Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement - Advanced.

BACKGROUND: Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model. METHODS: In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for cardiac medical and procedural conditions at BPCI-A hospitals compared with controls. Secondary outcomes included changes in patient complexity, care utilization, healthy days at home, readmissions, and mortality. RESULTS: Baseline spending for cardiac medical episodes at BPCI-A hospitals was $25 606. The differential change in spending for cardiac medical episodes at BPCI-A versus control hospitals was $16 (95% CI, -$228 to $261; P=0.90). Baseline spending for cardiac procedural episodes at BPCI-A hospitals was $37 961. The differential change in spending for cardiac procedural episodes was $171 (95% CI, -$429 to $772; P=0.58). There were minimal differential changes in physicians' care patterns such as the complexity of treated patients or in their care utilization. At BPCI-A versus control hospitals, there were no significant differential changes in rates of 90-day readmissions (differential change, 0.27% [95% CI, -0.25% to 0.80%] for medical episodes; differential change, 0.31% [95% CI, -0.98% to 1.60%] for procedural episodes) or mortality (differential change, -0.14% [95% CI, -0.50% to 0.23%] for medical episodes; differential change, -0.36% [95% CI, -1.25% to 0.54%] for procedural episodes). CONCLUSIONS: Participation in BPCI-A was not associated with spending reductions, changes in care utilization, or quality improvements for the cardiovascular medical events or procedures offered in the model.

Medical Costs of Nontuberculous Mycobacterial Pulmonary Disease, South Korea, 2015-2019.

Nontuberculous mycobacterial pulmonary disease (NTM-PD) prevalence is a rising public health concern. We assessed the long-term healthcare systems perspective of costs incurred by 147 NTM-PD patients at a tertiary hospital in South Korea. Median cumulative total medical cost in managing NTM-PD patients was US $5,044 (interquartile range US $3,586-$9,680) over 49.7 months (interquartile range 33.0-68.2 months) of follow-up. The major cost drivers were diagnostic testing and medication, accounting for 59.6% of total costs. Higher costs were associated with hospitalization for Mycobacterium abscessus infection and pulmonary comorbidities. Of the total medical care costs, 50.2% were patient co-payments resulting from limited national health insurance coverage. As South Korea faces significant problems of poverty during old age and increasing NTM-PD prevalence, the financial and socio-economic burden of NTM-PD may become a major public health concern that should be considered with regard to adequate strategies for NTM-PD patients.

Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure.

BACKGROUND: Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE: Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN: This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS: A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES: Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS: In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS: Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.

Diagnostics for regression models with semicontinuous outcomes.

Semicontinuous outcomes commonly arise in a wide variety of fields, such as insurance claims, healthcare expenditures, rainfall amounts, and alcohol consumption. Regression models, including Tobit, Tweedie, and two-part models, are widely employed to understand the relationship between semicontinuous outcomes and covariates. Given the potential detrimental consequences of model misspecification, after fitting a regression model, it is of prime importance to check the adequacy of the model. However, due to the point mass at zero, standard diagnostic tools for regression models (eg, deviance and Pearson residuals) are not informative for semicontinuous data. To bridge this gap, we propose a new type of residuals for semicontinuous outcomes that is applicable to general regression models. Under the correctly specified model, the proposed residuals converge to being uniformly distributed, and when the model is misspecified, they significantly depart from this pattern. In addition to in-sample validation, the proposed methodology can also be employed to evaluate predictive distributions. We demonstrate the effectiveness of the proposed tool using health expenditure data from the US Medical Expenditure Panel Survey.

Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review.

INTRODUCTION: Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs). METHODS: We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery. RESULTS: 77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE. CONCLUSIONS: CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

Association of surgeon's sex, and surgeon-patient dyad with financial outcomes among patients undergoing cancer surgery.

BACKGROUND AND OBJECTIVES: Surgeon sex has been associated with perioperative clinical outcomes among patients undergoing oncologic surgery. There may be variations in financial outcomes relative to the surgeon-patient dyad. We sought to define the association of surgeon's sex with perioperative financial outcomes following cancer surgery. METHODS: Patients who underwent resection of lung, breast, hepato-pancreato-biliary (HPB), or colorectal cancer between 2014 and 2021 were identified from the Medicare Standard Analytic Files. A generalized linear model with gamma regression was utilized to characterize the association between sex concordance and expenditures. RESULTS: Among 207,935 Medicare beneficiaries (breast: n = 14,753, 7.1%, lung: n = 59,644, 28.7%, HPB: n = 23,400, 11.3%, colorectal: n = 110,118, 53.0%), 87.8% (n = 182,643) and 12.2% (n = 25,292) of patients were treated by male and female surgeons, respectively. On multivariable analysis, female surgeon sex was associated with slightly reduced index expenditures (mean difference -$353, 95%CI -$580, -$126; p = 0.003). However, there were no differences in 90-day post-discharge inpatient (mean difference -$-225, 95%CI -$570, -$121; p = 0.205) and total expenditures (mean difference $133, 95%CI -$279, $545; p = 0.525). CONCLUSIONS: There was minor risk-adjusted variation in perioperative expenditures relative to surgeon sex. To improve perioperative financial outcomes, a diverse surgical workforce with respect to patient and surgeon sex is warranted.

The value-for money of preventing and managing periodontitis: Opportunities and challenges.

This article gives an overview of the societal and economic aspects of periodontitis and periodontal care. Despite its largely preventable nature, periodontitis is highly prevalent worldwide and imposes a substantial health and economic burden on individuals and society as a whole. The worldwide estimated direct treatment costs and productivity losses due to periodontitis (including for periodontitis-related tooth loss) amounted to US$ 186 billion and US$ 142 billion in 2019, respectively. The burden of periodontitis is particularly evident in low and disadvantaged populations. Smoking, dietary habits, and presence of systemic diseases along with social and commercial determinants are considered as risk factors for the periodontal diseases. The cost-effectiveness of preventing and managing periodontitis has been explored in several studies but it has been highlighted that there is scope for improvement in defining the methodology and quality of reporting of such studies. A recent report by The Economist Intelligence Unit examined the cost-effectiveness of interventions to prevent and manage periodontal diseases, suggesting that prevention of periodontitis through prevention of gingivitis by means of individual home care would be more cost-efficient than four other examined approaches. Future research in this field is recommended to further decipher the economic burden of periodontitis to society and to assess the value for money of alternative approaches to address periodontitis with particular emphasis on public health preventive strategies and intersectoral care approaches that address the common risk factors of periodontitis and other non-communicable diseases simultaneously.

The impact of the expanded health insurance coverage policy on healthcare spending: evidence from Korea.

BACKGROUND: South Korea's National Health Insurance (NHI) system pursues universal health coverage, but it has not been able to alleviate patients' financial burden owing to limited coverage and a high proportion of out-of-pocket expenses. In 2017, the government announced a plan to strengthen universality by providing coverage for all unincluded services, expanding coverage, and alleviating household financial burden. We aimed to evaluate the effect of "Moon Care" with a focus on changes in health expenditures following policy implementation, and to provide empirical evidence for future policies to strengthen the NHI system's universality. METHODS: Using data from the 2016 and 2018 Korea Health Panel (KHP), we established a treatment group affected by the policy and an unaffected control group; we ensured homogeneity between the groups using propensity score matching (PSM). Subsequently, we examined changes in NHI payments, non-payments, and out-of-pocket payments (OOP); we performed difference-in-differences (DID) analysis to evaluate the policy's effect. RESULTS: Following policy implementation, the control group had a higher increase than the treatment group in all categories of health expenditures, including NHI payments, non-payments, and OOP. We noted significant decreases in all three categories of health expenditures when comparing the differences before and after policy implementation, as well as between the treatment and control groups. However, we witnessed a significant decrease in the interaction term, which confirms the policy's effect, but only for non-payments. CONCLUSIONS: We observed the policy's intervention effect over time as a decrease in non-payments, on the effectivity of remunerating covered medical services. However, the policy did not work for NHI payments and OOP, suggesting that it failed to control the creation of new non-covered services as noncovered services were converted into covered ones. Thus, it is crucial to discuss the financial spending of health insurance regarding the inclusion of non-covered services in the NHI benefits package.

The impact of long-term care insurance on healthcare utilization and expenditures among middle-aged and older Chinese adults: a quasi-experiment study.

BACKGROUND: Long-term care insurance (LTCI) is essential to alleviate the challenges of rapid aging. Research on LTCI in developing countries is limited and conclusions remain controversial. This study aims to empirically evaluate how the LTCI pilot in selected cities influences healthcare utilization and expenditures among middle-aged and older Chinese adults. METHODS: Data was from 2013, 2015, and 2018 China Health and Retirement Longitudinal Study. 167 LTCI and 8225 non-LTCI group participants were identified. Propensity score matching difference-in-difference method was used to evaluate the net effect of LTCI. The robustness of the findings was tested using a placebo test. RESULTS: In the pilot cities, around 17.8% of the population had LTCI coverage, with approximately 59.9% participating in urban employee medical insurance and 81.4% being urban residents. LTCI significantly reduced the monthly out-of-pocket outpatient expenditure by 313.764 yuan (P < 0.05), but had no significant effects on the inpatient utilization and expenditure. Further analysis of vulnerable subgroup revealed that LTCI decreased monthly outpatient visits frequency, total outpatient expenditure, and out-of-pocket outpatient expenditure by 0.523 times, 643.500 yuan, and 302.367 yuan, respectively (P < 0.05). Robustness tests confirmed the stability of these results. CONCLUSIONS: The LTCI coverage rate has remained low. While LTCI has contributed to reducing outpatient utilization and expenditure, its impact on controlling inpatient-related outcomes is limited. It is recommended to broaden LTCI coverage beyond existing participants to encompass more vulnerable populations, and improve awareness and quality of LTCI services to achieve a significant effect on inpatient care.

Rural‒urban disparities in household catastrophic health expenditure in Bangladesh: a multivariate decomposition analysis.

BACKGROUND: Rural‒urban disparity in catastrophic healthcare expenditure (CHE) is a well-documented challenge in low- and middle-income countries, including Bangladesh, limiting financial protection and hindering the achievement of the Universal Health Coverage target of the United Nations Sustainable Development Goals. However, the factors driving this divide remain poorly understood. Therefore, this study aims to identify the key determinants of the rural‒urban disparity in CHE incidence in Bangladesh and their changes over time. METHODS: We used nationally representative data from the latest three rounds of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016). CHE incidence among households seeking healthcare was measured using the normative food, housing, and utilities method. To quantify covariate contributions to the rural‒urban CHE gap, we employed the Oaxaca-Blinder multivariate decomposition approach, adapted by Powers et al. for nonlinear response models. RESULTS: CHE incidence among rural households increased persistently during the study period (2005: 24.85%, 2010: 25.74%, 2016: 27.91%) along with a significant (p-value ≤ 0.01) rural‒urban gap (2005: 9.74%-points, 2010: 13.94%-points, 2016: 12.90%-points). Despite declining over time, substantial proportions of CHE disparities (2005: 87.93%, 2010: 60.44%, 2016: 61.33%) are significantly (p-value ≤ 0.01) attributable to endowment differences between rural and urban households. The leading (three) covariate categories consistently contributing significantly (p-value ≤ 0.01) to the CHE gaps were composition disparities in the lowest consumption quintile (2005: 49.82%, 2010: 36.16%, 2016: 33.61%), highest consumption quintile (2005: 32.35%, 2010: 15.32%, 2016: 18.39%), and exclusive reliance on informal healthcare sources (2005: -36.46%, 2010: -10.17%, 2016: -12.58%). Distinctively, the presence of chronic illnesses in households emerged as a significant factor in 2016 (9.14%, p-value ≤ 0.01), superseding the contributions of composition differences in household heads with no education (4.40%, p-value ≤ 0.01) and secondary or higher education (7.44%, p-value ≤ 0.01), which were the fourth and fifth significant contributors in 2005 and 2010. CONCLUSIONS: Rural‒urban differences in household economic status, educational attainment of household heads, and healthcare sources were the key contributors to the rural‒urban CHE disparity between 2005 and 2016 in Bangladesh, with chronic illness emerging as a significant factor in the latest period. Closing the rural‒urban CHE gap necessitates strategies that carefully address rural‒urban variations in the characteristics identified above.

Out-of-pocket pharmaceutical expenditure and its determinants among Iranian households with elderly members: a double-hurdle model.

OBJECTIVES: The population of older adults continues to grow in Iran, with pharmaceutical costs as a leading driver of household health-related costs. The present study was conducted to estimate the out-of-pocket pharmaceutical expenditure and its socioeconomic predictors among households with the elderly in Iran. METHOD: This study is a secondary analysis using 2019 national household expenditure and income survey data in Iran. The sample size was 9381 households with at least one member older than 65. The double-hurdle model in STATA 16 was used to examine the association between independent variables and households' out-of-pocket pharmaceutical expenditures. RESULTS: The mean out-of-pocket pharmaceutical expenditures for each household with elderly member was $8065 per year. There was a positive association between the (female) gender of the household head, urban residence, employment status, insurance expenditure and a higher level of education of the head of the household with the out-of-pocket pharmaceutical expenditures (P < 0.05). The income of elderly households did not affect these expenditures (P > 0.05). CONCLUSIONS: This study showed that the socioeconomic characteristics of elderly families not only influenced their decision to enter the medicine market, but also the rate of medicine purchase. It is helpful to manage and control the pharmaceutical costs among the elderly.

Modelling impacts of a salt and sugar tax on hypothetical intra-category food substitutions, BMI and environmental footprints in the UK population.

PURPOSE: Taxes on unhealthy foods can help improve population health in the United Kingdom (UK), but the health effects of food substitutions resulting from these taxes are often unclear. We investigated the potential impacts of a salt and sugar tax on hypothetical intra-category food substitutions, cost, body-mass index (BMI), and environmental footprints. METHODS: Purchase panel data from Kantar (2017) were used to determine the most popular foods high in salt or sugar within eight 'salt-intensive'/'sugar-intensive' food categories. Within food categories, the most popular lower salt (≤ 1.5 g salt/100 g product) and lower sugar (≤ 22.5 g sugar/100 g product) substitutes were also identified. Hypothetical swaps between high salt/sugar foods and lower salt/sugar substitutes were explored, focusing on changes to cost, caloric intake and BMI, and environmental impacts in the UK population. RESULTS: The suggested intra-category substitutions were largely like-for-like and did not accrue an added overall cost to consumers. The substitutions reduced calorie intake by about 200 kcal/day and lowered the prevalence of overweight and obesity in the UK from approximately 60-65% to about 40-45%. The proposed food substitutions led to a total reduction of -2.7Mt of greenhouse gases, ∼ -500.000 ha of land, -0.5km3 of blue water, -12km3 of scarcity weighted water, ∼ -12.000t of phosphorus, and nearly - 14.000t of sulphur dioxide over one year for the UK population due to reductions in calorie intake. CONCLUSION: Food substitutions following a tax on salt and sugar could lead to significant benefits for health and the environment, without necessarily resulting in major changes to people's expenditure on familiar salty and sugary snacks.

Out-of-pocket expenses and parent reported quality of life in children with cow's milk protein allergy in Bogotá, Colombia.

OBJECTIVE: To identify the out-of-pocket expenses and parent-reported quality of life (QoL) of children with a diagnosis of cow's milk protein allergy between the ages of 0 and 5 using the Food Allergy Quality of Life Questionnaire - Parent Form. METHODS: A cross-sectional study was conducted in two tertiary care centers in Bogotá. Demographic, medical information, and QoL scores were collected by parental interview. We carried out a cost-of-illness analysis based on self-reported out-of-pocket expenses attributed to the treatment as a whole and the family's monthly income. Exploratory analyses used the QoL scores and the percentage of out-of-pocket expenses attributable to treatment as outcomes. RESULTS: 122 families were analyzed. Median subject age was 17 months (Q1-Q3: 11-26.75 months) and female subjects made up 71% of the sample. The median QoL score was 3.21 points (Q1-Q3: 2.43-4.34) and only differed by age groups and personal history of other food allergies. The median out-of-pocket treatment related costs was 300,000 Colombian pesos (COP) (Q1-Q3: 280,000-340,000 COP). About 17% of the families had to pay over 15% of their monthly income to purchase food and dietary products. Out-of-pocket treatment related costs differed depending on whether the treatment included formulas (Mann-Whitney test p < 0.001). Out-of-pocket treatment expenses were uncorrelated with the QoL scores. CONCLUSION: Food allergy related QoL scores were not associated with out-of-pocket expenses as a whole or as a fraction of monthly income but were higher in children with additional food allergies and in older age groups, suggesting a lower QoL.

A panel vector autoregression analysis for the dynamics of medical and long-term care expenditures.

Although medical and long-term care expenditures for older adults are closely related, providing rigorous statistical analysis for their dynamic relationship is challenging. In this research, we propose a novel approach using the panel vector autoregression model to reveal the realized patterns of the interdependence. As an empirical application, we analyze monthly panel data on individuals in a city of Japan, where social insurance covers many formal services for long-term care. Our estimation results indicate the existence of intertemporal transition from expensive acute medical care to reasonable at-home medical care, then to at-home long-term care. Under this context, the enhancement of formal long-term care sector in Japan might have played an important role in the suppression of the total care cost in spite for its rapid aging over the past 2 decades. Additionally, we find that daycare plays multiple roles in Japanese long-term care, such as respite and rehabilitation, but there is no considerable transition from outpatient rehabilitation to daycare in the long-term care sector.

Frequency of use and cost in Japan of first-line palliative chemotherapies for recurrent or metastatic squamous cell carcinoma of the head and neck.

BACKGROUND: Over the last decade, novel anticancer drugs have improved the prognosis for recurrent or metastatic squamous cell carcinoma of the head and neck (RM-SCCHN). However, this has increased healthcare expenditures and placed a heavy burden on patients and society. This study investigated the frequency of use and costs of select palliative chemotherapy regimens in Japan. METHODS: From July 2021 to June 2022 in 54 healthcare facilities, we gathered data of patients diagnosed with RM-SCCHN and who had started first-line palliative chemotherapy with one of eight commonly used regimens. Patients with nasopharyngeal carcinomas were excluded. The number of patients receiving each regimen and the costs of each regimen for the first month and per year were tallied. RESULTS: The sample comprised 907 patients (674 were < 75 years old, 233 were ≥ 75 years old). 330 (36.4%) received Pembrolizumab monotherapy, and 202 (22.3%) received Nivolumab monotherapy. Over 90% of patients were treated with immune checkpoint inhibitors as monotherapy or in combination with chemotherapy. Treatment regimens' first-month costs were 612 851-849 241 Japanese yen (JPY). The cost of standard palliative chemotherapy until 2012 was about 20 000 JPY per month. The incremental cost over the past decade is approximately 600 000-800 000 JPY per month, a 30- to 40-fold increase in the cost of palliative chemotherapy for RM-SCCHN. CONCLUSION: First-line palliative chemotherapy for RM-SCCHN exceeds 600 000 JPY monthly. Over the last decade, the prognosis for RM-SCCHN has improved, but the costs of palliative chemotherapy have surged, placing a heavy burden on patients and society.

Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery.

BACKGROUND: We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS: A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS: Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION: Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.

Associations Between Rehabilitation Utilization and Out-of-Pocket Costs Among Older Adults With Breast Cancer in the United States.

OBJECTIVE: To examine the association between rehabilitation utilization within 12 months of breast cancer diagnosis and out-of-pocket costs in the second year (12-24mo after diagnosis). DESIGN: Secondary analysis of the 2009-2019 Surveillance, Epidemiology and End Results-Medicare linked database. Individuals who received rehabilitation services were propensity-score matched to individuals who did not receive services. Overall and health care service-specific models were examined using generalized linear models with a gamma distribution. SETTING: Inpatient and outpatient medical facilities. PARTICIPANTS: A total of 35,212 individuals diagnosed with nonmetastatic breast cancer and were continuously enrolled in Medicare Fee-For Service (parts A, B, and D) in the 12 months before and 24 months postdiagnosis. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Individual cost responsibility, a proxy for out-of-pocket costs, which was defined as deductibles, coinsurance, and copayments during the second year after diagnosis (12-24mo postdiagnosis). RESULTS: The mean individual cost responsibility was higher in individuals who used rehabilitation than those who did not ($4013 vs $3783), although it was not a clinically meaningful difference (d=0.06). Individuals who received rehabilitative services had significantly higher costs attributed to individual provider care ($1634 vs $1476), institutional outpatient costs ($886 vs $812), and prescription drugs ($959 vs $906), and significantly lower costs attributed to institutional inpatient costs ($455 vs $504), and durable medical equipment ($81 vs $86). CONCLUSIONS: Older adults with breast cancer who received rehabilitation services had higher cost responsibility during the second year after diagnosis than those who did not. Future work is needed to examine the relationship between rehabilitation and out-of-pocket costs across longer periods of time and in conjunction with perceived benefit.

Reduced red and processed meat consumption is associated with lower diet costs in US households: a national analysis of protein substitutions.

OBJECTIVE: To examine the association between red and processed meat consumption and total food expenditures in US households and explore whether households could reduce food costs by substituting these meats with other protein sources such as poultry, seafood, eggs and plant proteins. DESIGN: Cross-sectional study using data from the National Household Food Acquisition and Purchase Survey (FoodAPS). Using adult male equivalents (AME) for standardisation, we categorised red and processed meat purchases into quintiles. We used generalised linear models to explore the association between red or processed meat consumption and food expenditures and the cost effect of substituting meat with other proteins. SETTING: United States. PARTICIPANTS: Data from 4739 households with valid acquisition information from FoodAPS, a stratified multistage probability sample of US households. RESULTS: Higher red and processed meat consumption were both significantly associated with higher total weekly food expenditures, particularly among households with low income. Substituting red or processed meat with poultry, eggs or plant proteins did not significantly affect overall food expenditures, whereas replacing meat with seafood, especially varieties high in n-3 fatty acids, led to increased costs. CONCLUSIONS: Reducing red and processed meat consumption could offer savings for households, particularly those with low income. Although substitutions with seafood high in n-3 could increase expenses, alternative protein sources like poultry and plant proteins may serve as cost-neutral replacements. Public health strategies should emphasise dietary shifts' economic, health and environmental benefits and aim to make nutritious yet affordable protein sources more accessible.

Health Care Spending on Respiratory Diseases in the United States, 1996-2016.

Rationale: Respiratory conditions account for a large proportion of health care spending in the United States. A full characterization of spending across multiple conditions and over time has not been performed. Objectives: To estimate health care spending in the United States for 11 respiratory conditions from 1996 to 2016, providing detailed trends and an evaluation of factors associated with spending growth. Methods: We extracted data from the Institute of Health Metrics and Evaluation's Disease Expenditure Project Database, producing annual estimates in spending for 38 age and sex groups, 7 types of care, and 3 payer types. We performed a decomposition analysis to estimate the change in spending associated with changes in each of five factors (population growth, population aging, disease prevalence, service usage, and service price and intensity). Measurements and Main Results: Total spending across all respiratory conditions in 2016 was $170.8 billion (95% confidence interval [CI], $164.2-179.2 billion), increasing by $71.7 billion (95% CI, $63.2-80.8 billion) from 1996. The respiratory conditions with the highest spending in 2016 were asthma and chronic obstructive pulmonary disease, contributing $35.5 billion (95% CI, $32.4-38.2 billion) and $34.3 billion (95% CI, $31.5-37.3 billion), respectively. Increasing service price and intensity were associated with 81.4% (95% CI, 70.3-93.0%) growth from 1996 to 2016. Conclusions: U.S. spending on respiratory conditions is high, particularly for chronic conditions like asthma and chronic obstructive pulmonary disease. Our findings suggest that service price and intensity, particularly for pharmaceuticals, should be a key focus of attention for policymakers seeking to reduce health care spending growth.

Characteristics and spending patterns of high-cost child patients: findings from Fujian in China.

BACKGROUND: The health condition during childhood has been shown to influence an individual's health and socioeconomic status in adulthood. Understanding the concentration and persistence patterns in children's healthcare expenditures is crucial for providing risk protection and promoting the well-being of children. Studies regarding the concentration and persistence of health expenditures have focused mainly on elderly individuals in developed regions. To gain insights into factors that contribute to childhood health expenditures, this article examined children with high costs (that is, in the top 10% of the expenditure distribution) and explored the characteristics and spending patterns that distinguished them from other patients in the context of the largest developing economy-China. METHODS: By using a unique individual-level administrative claims dataset over a 5-year observation period, this study identified spending concentrations and the proportion of children whose costs remained high over five years using a linear probability model and logit regression analysis. RESULTS: Teenagers from 12 to 17 years old were more likely to persist in the high-cost group than any other age groups in the study. Pediatric complex chronic conditions and other severe health ailments were predictive factors for entry into and persistence in the high-cost category. More than half of the total health expenditures were attributed to children in the top 10% expenditure group. In addition, risk protection and healthcare insurance support for high-cost children was found to be inadequate, particularly for children from low-income families. CONCLUSIONS: Healthcare support for children impacts individual development and family financial status. This study described the characteristics and spending patterns of children patients in the largest developing country. The fact that over half of total expenditures are concentrated toward 10% of patients makes it valuable to consider relevant support for this group, especially for families whose medical costs are higher than income.