Chronic Medication Burden After Cardiac Surgery for Pediatric Medicaid Beneficiaries.

BACKGROUND: Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden. OBJECTIVES: The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population. METHODS: This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics. RESULTS: We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication. CONCLUSIONS: Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population.

Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid.

BACKGROUND: Understanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. OBJECTIVES: The purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. METHODS: All Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. RESULTS: In 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors' offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. CONCLUSIONS: Children after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.

Temperature and work: Time allocated to work under varying climate and labor market conditions.

Workers in climate exposed industries such as agriculture, construction, and manufacturing face increased health risks of working on high temperature days and may make decisions to reduce work on high-heat days to mitigate this risk. Utilizing the American Time Use Survey (ATUS) for the period 2003 through 2018 and historical weather data, we model the relationship between daily temperature and time allocation, focusing on hours worked by high-risk laborers. The results indicate that labor allocation decisions are context specific and likely driven by supply-side factors. We do not find a significant relationship between temperature and hours worked during the Great Recession (2008-2014), perhaps due to high competition for employment, however during periods of economic growth (2003-2007, 2015-2018) we find a significant reduction in hours worked on high-heat days. During periods of economic growth, for every degree above 90 on a particular day, the average high-risk worker reduces their time devoted to work by about 2.6 minutes relative to a 90-degree day. This effect is expected to intensify in the future as temperatures rise. Applying the modeled relationships to climate projections through the end of century, we find that annual lost wages resulting from decreased time spent working on days over 90 degrees across the United States range from $36.7 to $80.0 billion in 2090 under intermediate and high emission futures, respectively.

Estimating Causal Effects of Particulate Matter Regulation on Mortality.

BACKGROUND: Estimating the causal effect of pollution on human health is integral for evaluating returns to pollution regulation, yet separating out confounding factors remains a perennial challenge. METHODS: We use a quasi-experimental design to investigate the causal relationship between regulation of particulate matter smaller than 2.5 micrograms per cubic meter (PM2.5) and mortality among those 65 years of age and older. We exploit regulatory changes in the Clean Air Act Amendments (CAAA). Regulation in 2005 impacted areas of the United States differentially based on pre-regulation air quality levels for PM2.5. We use county-level mortality data, extracted from claims data managed by the Centers for Medicare & Medicaid Services, merged to county-level average PM2.5 readings and attainment status as classified by the Environmental Protection Agency. RESULTS: Based on estimates from log-linear difference-in-differences models, our results indicate after the CAAA designation for PM2.5 in 2005, PM2.5 levels decreased 1.59 micrograms per cubic meter (95% CI = 1.39, 1.80) and mortality rates among those 65 and older decreased by 0.93% (95% CI = 0.10%, 1.77%) in nonattainment counties, relative to attainment ones. Results are robust to a series of alternate models, including nearest-neighbor matching based on propensity score estimates. CONCLUSION: This analysis suggests large health returns to the 2005 PM2.5 designations, and provides evidence of a causal association between pollution and mortality among the Medicare population.

Cost-effectiveness of diabetes screening initiated through a dental visit.

OBJECTIVE: To analyse the cost-effectiveness of a screening programme and follow-up interventions for persons with dysglycemia who are identified during a dental visit. METHODS: This study is a secondary analysis utilizing data from two relevant publications. Those studies identified persons with dysglycemia who were seen in a dental school clinic for routine dental care and determined compliance with a recommendation to seek medical care. The response site was 59.4%. The Archimedes disease simulation model was utilized to simulate the effect of a weight loss programme for identified subjects on several outcomes. RESULTS: Two scenarios for weight loss programmes were considered: a 10% permanent loss in body weight and a 10% loss that decays over time. Both diabetes and prediabetes were analysed. The decay path costs $21 243 per quality adjusted life year (QALY) with 3 years required to achieve the weight reduction. This cost decreases to $6655 if only 1 year is needed to achieve the weight goal. Without decay, the cost per QALY is $15 873 with 20 years of intervention, vs $647 per QALY with 10 years of intervention. For individuals with type 2 diabetes mellitus, the cost per QALY is $48 604 to $56 207 depending on adherence. With the addition of oral medication (a sulfonylurea), the cost is three times higher. CONCLUSIONS: Under the conditions described here, identification of persons with dysglycemia in the dental office for initiating prediabetic care is a cost-effective means of identifying and treating affected individuals.

Trends in mortality, length of stay, and hospital charges associated with health care-associated infections, 2006-2012.

BACKGROUND: Many factors associated with hospital-acquired infections (HAIs), including reimbursement policies, drug prices, practice patterns, and the distribution of organisms causing infections, change over time. We examined whether outcomes, including mortality, length of stay (LOS), daily charges, and total charges associated with HAIs, changed during 2006-2012. METHODS: Electronic data on adults discharged from 2 tertiary-quaternary hospitals and 1 community hospital during 2006-2012 were collected retrospectively. Computerized algorithms identified infections using laboratory and administrative codes. Propensity scores were used to match cases with uninfected controls. Differences in mortality, LOS, daily charges, and total charges were modeled against infection status and time period (2006-2008 vs 2009-2012), including interaction for infection status by time period. RESULTS: Among 352,077 discharges, 24,466 HAIs were detected. There was no significant change in mortality. LOS declined only for bloodstream infections (3-day reduction; P < 0.01). Daily charges rose 4% for urinary tract infections but did not change significantly for other HAIs. Total charges declined by 11% for bloodstream infections and 13% for pneumonia. CONCLUSIONS: We found no appreciable or consistent improvement in HAI mortality or LOS during 2006-2012. Costs of bloodstream infections and pneumonia have declined, with most of the change occurring before 2008.

Cost-Effectiveness Analysis of Dental Sealants versus Fluoride Varnish in a School-Based Setting.

While sealants are more effective than fluoride varnish in reducing the development of new carious lesions on occlusal surfaces, and a course of treatment requires fewer clinical visits, they are more expensive per application. This analysis assessed which treatment is more cost-effective. We estimate the costs of sealants and fluoride varnish over a 4-year period in a school-based setting, and compare this to existing estimates of the relative benefits in terms of caries reduction to calculate the relative cost-effectiveness of these two preventive treatments. In our base case scenario, varnish is more cost-effective in preventing caries. Allowing for caries benefits to nonocclusal surfaces further improves the cost-effectiveness of varnish. Although we found that varnish is more cost-effective, the results are context specific. Sealants become equally cost-effective if a dental hygienist applies the sealants instead of a dentist, while varnish becomes increasingly cost-effective when making comparisons outside of a traditional dental clinic setting.

The Norwood operation: Relative effects of surgeon and institutional volumes on outcomes and resource utilization.

BACKGROUND: Hypoplastic left heart syndrome is the most expensive birth defect managed in the United States, with a 5-year survival rate below 70%. Increasing evidence suggests that hospital volumes are inversely associated with mortality for infants with single ventricles undergoing stage 1 surgical palliation. Our aim was to examine the relative effects of surgeon and institutional volumes on outcomes and resource utilisation for these children. METHODS: A retrospective study was conducted using the Pediatric Health Information System database to examine the effects of the number of procedures performed per surgeon and per centre on mortality, costs, and post-operative length of stay for infants undergoing Risk Adjustment for Congenital Heart Surgery risk category six operations at tertiary-care paediatric hospitals, from 1 January, 2004 to 31 December, 2013. Multivariable modelling was used, adjusting for patient and institutional characteristics. Gaussian kernel densities were constructed to show the relative distributions of the effects of individual institutions and surgeons, before and after adjusting for the number of cases performed. RESULTS: A total of 2880 infants from 35 institutions met the inclusion criteria. Mortality was 15.0%. Median post-operative length of stay was 24 days (IQR 14-41). Median standardized inpatient hospital costs were $156,000 (IQR $108,000-$248,000) in 2013 dollars. In the multivariable analyses, higher institutional volume was inversely associated with mortality (p=0.001), post-operative length of stay (p=0.004), and costs (p=0.001). Surgeon volume was associated with none of the measured outcomes. Neither institutional nor surgeon volumes explained much of the wide variation in outcomes and resource utilization observed between institutions and between surgeons. CONCLUSIONS: Increased institutional - but not surgeon - volumes are associated with reduced mortality, post-operative length of stay, and costs for infants undergoing stage 1 palliation.

Prenatal exposure to airborne polycyclic aromatic hydrocarbons and IQ: estimated benefit of pollution reduction.

Outdoor air pollution, largely from fossil fuel burning, is a major cause of morbidity and mortality in the United States, costing billions of dollars every year in health care and loss of productivity. The developing fetus and young child are especially vulnerable to neurotoxicants, such as polycyclic aromatic hydrocarbons (PAH) released to ambient air by combustion of fossil fuel and other organic material. Low-income populations are disproportionately exposed to air pollution. On the basis of the results of a prospective cohort study in a low-income population in New York City (NYC) that found a significant inverse association between child IQ and prenatal exposure to airborne PAH, we estimated the increase in IQ and related lifetime earnings in a low-income urban population as a result of a hypothesized modest reduction of ambient PAH concentrations in NYC of 0.25 ng/m(3). For reference, the current estimated annual mean PAH concentration is ~1 ng/m(3). Restricting to NYC Medicaid births and using a 5 per cent discount rate, we estimated the gain in lifetime earnings due to IQ increase for a single year cohort to be US$215 million (best estimate). Using much more conservative assumptions, the estimate was $43 million. This analysis suggests that a modest reduction in ambient concentrations of PAH is associated with substantial economic benefits to children.

Costs of healthcare- and community-associated infections with antimicrobial-resistant versus antimicrobial-susceptible organisms.

OBJECTIVE: We compared differences in the hospital charges, length of hospital stay, and mortality between patients with healthcare- and community-associated bloodstream infections, urinary tract infections, and pneumonia due to antimicrobial-resistant versus -susceptible bacterial strains. METHODS: A retrospective analysis of an electronic database compiled from laboratory, pharmacy, surgery, financial, and patient location and device utilization sources was undertaken on 5699 inpatients who developed healthcare- or community-associated infections between 2006 and 2008 from 4 hospitals (1 community, 1 pediatric, 2 tertiary/quaternary care) in Manhattan. The main outcome measures were hospital charges, length of stay, and mortality among patients with antimicrobial-resistant and -susceptible infections caused by Staphylococcus aureus, Enterococcus faecium, Enterococcus faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. RESULTS: Controlling for multiple confounders using linear regression and nearest neighbor matching based on propensity score estimates, resistant healthcare- and community-associated infections, when compared with susceptible strains of the same organism, were associated with significantly higher charges ($15,626; confidence interval [CI], $4339-$26,913 and $25,573; CI, $9331-$41,816, respectively) and longer hospital stays for community-associated infections (3.3; CI, 1.5-5.4). Patients with resistant healthcare-associated infections also had a significantly higher death rate (0.04; CI, 0.01-0.08). CONCLUSIONS: With careful matching of patients infected with the same organism, antimicrobial resistance was associated with higher charges, length of stay, and death rates. The difference in estimates after accounting for censoring for death highlight divergent social and hospital incentives in reducing patient risk for antimicrobial resistant infections.

Cost of developmental delay from prenatal exposure to airborne polycyclic aromatic hydrocarbons.

Early life exposure to ambient polycyclic aromatic hydrocarbons (PAHs) can result in developmental delay. The negative health effects of PAHs have been well-documented but the cost of developmental delay due to PAH exposure has not been studied. The Columbia Center for Children's Environmental Health previously has reported the significant effect of prenatal exposure to ambient PAHs on delayed mental development at three years, using the Bayley Scales in a cohort of low-income women and children in New York City (NYC). Here we have used the cohort results to estimate the annual costs of preschool special education services for low-income NYC children with developmental delay due to PAH exposure using the Environmentally Attributable Fraction method. The estimated cost of PAH-exposure-related services is over $13.7 million per year for Medicaid births in NYC. This high cost supports policies to reduce level of PAHs in NYC air.

The effect of an early education program on adult health: the Carolina Abecedarian Project randomized controlled trial.

OBJECTIVES: We explored whether a successful randomized controlled trial of early education, the Carolina Abecedarian Project (ABC), which enrolled infants from 1972 to 1977 at the Frank Porter Graham Child Development Institute in Chapel Hill, North Carolina, improved health outcomes and behaviors by 21 years of age. METHODS: ABC randomized 111 infants to receive an intensive early education program or nutritional supplements and parental counseling alone; participants have been followed to the present day. We examined the effect of ABC on health outcomes and behavioral risk factors when participants were aged 21 years, and then explored the mediators of this relationship. RESULTS: Relative to the control group, the ABC treatment group was previously found to have improved cognition and educational attainment. We found that the intervention also improved heath (P = .05) and health behaviors (P = .03) when participants were aged 21 years. These improvements in behaviors were not mediated by IQ, math and reading scores at 15 years of age, educational attainment, or health insurance. CONCLUSIONS: Effective early education programs may improve health and reduce risky health behaviors in adulthood.

The association between community water fluoridation and adult tooth loss.

OBJECTIVES: We sought to estimate the association between community water fluoridation (CWF) exposure at various stages of life and adult tooth loss. METHODS: We used data from the 1995 through 1999 Behavioral Risk Factor Surveillance System, merged with data from the 1992 Water Fluoridation Census, to estimate interval regression models that relate CWF exposure with tooth loss. RESULTS: Our results indicate that CWF levels in the county of residence at the time of the respondent's birth are significantly related to tooth loss but current CWF levels are not. In addition, the impact of CWF exposure is larger for individuals of lower socioeconomic status. CONCLUSIONS: This study suggests that the benefits of CWF may be larger than previously believed and that CWF has a lasting improvement in racial/ethnic and economic disparities in oral health.

Factors associated with variation in estimates of the cost of resistant infections.

BACKGROUND: Existing estimates of the costs of antimicrobial resistance exhibit broad variability, and the contributing factors are not well understood. This study examines factors that contribute to variation in these estimates. METHODS: Studies of the costs of resistant infections (1995-2009) were identified, abstracted, and stated in comparable terms (eg, converted to 2007 U.S. dollars). Linear regressions were conducted to assess how costs incurred by patients with resistant infections versus those incurred by uninfected or susceptible-organism-infected controls varied according to (1) costs incurred by control subjects; (2) study population characteristics; (3) methodological factors (eg, matching); and (4) length of stay. RESULTS: Estimates of difference in costs incurred by patients with resistant infections versus patients without resistant infections varied between $-27,609 (control costs exceeded case costs) and $126,856. Differences were greater when the costs incurred by control subjects were higher (ie, when the underlying cost of care was high). Study-adjusted cost differences were greater for bloodstream infections (vs. any other infection site), for studies that reported median (vs. mean) costs, for studies that reported total (vs. postinfection or infection-associated) costs, for studies that used uninfected (vs. susceptible-organism-infected) controls, and for studies that did not match or adjust for length of stay before infection. CONCLUSION: The cost of antimicrobial resistance seems to vary with the underlying cost of care. Increased costs of resistance are partially explained by longer length of stay for patients with resistant infections. Further research is needed to assess whether interventions should be differentially targeted at the highest cost cases.

Health care savings attributable to integrating guidelines-based asthma care in the pediatric medical home.

OBJECTIVE: To estimate savings to health care system of a best-practice asthma intervention in primary care for inner-city children. METHODS: Data were analyzed from National Heart, Lung and Blood Institute (NHLBI) Guidelines-based initial (n=244) and follow-up (n=202) asthma assessments of patients who received enhanced treatment in primary care. Savings were calculated using cost-of-illness model and compared with program cost. RESULTS: Patients were about equally distributed between African American and Hispanic children (mean age = 7 years; range 36 months-19 years). Of those with persistent asthma, 36% had been prescribed a controller medication. This significantly improved on follow-up (p<.01). There were significant reductions in asthma severity (p<.05) and emergency department use (p<.01), and near-significant reduction in asthma hospitalizations (p=.059). CONCLUSION: Total annual savings attributable to clinical outcomes was $4,202,813 or $4,525 per patient with asthma. Total annual cost of the implementation was $390,169 or $420 per asthma patient. Conservatively estimated savings exceeded cost of intervention by nearly 11 to 1.

Medical technology adoption, uncertainty, and irreversibilities: is a bird in the hand really worth more than in the bush?

The influence of current medical technology adoption decisions on the use of future potential interventions is often overlooked. Some health interventions, once exercised, restrict future potential interventions for both related and unrelated medical conditions. For example, treatment of a patient with an antibiotic may lead to resistance in that patient that precludes future treatment with the same or related compounds. This irreversibility raises the value of treatment modalities that preserve future treatment options. Surprisingly, partial reversibility with or without learning can either increase or decrease this value, depending on the distribution of patient types within the treated population. Evaluations that ignore these option values miss an important part of the welfare equation that is becoming increasingly important as individuals live longer and the stock of medical treatments increases.

Air quality warnings and outdoor activities: evidence from Southern California using a regression discontinuity design.

BACKGROUND: A study was undertaken to assess the impact of air quality warnings associated with ground-level ozone on outdoor activities in Southern California. METHODS: Data on aggregate daily attendance at two major outdoor facilities were collected and merged with observed and forecasted air quality and meteorology at the daily level. A quasi-experimental regression discontinuity design was used to estimate the impact of warnings. RESULTS: Attendance declined significantly when stage 1 air quality warnings ('smog alerts') were issued. Consistent with expectations, responses were greater for populations more likely to be considered susceptible and more likely to be local residents. CONCLUSIONS: Air quality warnings are an important policy tool for protecting the public's health from high levels of ambient air pollution.

Effects of a prekindergarten educational intervention on adult health: 37-year follow-up results of a randomized controlled trial.

OBJECTIVES: We used 37 years of follow-up data from a randomized controlled trial to explore the linkage between an early educational intervention and adult health. METHODS: We analyzed data from the High/Scope Perry Preschool Program (PPP), an early school-based intervention in which 123 children were randomized to a prekindergarten education group or a control group. In addition to exploring the effects of the program on health behavioral risk factors and health outcomes, we examined the extent to which educational attainment, income, family environment, and health insurance access mediated the relationship between randomization to PPP and behavioral and health outcomes. RESULTS: The PPP led to improvements in educational attainment, health insurance, income, and family environment Improvements in these domains, in turn, lead to improvements in an array of behavioral risk factors and health (P = .01). However, despite these reductions in behavioral risk factors, participants did not exhibit any overall improvement in physical health outcomes by the age of 40 years. CONCLUSIONS: Early education reduces health behavioral risk factors by enhancing educational attainment, health insurance coverage, income, and family environments. Further follow-up will be needed to determine the long-term health effects of PPP.

Air pollution, health, and socio-economic status: the effect of outdoor air quality on childhood asthma.

This paper estimates the effect of air pollution on child hospitalizations for asthma using naturally occurring seasonal variations in pollution within zip codes. Of the pollutants considered, carbon monoxide (CO) has a significant effect on asthma for children ages 1-18: if 1998 pollution levels were at their 1992 levels, there would be a 5-14% increase in asthma admissions. Also, households respond to information about pollution with avoidance behavior, suggesting it is important to account for these endogenous responses when measuring the effect of pollution on health. Finally, the effect of pollution is greater for children of lower socio-economic status (SES), indicating that pollution is one potential mechanism by which SES affects health.