Costs of Chronic Diseases at the State Level: The Chronic Disease Cost Calculator.

INTRODUCTION: Many studies have estimated national chronic disease costs, but state-level estimates are limited. The Centers for Disease Control and Prevention developed the Chronic Disease Cost Calculator (CDCC), which estimates state-level costs for arthritis, asthma, cancer, congestive heart failure, coronary heart disease, hypertension, stroke, other heart diseases, depression, and diabetes. METHODS: Using publicly available and restricted secondary data from multiple national data sets from 2004 through 2008, disease-attributable annual per-person medical and absenteeism costs were estimated. Total state medical and absenteeism costs were derived by multiplying per person costs from regressions by the number of people in the state treated for each disease. Medical costs were estimated for all payers and separately for Medicaid, Medicare, and private insurers. Projected medical costs for all payers (2010 through 2020) were calculated using medical costs and projected state population counts. RESULTS: Median state-specific medical costs ranged from $410 million (asthma) to $1.8 billion (diabetes); median absenteeism costs ranged from $5 million (congestive heart failure) to $217 million (arthritis). CONCLUSION: CDCC provides methodologically rigorous chronic disease cost estimates. These estimates highlight possible areas of cost savings achievable through targeted prevention efforts or research into new interventions and treatments.

Effects of mental health benefits legislation: a community guide systematic review.

CONTEXT: Health insurance benefits for mental health services typically have paid less than benefits for physical health services, resulting in potential underutilization or financial burden for people with mental health conditions. Mental health benefits legislation was introduced to improve financial protection (i.e., decrease financial burden) and to increase access to, and use of, mental health services. This systematic review was conducted to determine the effectiveness of mental health benefits legislation, including executive orders, in improving mental health. EVIDENCE ACQUISITION: Methods developed for the Guide to Community Preventive Services were used to identify, evaluate, and analyze available evidence. The evidence included studies published or reported from 1965 to March 2011 with at least one of the following outcomes: access to care, financial protection, appropriate utilization, quality of care, diagnosis of mental illness, morbidity and mortality, and quality of life. Analyses were conducted in 2012. EVIDENCE SYNTHESIS: Thirty eligible studies were identified in 37 papers. Implementation of mental health benefits legislation was associated with financial protection (decreased out-of-pocket costs) and appropriate utilization of services. Among studies examining the impact of legislation strength, most found larger positive effects for comprehensive parity legislation or policies than for less-comprehensive ones. Few studies assessed other mental health outcomes. CONCLUSIONS: Evidence indicates that mental health benefits legislation, particularly comprehensive parity legislation, is effective in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. Evidence was limited for other mental health outcomes.

Medical expenditures associated with major depressive disorder among privately insured working-age adults with diagnosed diabetes in the United States, 2008.

AIM: We aimed at estimating excess medical expenditures associated with major depressive disorder (MDD) among working-age adults diagnosed with diabetes, disaggregated by treatment mode: insulin-treated diabetes (ITDM) or non-insulin-treated diabetes (NITDM). METHODS: We analyzed data for over 500,000 individuals with diagnosed diabetes from the 2008 U.S. MarketScan claims database. We grouped diabetic patients first by treatment mode (ITDM or NITDM), then by MDD status (with or without MDD), and finally by whether those with MDD used antidepressant medication. We estimated annual mean excess outpatient, inpatient, prescription drug, and total expenditures using regression models, controlling for demographics, types of health coverage, and comorbidities. RESULTS: Among persons having ITDM, the estimated annual total mean expenditure for those with no MDD (the comparison group) was $19,625. For those with MDD, the expenditures were $12,406 (63%) larger if using antidepressant medication and $7322 (37%) larger if not using antidepressant medication. Among persons having NITDM, the corresponding estimated expenditure for the comparison group was $10,746, the excess expenditures were $10,432 (97%) larger if using antidepressant medication and $5579 (52%) larger if not using antidepressant medication, respectively. Inpatient excess expenditures were the largest of total excess expenditure for those with ITDM and MDD treated with antidepressant medication; for all others with diabetes and MDD, outpatient expenditures were the largest excess expenditure. CONCLUSIONS: Among working-age adults with diabetes, MDD was associated with substantial excess medical expenditures. Implementing the effective interventions demonstrated in clinical trials and treatment guidelines recommended by professional organizations might reduce the economic burden of MDD in this population.

Relationship between adverse childhood experiences and unemployment among adults from five U.S. states.

PURPOSE: Our study assesses the relationships between self-reported adverse childhood experiences (ACEs) (including sexual, physical, or verbal abuse, along with household dysfunction including parental separation or divorce, domestic violence, mental illness, substance abuse, or incarcerated household member) and unemployment status in five US states in 2009. METHODS: We examined these relationships using the 2009 Behavioral Risk Factor surveillance system survey data from 17,469 respondents (aged 18-64 years) who resided in five states, completed the ACE Questionnaire, and provided socio-demographic and social support information. We also assessed the mediation of these relationships by respondents' educational attainment, marital status, and social support. RESULTS: About two-third of respondents reported having had at least one ACEs, while 15.1% of men and 19.3% of women reported having had ≥4 ACEs. Among both men and women, the unemployment rate in 2009 was significantly higher among those who reported having had any ACE than among those who reported no ACEs (p < 0.05). Educational attainment, marital status, and social support mediated the relationship between ACEs and unemployment, particularly among women. CONCLUSIONS: ACEs appear to be associated with increased risk for unemployment among men and women. Further studies may be needed to better understand how education, marital status, and social support mediate the association between multiple ACEs and unemployment.

Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis.

CONTEXT: To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. EVIDENCE ACQUISITION: A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. EVIDENCE SYNTHESIS: An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). CONCLUSIONS: Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level.

Economics of collaborative care for management of depressive disorders: a community guide systematic review.

CONTEXT: Major depressive disorders are frequently underdiagnosed and undertreated. Collaborative Care models developed from the Chronic Care Model during the past 20 years have improved the quality of depression management in the community, raising intervention cost incrementally above usual care. This paper assesses the economic efficiency of collaborative care for management of depressive disorders by comparing its economic costs and economic benefits to usual care, as informed by a systematic review of the literature. EVIDENCE ACQUISITION: The economic review of collaborative care for management of depressive disorders was conducted in tandem with a review of effectiveness, under the guidance of the Community Preventive Services Task Force, a nonfederal, independent group of public health leaders and experts. Economic review methods developed by the Guide to Community Preventive Services were used by two economists to screen, abstract, adjust, and summarize the economic evidence of collaborative care from societal and other perspectives. An earlier economic review that included eight RCTs was included as part of the evidence. The present economic review expanded the evidence with results from studies published from 1980 to 2009 and included both RCTs and other study designs. EVIDENCE SYNTHESIS: In addition to the eight RCTs included in the earlier review, 22 more studies of collaborative care that provided estimates for economic outcomes were identified, 20 of which were evaluations of actual interventions and two of which were based on models. Of seven studies that measured only economic benefits of collaborative care in terms of averted healthcare or productivity loss, four found positive economic benefits due to intervention and three found minimal or no incremental benefit. Of five studies that measured both benefits and costs, three found lower collaborative care cost because of reduced healthcare utilization or enhanced productivity, and one found the same for a subpopulation of the intervention group. One study found that willingness to pay for collaborative care exceeded program costs. Among six cost-utility studies, five found collaborative care was cost effective. In two modeled studies, one showed cost effectiveness based on comparison of $/disability-adjusted life-year to annual per capita income; the other demonstrated cost effectiveness based on the standard threshold of $50,000/quality-adjusted life year, unadjusted for inflation. Finally, six of eight studies in the earlier review reported that interventions were cost effective on the basis of the standard threshold. CONCLUSIONS: The evidence indicates that collaborative care for management of depressive disorders provides good economic value.

Health-related quality of life and health behaviors by social and emotional support. Their relevance to psychiatry and medicine.

BACKGROUND: Social and emotional support is an important construct, which has been associated with a reduced risk of mental illness, physical illness, and mortality. Despite its apparent relevance to health, there have been no recent state or national population-based U.S. studies regarding social and emotional support. In order to better address this issue, we examined health-related quality of life (HRQOL) and health behaviors by level of social and emotional support in community-dwelling adults in the United States and its territories. METHODS: Data were obtained from the Behavioral Risk Factor Surveillance System, an ongoing, state-based, random digit telephone survey of the noninstitutionalized U.S. population aged > or =18 years. In 2005, one social and emotional support question, four HRQOL questions, two disability questions, one life satisfaction question, and four health behavior questions were administered in the 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. An additional five HRQOL questions were administered in two states. RESULTS: An estimated 8.6% of adults reported that they rarely/never received social and emotional support; ranging in value from 4.2% in Minnesota to 12.4% in the U.S. Virgin Islands. As the level of social and emotional support decreased, the prevalence of fair/poor general health, dissatisfaction with life, and disability increased, as did the mean number of days of physical distress, mental distress, activity limitation, depressive symptoms, anxiety symptoms, insufficient sleep, and pain. Moreover, the prevalence of smoking, obesity, physical inactivity, and heavy drinking increased with decreasing level of social and emotional support. Additionally, the mean number of days of vitality slightly decreased with decreasing level of social and emotional support; particularly between those who always/usually received social and emotional support and those who sometimes received support. CONCLUSIONS: These findings indicate that the assessment of social and emotional support is highly congruent with the practice of psychiatry. Assessment of social and emotional support, both in psychiatric and medical settings, may identify risk factors germane to adverse health behaviors, and foster interventions designed to improve the mental and physical health of at risk segments of the population.

Health-related quality of life and health risk behaviors among smokers.

BACKGROUND: It is well established that smoking has detrimental effects on physical health, but its associations with health-related quality of life (HRQOL) and a variety of health behaviors have not been widely investigated in the U.S. population. METHODS: Data obtained from the Behavioral Risk Factor Surveillance System (BRFSS), an ongoing, state-based, random-digit-dialed telephone survey of non-institutionalized persons aged > or =18 years in the United States, Guam, Puerto Rico, and the Virgin Islands, were used in this investigation. The BRFSS monitors the prevalence of key health- and safety-related behaviors and characteristics. In 2001 and 2002 combined, trained interviewers administered HRQOL questions in 23 states and the District of Columbia (n=82,918). This analysis was conducted in 2004. RESULTS: Overall, an estimated 22.4% of adults were current smokers, 24.1% were former smokers, and 53.6% never smoked. Current smokers had significantly poorer HRQOL than those who had never smoked, and were more likely to drink heavily, to binge drink, and to report depressive and anxiety symptoms. Additionally, current smokers were significantly more likely than those who never smoked to be physically inactive, to report frequent sleep impairment, to report frequent pain, and to eat less than five servings of fruits and vegetables per day. CONCLUSIONS: While there are strong positive relationships between smoking and both alcohol consumption and mood disturbance, smoking is also associated with an array of other modifiable risk factors meriting assessment and intervention. In addition to smoking cessation, the increased morbidity and mortality characterizing smokers may potentially be further reduced by improvements in diet, physical activity, and sleep.

Risk behaviors and healthcare coverage among adults by frequent mental distress status, 2001.

BACKGROUND: Given the increased emphasis on chronic diseases in the United States, physicians and health survey analysts are now gathering information on patients' subjective measures of health, also known as health-related quality-of-life measures. Studies indicate that these measures can be more powerful predictors of chronic disease-related morbidity and mortality than objective measures. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of the non-institutionalized U.S. population aged 18 years or older. This study examined frequent mental distress (FMD), defined as self-reported 14 or more mentally unhealthy days in the past 30 days, and its association with adverse health behaviors and lack of healthcare coverage. RESULTS: In 2001, approximately 10% of adults reported FMD. Persons reporting FMD had a higher prevalence of smoking, drinking heavily, physical inactivity, and obesity than did persons without FMD. They were also more often without healthcare coverage. In addition, persons with FMD were more likely to engage in multiple adverse behaviors than were persons without FMD. CONCLUSIONS: Persons reporting FMD are at higher risk of chronic diseases because they engage in risky health behaviors and lack healthcare coverage. This study provides further support that mental health screening as well as physical health screening is important in clinical practice. Further research is needed to identify therapeutic or mental health-promoting interventions to reduce mental distress and reinforce healthy behaviors.

Adverse childhood experiences and risk of paternity in teen pregnancy.

OBJECTIVE: Few studies have investigated risk factors that predispose males to be involved in teen pregnancies. To provide new information on such factors, we examined the relationships of eight common adverse childhood experiences to a male's risk of impregnating a teenager. METHODS: We conducted a retrospective cohort study using questionnaire responses from 7399 men who visited a primary care clinic of a large health maintenance organization in California. Data included age of the youngest female ever impregnated; the man's own age at the time; his history of childhood emotional, physical, or sexual abuse; having a battered mother; parental separation or divorce; and having household members who were substance abusers, mentally ill, or criminals. Odds ratios (ORs) for the risk of involvement in a teen pregnancy were adjusted for age, race, and education. RESULTS: At least one adverse childhood experience was reported by 63% of participants, and 34% had at least two adverse childhood experiences; 19% of men had been involved in a teen pregnancy. Each adverse childhood experience was positively associated with impregnating a teenager, with ORs ranging from 1.2 (sexual abuse) to 1.8 (criminal in home). We found strong graded relationships (P <.001) between the number of adverse childhood experiences and the risk of involvement in a teen pregnancy for each of four birth cohorts during the last century. Compared with males with no adverse childhood experiences, a male with at least five adverse childhood experiences had an OR of 2.6 (95% confidence interval [CI] 2.0, 3.4) for impregnating a teenager. The magnitude of the ORs for the adverse childhood experiences was reduced 64-100% by adjustment for potential intermediate variables (age at first intercourse, number of sexual partners, having a sexually transmitted disease, and alcohol or drug abuse) that also exhibited a strong graded relationship to adverse childhood experiences. CONCLUSION: Adverse childhood experiences have an important relationship to male involvement in teen pregnancy. This relationship has persisted throughout four successive birth cohorts dating back to 1900-1929, suggesting that the effects of adverse childhood experiences transcend changing sexual mores and contraceptive methods. Efforts to prevent teen pregnancy will likely benefit from preventing adverse childhood experiences and their associated effects on male behaviors that might mediate the increased risk of teen pregnancy.