibiotic use.

CONTEXT: Large-scale strategies are needed to reduce overuse of antibiotics in US communities. OBJECTIVES: To evaluate the impact of a mass media campaign-"Get Smart Colorado"-on public exposure to campaign, antibiotic use, and office visit rates. DESIGN: Nonrandomized controlled trial. SETTING: Two metropolitan communities in Colorado, United States. SUBJECTS: The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities. INTERVENTION: : The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003. PRINCIPAL MEASURES: Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign. RESULTS: After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections. CONCLUSIONS: A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.

Pediatric telephone call centers: how do they affect health care use and costs?

OBJECTIVES: After-hours call centers have been shown to provide appropriate triage with high levels of parental and provider satisfaction. However, few data are available on the costs and outcomes of call centers from the perspective of the health care system. With this study we sought to determine these outcomes. METHODS: Parents who called the Pediatric After-hours Call Center at the Children's Hospital of Denver from March 19, 2004, to April 19, 2004, were asked an open-ended question before triage: "We would like to know, what you would have done if you could not have called our call center this evening/today?" RESULTS: The response rate for the survey was 77.8% (N = 8980). Parents reported that they would have (1) gone to an emergency department or urgent care facility (46%), (2) treated the child at home (21%), (3) called a physician's office the next day (12%), (4) asked another person for advice (13%), (5) consulted a written source (2%), or (6) other (7%). Of the 46% of callers who would have sought emergent care, only 13.5% subsequently were given an urgent disposition by the call center. Fifteen percent of cases in which the parents would have stayed at home were given an urgent disposition by nurses. Assuming that all callers followed the advice provided, the estimated savings per call, based on local costs, was 42.61 dollars per call. Savings based on Medical Expenditure Panel Survey national payment data were 56.26 dollars per call. CONCLUSIONS: Two thirds of the cases in which parents reported initial intent to go to an emergency department or urgent care facility were not deemed urgent by the call center, whereas 15% of calls from parents who intended to stay home were deemed urgent. If call-center triage recommendations were followed in even half of all cases, then these results would translate into substantial cost savings for the health care system.

Methods for using narrative text from injury reports to identify factors contributing to construction injury.

BACKGROUND: Several methods exist for classifying injuries from written text, thereby identifying possible points of intervention. We describe an innovative method for such classification. METHODS: Using Haddon's matrix as a framework, two independent reviewers coded text from over 4,000 injury reports into a qualitative software package to identify factors contributing to injuries sustained during construction of Denver International Airport (DIA). We compared our classification scheme with three others. RESULTS: This process created a coded data set, an expanded version of Haddon's matrix adapted for construction injury, and coding rules for interpreting narrative text. Haddon's matrix provides a flexible theoretical framework for coding information about a spectrum of contributing factors. CONCLUSIONS: Narrative descriptions from injury reports can provide detail on circumstances surrounding injuries and identify factors contributing to injury. Forms guiding investigators to explicitly consider human, organizational, and environmental factors could foster more complete descriptions of factors contributing to construction injury.

The cost of giving childhood vaccinations: differences among provider types.

OBJECTIVE: To describe costs to providers of delivering childhood immunizations. METHODS: We collected variable costs--costs that vary with the amount of services rendered--including cost of practitioner and staff time and supplies, using a cost accounting method, from 12 practices (4 pediatric practices, 4 family practices, and 4 public health agencies) in rural and urban areas in Colorado. For private practices, we estimated fixed costs--costs that do not vary with the amount of services, eg, rent and insurance). We also collected reimbursement information for vaccinations for private practices. RESULTS: Variable costs per shot (excluding vaccine cost) were 8.15 dollars for pediatric practices, 5.79 dollars for family practices, and 5.41 dollars for public health agencies. Total costs per shot, including fixed costs, were 10.67 dollars for pediatric practices and 7.57 dollars for family practices. Average reimbursement for pediatricians and private family practices was 8.27 dollars and 6.68 dollars, respectively. For pediatric practices, average variable costs were barely exceeded by average reimbursement, and reimbursement was 22% less than average total costs. This contrasts with an earlier study of the rural practices investigated here, in which there was a comfortable margin between reimbursement and variable costs. CONCLUSION: The decline in the ratio of reimbursement to cost for private practices, particularly for pediatric practices, suggests that referral to public agencies by private providers for vaccinations may increase and that if vaccinations are not as frequently provided in the child's medical home, then the currently high childhood immunization rates may be in jeopardy.