Health care costs associated with traumatic brain injury and psychiatric illness in adults.

A cohort design was used to determine the contribution of traumatic brain injury (TBI) and psychiatric illness to health care costs for adolescents and adults in the 3 years following mild or moderate-to-severe TBI compared to a matched cohort without TBI, controlling for confounders. In all, 3756 subjects 15 years or older from a large health maintenance organization database were examined. We identified subjects who sustained a TBI in 1993 (n=939) and selected three control subjects per TBI-exposed subject (n=2817), matched for age, sex, and enrollment at the time of injury. Unadjusted mean costs in 2009-adjusted dollars were compared using Kruskal-Wallis tests and Mann-Whitney U tests, and adjusted mean costs were compared using gamma regression analyses. Average costs were 76% higher in the 3 years after injury for the mild TBI group, and 5.75 times greater for the moderate-to-severe TBI group compared to controls. The presence of psychiatric illness was associated with more than doubling of total costs for both inpatient and outpatient non-mental health care. Gamma regression analyses confirmed significantly higher costs in patients with TBI or psychiatric illness. A significant interaction between moderate-to-severe TBI and psychiatric illness indicated a 3.39 times greater cost among patients with both exposures compared with those exposed to moderate-to-severe TBI without psychiatric illness. TBI and psychiatric illness were each associated with significant increases in health care costs; those with the combination of moderate-to-severe TBI and psychiatric illness had much higher costs than any other group.

Trends in the prescription of opioids for adolescents with non-cancer pain.

OBJECTIVES: Opioids are among the most commonly abused drugs among adolescents, and the prescription of these drugs has increased over the last decade. The goal of the current study is to examine trends and factors associated with prescription opioid use among adolescents with common non-cancer pain (NCP) conditions, sampled from two contrasting populations. METHODS: We conducted a secondary data analysis examining time trends from 2001 to 2005 in opioid use in two dissimilar populations: a national, commercially insured population and a state Medicaid plan. We examined trends in mean dose prescribed, mean number of prescriptions and types of medications given, as well as clinical and demographic features of adolescents receiving opioids. RESULTS: In 2005, 21% of adolescents with common NCP conditions in HealthCore and 40.2% of adolescents with NCP in Arkansas Medicaid had received prescription opioids. The majority of opioid prescriptions in both 2001 and 2005 were for DEA Schedule II and III short-acting opioids. In both samples, rates of prescription were higher for adolescents with comorbid mental health diagnoses compared to those without and for adolescents with multiple pain conditions compared to a single pain condition. DISCUSSION: Prescription of opioids among adolescents with NCP is common, and the prescription rate is higher among adolescents with multiple pain conditions and comorbid mental health disorders. Further research is necessary to determine risk factors for abuse and misuse of opioids in adolescents to help develop guidelines for use in this age group.

Long-term chronic opioid therapy discontinuation rates from the TROUP study.

OBJECTIVE: To report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation. METHODS: Medical and pharmacy claims records from January 2000 through December 2005 from a national private health network (HealthCore), and Arkansas (AR) Medicaid were used to identify ambulatory adult enrollees who had 90 days of opioids supplied. Recipients were followed until they discontinued opioid prescription fills or disenrolled. Kaplan Meier survival models and Cox proportional hazards models were estimated to identify factors associated with time until opioid discontinuation. RESULTS: There were 23,419 and 6,848 chronic opioid recipients followed for a mean of 1.9 and 2.3 years in the HealthCore and AR Medicaid samples. Over a maximum follow up of 4.8 years, 67.0% of HealthCore and 64.9% AR Medicaid recipients remained on opioids. Recipients on high daily opioid dose (greater than 120 milligrams morphine equivalent (MED)) were less likely to discontinue than recipients taking lower doses: HealthCore hazard ratio (HR) = 0.66 (95%CI: 0.57-0.76), AR Medicaid HR = 0.66 (95%CI: 0.50-0.82). Recipients with possible opioid misuse were also less likely to discontinue: HealthCore HR = 0.83 (95%CI: 0.78-0.89), AR Medicaid HR = 0.78 (95%CI: 0.67-0.90). CONCLUSIONS: Over half of persons receiving 90 days of continuous opioid therapy remain on opioids years later. Factors most strongly associated with continuation were intermittent prior opioid exposure, daily opioid dose ≥ 120 mg MED, and possible opioid misuse. Since high dose and opioid misuse have been shown to increase the risk of adverse outcomes special caution is warranted when prescribing more than 90 days of opioid therapy in these patients.

Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms.

OBJECTIVE: Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults. METHODS: Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs. RESULTS: Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) (p = 0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms. CONCLUSION: Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms.

Healthcare costs associated with mild traumatic brain injury and psychological distress in children and adolescents.

PRIMARY OBJECTIVE: Comparison of healthcare costs for youth with mild traumatic brain injuries (TBIs) to costs in a matched cohort of children without TBI in the 3 years following injury. RESEARCH DESIGN: This study used a prospective cohort design with 3-year follow-up. Costs were examined using the well-established two-step model and controlling for potential confounding variables. METHODS AND PROCEDURES: Four-hundred and ninety subjects from a large health maintenance organization, 14 years old or younger, who sustained a mild TBI in 1993, were identified using computerized records. For each youth with mild TBI, three control subjects were selected (n = 1470), matched on age, sex and enrolment at the time of injury. EXPERIMENTAL INTERVENTIONS: Not applicable. MAIN OUTCOMES AND RESULTS: TBI exposure was associated with an increase in the proportion of subjects who had non-zero medical costs in all categories examined and a 75% increase in mean total costs. Presence of psychological distress was also associated with increased proportion of subjects with costs in all categories examined and was associated with an approximate doubling of mean total costs. CONCLUSIONS: Mild TBI and psychological distress were each associated with significant increases in healthcare costs in an HMO setting.

An analysis of heavy utilizers of opioids for chronic noncancer pain in the TROUP study.

CONTEXT: Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about opioid dosing patterns among individuals with CNCP in usual care settings, and how these are changing over time. OBJECTIVES: To investigate the distribution of mean daily dose and mean days supply among patients with CNCP in two disparate populations, one national and commercially insured population (HealthCore) and one state based and publicly insured (Arkansas Medicaid), for years 2000 and 2005. METHODS: For individuals with any opioid use, we calculated the distribution of mean daily dose (in milligram morphine equivalents), mean days supply in a year, mean annual dose, and patient characteristics associated with heavy utilizers of opioids. RESULTS: Between 2000 and 2005, across all percentiles, there was little change in the mean daily opioid dose. In HealthCore, mean days supply increased most rapidly at the top end of the days supply distribution, whereas in Arkansas Medicaid, the greatest increases were near the median of days supply. In HealthCore, the top 5% of users accounted for 70% of total use (measured in milligram morphine equivalents), and the top 5% of Arkansas Medicaid users accounted for 48% of total use. The likelihood of heavy opioid utilization was increased among individuals with multiple pain conditions, and in HealthCore, among those with mental health and substance use disorders. CONCLUSION: Opioid use is heavily concentrated among a small percent of patients. The characteristics of these high utilizers need to be further established, and the benefits and risks of their treatment evaluated.

Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study.

The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in the abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. A total of 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000-2005 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of short-acting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially >120 mg MED per day) and short-acting Schedule II opioids appears to increase the risk of misuse. The consistency of the findings across diverse patient populations and the varying levels of misuse suggest that these results will generalize broadly, but await confirmation in other studies.

Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study.

OBJECTIVES: Use of prescription opioids for chronic pain is increasing, as is abuse of these medications, though the nature of the link between these trends is unclear. These increases may be most marked in patients with mental health (MH) and substance use disorders (SUDs). We analyzed trends between 2000 and 2005 in opioid prescribing among individuals with noncancer pain conditions (NCPC), with and without MH and SUDs. METHODS: Secondary data analysis of longitudinal administrative data from 2 dissimilar populations: a national, commercially insured population and Arkansas Medicaid enrollees. We examined these opioid outcomes: (1) rates of any prescription opioid use in the past year, (2) rates of chronic use of prescription opioids (greater than 90 d in the past year), (3) mean days supply of opioids, (4) mean daily opioid dose in morphine equivalents, and (5) percentage of total opioid dose that was Schedule II opioids. RESULTS: In 2000, among individuals with NCPC, chronic opioid use was more common among those with a MH or SUD than among those without in commercially insured (8% vs. 3%, P<0.001) and Arkansas Medicaid (20% vs. 13%, P<0.001) populations. Between 2000 and 2005, in commercially insured, rates of chronic opioid use increased by 34.9% among individuals with an MH or SUD and 27.8% among individuals without these disorders. In Arkansas Medicaid chronic, opioid use increased by 55.4% among individuals with an MH or SUD and 39.8% among those without. DISCUSSION: Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses. Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment.

Age and sex trends in long-term opioid use in two large American health systems between 2000 and 2005.

OBJECTIVE: To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems. DESIGN: Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18-44, 45-64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2). PATIENTS: Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000). RESULTS: Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35-50% increase). Per-patient daily doses did not increase. CONCLUSIONS: No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.

Healthcare costs associated with depression in medically Ill fee-for-service medicare participants.

OBJECTIVES: To examine the association between depression and healthcare costs in medically ill fee-for-service (FFS) Medicare recipients. STUDY DESIGN: Observational analysis of Medicare claims data. SETTING: Medicare Health Support (MHS) program at Green Ribbon Health. PARTICIPANTS: Fourteen thousand nine hundred two participants with diabetes mellitus, congestive heart failure (CHF), or both. MEASUREMENTS: This study examined participant data for a 12-month period before MHS enrollment (collected between November 2004 and August 2006). Twelve-month healthcare costs (based on Medicare claims) in 2,108 participants with International Classification of Diseases, Ninth Revision, claims diagnoses of depression, 1,081 participants with possible depression (positive depression screen on the two-item Patient Health Questionnaire or self reported antidepressant use), and 11,713 participants without depression were compared. Gamma regression models were used to adjust for demographic and clinical differences and nonnormal distribution of cost data. RESULTS: Participants with depression had significantly higher total healthcare costs than those without ($20,046 vs $11,956; P<.01). Higher costs were observed in participants with depression in every cost category except specialty mental health care, which accounted for less than 1% of total healthcare costs. Participants with depression had higher costs in each quartile of increasing medical severity (measured using the Charlson Comorbidity Index). These differences remained statistically significant after adjusting for demographic and other clinical differences. CONCLUSION: Depression is associated with significantly higher healthcare costs in FFS Medicare recipients with diabetes mellitus and CHF. Only a small proportion of the increased costs are spent on mental health specialty care.

Depression and diabetes: a potentially lethal combination.

OBJECTIVE: To assess whether Medicare fee-for-service beneficiaries with depression and diabetes had a higher mortality rate over a 2-year period compared with beneficiaries with diabetes alone. DESIGN: Evidence of depression was based on a physician diagnosis or self-reported prescription of an antidepressant in the year prior to screening, or a score of > or = 3 on the Patient Health Questionnaire two-item questionnaire. Mortality was assessed bi-monthly by checking Medicare claims and eligibility files or from information from telephone contact with the participant's family. Cox proportional hazard regression models were used to calculate adjusted hazard ratios of death in depressed versus nondepressed beneficiaries with diabetes. PARTICIPANTS: A total of 10,704 beneficiaries with diabetes enrolled in a disease management program were surveyed with a health assessment questionnaire and followed over a two-year period. MAIN RESULTS: Comorbid depression in Medicare beneficiaries with diabetes participating in a disease management program was associated with an increased risk for all-cause mortality over a two-year period of approximately 36% to 38%, depending on the definition of depression that was used. No significant increase in rates of cause-specific mortality from macrovascular disease were found in depressed versus nondepressed beneficiaries. CONCLUSION: Among a large Medicare cohort of fee-for-service beneficiaries with diabetes, comorbid depression was associated with an increase in all-cause mortality over a two-year period. Future research will be required to determine whether the increase in mortality associated with depression is due to potential behavioral mediators (i.e., smoking, poor adherence to diet) or physiologic abnormalities (i.e., hypothalamic-pituitary axis dysregulation) associated with depression.

Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study.

Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large observational studies in actual clinical practice assessing patterns of opioid use over extended periods of time. The TROUP (Trends and Risks of Opioid Use for Pain) study reports on trends in opioid therapy for NCPC in two disparate populations, one national and commercially insured population (HealthCore plan data) and one state-based and publicly-insured (Arkansas Medicaid) population over a six year period (2000-2005). We track enrollees with the four most common NCPC conditions: arthritis/joint pain, back pain, neck pain, headaches, as well as HIV/AIDS. Rates of NCPC diagnosis and opioid use increased linearly during this period in both groups, with the Medicaid group starting at higher rates and the HealthCore group increasing more rapidly. The proportion of enrollees receiving NCPC diagnoses increased (HealthCore 33%, Medicaid 9%), as did the proportion of enrollees with NCPC diagnoses who received opioids (HealthCore 58%, Medicaid 29%). Cumulative yearly opioid dose (in mg. morphine equivalents) received by NCPC patients treated with opioids increased (HealthCore 38%, Medicaid 37%) due to increases in number of days supplied rather than dose per day supplied. Use of short-acting Drug Enforcement Administration Schedule II opioids increased most rapidly, both in proportion of NCPC patients treated (HealthCore 54%, Medicaid 38%) and in cumulative yearly dose (HealthCore 95%, Medicaid 191%). These trends have occurred without any significant change in the underlying population prevalence of NCPC or new evidence of the efficacy of long-term opioid therapy and thus likely represent a broad-based shift in opioid treatment philosophy.

Long-term cost effects of collaborative care for late-life depression.

OBJECTIVE: To determine the long-term effects on total healthcare costs of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program for late-life depression compared with usual care. STUDY DESIGN: Randomized controlled trial with enrollment from July 1999 through August 2001. The IMPACT trial, conducted in primary care practices in 8 delivery organizations across the United States, enrolled 1801 depressed primary care patients 60 years or older. Data are from the 2 IMPACT sites for which 4-year cost data were available. Trial enrollment across these 2 health maintenance organizations was 551 patients. METHODS: Participants were randomly assigned to the IMPACT intervention (n = 279) or to usual primary care (n = 272). Intervention patients had access to a depression care manager who provided education, behavioral activation, support of antidepressant medication management prescribed by their regular primary care provider, and problem-solving treatment in primary care for up to 12 months. Care managers were supervised by a psychiatrist and a primary care provider. The main outcome measures were healthcare costs during 4 years. RESULTS: IMPACT participants had lower mean total healthcare costs ($29 422; 95% confidence interval, $26 479-$32 365) than usual care patients ($32 785; 95% confidence interval, $27 648-$37 921) during 4 years. Results of a bootstrap analysis suggested an 87% probability that the IMPACT program was associated with lower healthcare costs than usual care. CONCLUSION: Compared with usual primary care, the IMPACT program is associated with a high probability of lower total healthcare costs during a 4-year period.

Mental health service use by older adults: the role of chronic pain.

OBJECTIVE: Mental health disorders commonly co-occur in patients with chronic pain, but little is known about the role of chronic pain in mental health service use. In this study, the authors explored the role of chronic pain in mental health service use by adults according to age group. METHOD: The authors conducted a cross-sectional analysis of survey data from the second wave of the Health Care for Communities telephone survey collected in 2000-2001. Participants consisted of U.S. civilian adults (N = 6629) from randomly selected U.S. households. Common mental disorders were assessed using the short-form versions of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and mental health services received were identified by self-report. Physical and mental functioning was assessed using the Short Form-12. RESULTS: Adults older than age 60 had higher rates of chronic pain and lower rates of mental health service use compared with those aged 18-60 years. In multiple logistic regression models, an interaction effect was found between age and chronic pain (odds ratio: 3.0 [1.1-8.0]) with chronic pain significantly increasing the odds of any mental health care in the past year in adults older than 60 years of age. CONCLUSIONS: Chronic pain increases the likelihood of mental health service use among older adults. Chronic pain may facilitate the presentation of distress in medical settings for these adults.

One extra month of depression: the effects of caregiving on depression outcomes in the IMPACT trial.

BACKGROUND: Depression occurs in 5-10% of older adults and there are nearly 6 million informal caregivers aged 65 or older. Prior research has focused on vulnerability to psychological distress in caregivers. Research has not addressed the caregiving burden of depressed elderly patients or how that burden affects depression treatment outcomes. AIMS: To describe the self-reported caregiving burden in a large, representative cohort of depressed elderly patients and compare depression treatment outcomes between caregivers and non-caregivers. METHODS: Univariate and multiple regression analyses were performed comparing 24-month depression outcomes (measured as depression free days) in those providing care at any time over the 24-month trial to those who never reported a caregiving burden. RESULTS: At 3, 6, 12, 18, and 24 months, nearly 10% of cohabitating elderly depressed patients provided care for basic activities such as bathing or dressing while nearly 20% reported providing care for other activities such as making phone calls or taking medication. Over 24 months, after adjusting for marital status, intervention status, and number of medical comorbidities, those reporting any caregiving burden had over 30 more days with depression compared to those with no caregiving burden. The IMPACT collaborative care model did not modify the effect of caregiving on depression outcomes. CONCLUSION: Caregiving is common in depressed older adults and appears to affect response to depression treatment. In the future, interventions for depressed older adults should consider and specifically address caregiving activities in addition to specific depression treatment.

Incremental cost-effectiveness of a collaborative care intervention for panic disorder.

BACKGROUND: Panic disorder is a prevalent, often disabling, disorder among primary-care patients, but there are large gaps in quality of treatment in primary care. This study describes the incremental cost-effectiveness of a combined cognitive behavioral therapy (CBT) and pharmacotherapy intervention for patients with panic disorder versus usual primary-care treatment. METHOD: This randomized control trial recruited 232 primary-care patients meeting DSM-IV criteria for panic disorder from March 2000 to March 2002 from six primary-care clinics from university-affiliated clinics at the University of Washington (Seattle) and University of California (Los Angeles and San Diego). Patients were randomly assigned to receive either treatment as usual or a combined CBT and pharmacotherapy intervention for panic disorder delivered in primary care by a mental health therapist. Intervention patients had up to six sessions of CBT modified for the primary-care setting in the first 12 weeks, and up to six telephone follow-ups over the next 9 months. The primary outcome variables were total out-patient costs, anxiety-free days (AFDs) and quality adjusted life-years (QALYs). RESULTS: Relative to usual care, intervention patients experienced 60.4 [95% confidence interval (CI) 42.9-77.9] more AFDs over a 12-month period. Total incremental out-patient costs were 492 US dollars higher (95% CI 236-747 US dollars ) in intervention versus usual care patients with a cost per additional AFD of 8.40 US dollars (95% CI 2.80-14.0 US dollars ) and a cost per QALY ranging from 14,158 US dollars (95% CI 6,791-21,496 US dollars ) to 24,776 US dollars (95% CI 11,885-37,618 US dollars ). The cost per QALY estimate is well within the range of other commonly accepted medical interventions such as statin use and treatment of hypertension. CONCLUSIONS: The combined CBT and pharmacotherapy intervention was associated with a robust clinical improvement compared to usual care with a moderate increase in ambulatory costs.

Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression.

OBJECTIVE: To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression. RESEARCH DESIGN AND METHODS: This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care. RESULTS: Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found. CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care.

Cost-effectiveness of improving primary care treatment of late-life depression.

CONTEXT: Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care. OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy). MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years. RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness). CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.

Predictors of health resource use by disabled older female Medicare beneficiaries living in the community.

OBJECTIVES: To identify specific clinical factors that could best predict resource use by disabled older women. DESIGN: Cross-sectional. SETTING: Urban community in Baltimore, Maryland. PARTICIPANTS: One thousand two community-dwelling, moderately to severely disabled, female Medicare beneficiaries aged 65 and older, from the Women's Health and Aging Study I (WHAS). MEASUREMENTS: WHAS data were merged with participants' 1992-1994 Medicare claims data for the year after baseline evaluation, reflecting inpatient, outpatient, home-based, and skilled-nursing services. The independent contributions of factors hypothesized to predict health expenditures were assessed, using chi-square and regression analyses, with the logarithm of Medicare expenditures as the primary outcome. RESULTS: Demographic factors were not associated with Medicare expenditures. Factors associated with expenditures in bivariate analyses included heart disease (1.4x), chronic obstructive pulmonary disease (1.3x), diabetes mellitus (1.1x), smoking, comorbidity, and severity of disability, as well as low creatinine clearance, serum albumin, caloric expenditure, or skinfold thickness. Heart disease, diabetes mellitus, and low skinfold thickness remained significant after adjustment for other factors. CONCLUSION: Heart disease, diabetes mellitus, and low skinfold thickness are important independent predictors of 1-year Medicare expenditures by disabled older women. Many other variables that reflect disease, disability, nutrition, or personal habits have less predictive ability. Most demographic factors are not predictors of expenditures in this population. Focusing on the best predictors may facilitate more-effective risk adjustment and creation of related health policies.