Association Between Glucocorticoid Exposure and Healthcare Expenditures for Potential Glucocorticoid-related Adverse Events in Patients with Rheumatoid Arthritis.

OBJECTIVE: Oral glucocorticoid (OGC) use for rheumatoid arthritis (RA) is debated because of the adverse event (AE) profile of OGC. We evaluated the associations between cumulative doses of OGC and potential OGC-related AE, and quantified the associated healthcare expenditures. METHODS: Using the MarketScan databases, patients ≥ 18 years old who have RA with continuous enrollment from January 1 to December 31, 2012 (baseline), and from January 1 to December 31, 2013 (evaluation period), were identified. Cumulative OGC dose was measured using prescription claims during the baseline period. Potential OGC-related AE (osteoporosis, fracture, aseptic necrosis of the bone, type 2 diabetes, ulcer/gastrointestinal bleeding, cataract, hospitalization for opportunistic infection, myocardial infarction, or stroke) and AE-related expenditures (2013 US$) were gathered during the evaluation period. Multivariable regression models were fitted to estimate OR of AE and incremental costs for patients with AE. RESULTS: There were 84,357 patients analyzed, of whom 48% used OGC during the baseline period and 26% had an AE during the evaluation period. A cumulative OGC dose > 1800 mg was associated with an increased risk of any AE compared with no OGC exposure (OR 1.19, 99.65% CI 1.09-1.30). Incremental costs per patient with any AE were significantly greater for cumulative OGC dose > 1800 mg compared with no OGC exposure (incremental cost = $3528, 99.65% CI $2402-$4793). CONCLUSION: Chronic exposure to low to medium doses of OGC was associated with significantly increased risk of potential OGC-related AE in patients with RA, and greater cumulative OGC dose was associated with substantially higher AE-related healthcare expenditures among patients with AE.

Diagnostic Pathways to Alzheimer Disease: Costs Incurred in a Medicare Population.

Despite its implications on the personal and policy level, little is currently known about the specific diagnostic pathways that patients with cognitive impairment (CI) pass through before being diagnosed with Alzheimer disease (AD). Four major diagnostic pathways were identified in the Medicare claims records for 2001 to 2006: AD as initial diagnosis, cognitive disturbance followed by AD; dementia with suspected etiologies followed by AD; dementia without known cause followed by AD; and 1 triple pathway, cognitive disturbance followed by dementia without known cause followed by AD. For all of these pathways, previously low medical costs peaked during patients' month of initial diagnosis and then declined to a level substantially higher than before. The 3 CI pathways that transition to AD included another peak in costs when a secondary AD diagnosis occurred. Each time, inpatient and skilled nursing facility services were major cost contributors. The primary diagnoses on Medicare claims for the AD event were usually comorbidities rather than CI. A linear regression model adjusting for demographic factors, selected comorbidities, and overall frailty found that the transitional CI diagnoses were significant independent cost determinants. They increased Medicare expenditures by an estimated $4600 to $14,200 relative to patients whose initial CI diagnosis was AD.

Incidence of giant cell arteritis and characteristics of patients: data-driven analysis of comorbidities.

OBJECTIVE: To establish the incidence of giant cell arteritis (GCA), cumulative use of prednisolone, and comorbidities most associated with GCA. METHODS: The data source was the UK Clinical Practice Research Datalink. Selection criteria included ≥1 record of a diagnostic term for GCA between January 1, 2000 and December 31, 2011, age ≥50 years, and ≥1 prescription of oral or systemic corticosteroid. Controls were selected randomly (2:1), with year of birth, practice, and followup duration (<2 or ≥2 years) as matching variables. Analysis was data driven; all comorbidities were identified in a 2-year window, with relative risk (RR) calculated and rank ordered. RESULTS: A total of 4,671 patients fulfilled the definition of GCA (incidence, 1.0 per 10,000 person-years), with highest incidence (7.4 per 10,000 person-years) in women ages 70-79 years. Of the 4,671 patients, 4,655 (99.7%) were prescribed prednisolone. In the group with ≥2 years' followup (n = 3,074), the mean number of prednisolone prescriptions was 32.1, and the mean cumulative dose was 8,640 mg; 1,034 patients (33.4%) received a cumulative dose of ≥10,000 mg. Comorbidities strongly associated with GCA were polymyalgia rheumatica (RR 14.9, 95% confidence interval [95% CI] 11.9-18.7), visual disturbances (RR 4.6, 95% CI 2.7-7.8), facial pain (RR 3.3, 95% CI 2.1-5.3), osteoporosis (RR 2.9, 95% 2.3-3.7), hypokalemia (RR 2.5, 95% CI 1.6-3.9), and various infections such as oral/esophageal thrush (RR 3.7, 95% CI 2.2-6.0) and herpes zoster (RR 2.6, 95% CI 1.6-4.1). CONCLUSION: GCA is relatively uncommon; its incidence peaks at age 70-79 years in women. Overall, GCA patients in the UK are treated with high cumulative prednisolone doses. Many conditions are associated with GCA, including several related to corticosteroid use.

Analysis of cognitive, functional, health service use, and cost trajectories prior to and following memory loss.

OBJECTIVES: This brief report examines whether significant changes in cognition, functional dependence, health service use, and out-of-pocket medical expenditures (OOPMD) occur in the years prior to a physician-identified memory problem in a nationally representative sample of older adults. METHOD: Longitudinal data from the RAND-Health and Retirement Survey were utilized. Those who reported a physician-identified memory problem (n = 387) were compared with a randomly selected control group of similar age, race, and gender who did not indicate a memory problem (n = 387). Multilevel linear models were used to construct trajectories for various measures of cognition, function, health service use, and OOPMD in the years prior to and following memory problem identification. RESULTS: Several trajectories demonstrated significant rates of change in the years leading up to a physician-identified memory problem, including symptoms (mental status, fine motor skills, and instrumental activities of daily living) and utilization (OOPMD and overnight stays in hospital). DISCUSSION: Preclinical declines in mental status and function and increases in hospital use and OOPMD are apparent prior to the formal identification of memory problems. Earlier identification of these changes might provide a basis for interventions that could alter the clinical course of dementia.

The impact of social disparity on prefrontal function in childhood.

The prefrontal cortex (PFC) develops from birth through late adolescence. This extended developmental trajectory provides many opportunities for experience to shape the structure and function of the PFC. To date, a few studies have reported links between parental socioeconomic status (SES) and prefrontal function in childhood, raising the possibility that aspects of environment associated with SES impact prefrontal function. Considering that behavioral measures of prefrontal function are associated with learning across multiple domains, this is an important area of investigation. In this study, we used fMRI to replicate previous findings, demonstrating an association between parental SES and PFC function during childhood. In addition, we present two hypothetical mechanisms by which SES could come to affect PFC function of this association: language environment and stress reactivity. We measured language use in the home environment and change in salivary cortisol before and after fMRI scanning. Complexity of family language, but not the child's own language use, was associated with both parental SES and PFC activation. Change in salivary cortisol was also associated with both SES and PFC activation. These observed associations emphasize the importance of both enrichment and adversity-reduction interventions in creating good developmental environments for all children.

Biologic disease-modifying drug treatment patterns and associated costs for patients with rheumatoid Arthritis.

OBJECTIVE: To assess the influence of biologic treatment patterns on healthcare costs for patients with rheumatoid arthritis (RA) initiating tumor necrosis factor-α (TNF-α) antagonist therapy. METHODS: Patients with 2 RA diagnoses (International Classification of Diseases, 9th ed, 714.xx), and without psoriasis or Crohn's disease, were identified in a US employer-based insurance claims database. A sample of 2545 was constructed based on an index event of initiating TNF-α antagonist therapy and 30 months of continuous enrollment. Baseline characteristics were assessed in the 6-month pre-index period and treatment patterns were determined during the 12-month post-index period. Medical service and prescription drug costs were analyzed for Months 13-24 using multivariate regression analysis to control for baseline characteristics and time-varying confounding associated with treatment and disease severity. RESULTS: In the first year after TNF-α initiation, 89% used a single TNF-α antagonist; only 9% and 2% had switched TNF-α antagonists or received non-TNF biologic disease-modifying antirheumatic drugs, respectively. Descriptive analyses revealed pairwise differences between groups (p < 0.05) in baseline characteristics (comorbidities, RA-related procedure use, and prescription drug use). Controlling for observed baseline characteristics, costs were greater for those treated with multiple vs single TNF-α antagonists: annual RA-related prescription drug costs ($8,340 vs $7,058; p = 0.012), RA-related healthcare costs ($15,048 vs $13,312; p = 0.008), and total healthcare costs ($26,697 vs $21,381; p < 0.001). CONCLUSION: In this sample, the majority of patients with RA were treated with a single TNF-α antagonist over the first year on therapy. For those who switched therapy, Year 2 RA-related and total direct healthcare costs were higher, adjusting for claims-based measures of RA disease severity.

Does caregiver burden mediate the effects of behavioral disturbances on nursing home admission?

OBJECTIVES: The primary objective of this study was to determine whether caregiving burden mediated the relationship between specific behavior disturbances and time to nursing home admission (NHA) for persons with dementia (i.e., Alzheimer disease or a related disorder). DESIGN: The study used secondary longitudinal data from the Medicare Alzheimer's Disease Demonstration, a Medicare-covered home care benefit and case management program for family caregivers of persons with dementia. Primary caregivers of persons with dementia were assessed via in-person and telephone interviews every 6 months over a 3-year period. SETTING: Dementia caregivers were recruited from eight catchment areas throughout the United States. PARTICIPANTS: The baseline sample included 5,831 dementia caregivers. Just more than 40% (43.9%; N = 2,556) of persons with dementia permanently entered a nursing home during the 3-year study period. MEASUREMENTS: Individual behavior problems were measured with the Memory and Behavior Problem Checklist. Caregiving burden was assessed with a short version of the Zarit Burden Inventory. Key covariates, including sociodemographic background, functional status, and service utilization, were also considered. RESULTS: Event history analyses revealed that time-varying measures of caregiver burden fully mediated the relationship between four behavioral disturbances (episodes of combativeness, property destruction, repetitive questions, and reliving the past) and NHA. CONCLUSIONS: The findings highlight the multifaceted, complex pathway to NHA for persons with dementia and their family caregivers. The results emphasize the need for comprehensive treatment approaches that incorporate the burden of caregivers and the behavioral/psychiatric symptoms of persons with dementia simultaneously.

The association between insomnia severity and healthcare and productivity costs in a health plan sample.

STUDY OBJECTIVES: Insomnia is a chronic condition with significant burden on health care and productivity costs. Despite this recognized burden, very few studies have examined associations between insomnia severity and healthcare and productivity costs. DESIGN: A retrospective study linking health claims data with a telephone survey of members of a health plan in the Midwestern region of the United States. PARTICIPANTS: The total healthcare costs study sample consisted of 2086 health plan members who completed the survey and who had complete health claims data. The productivity costs sample consisted of 1329 health plan members who worked for pay-a subset of the total healthcare costs sample. MEASUREMENTS: Subjects' age, gender, demographic variables, comorbidities, and total health care costs were ascertained using health claims. Insomnia severity and lost productivity related variables were assessed using telephone interview. RESULTS: Compared with the no insomnia group, mean total healthcare costs were 75% larger in the group with moderate and severe insomnia ($1323 vs. $757, P<0.05). Compared with the no insomnia group, mean lost productivity costs were 72% larger in the moderate and severe insomnia group ($1739 vs. $1013, P<0.001). Chronic medical comorbidities and psychiatric comorbidities were positively associated with health care cost. In contrast, psychiatric comorbidities were associated with lost productivity; while, medical comorbidities were not associated with lost productivity. CONCLUSIONS: Health care and lost productivity costs were consistently found to be greater in moderate and severe insomniacs compared with non-insomniacs. Factors associated with lost productivity and health care costs may be fundamentally different and may require different kinds of interventions. Future studies should focus on better understanding mechanisms linking insomnia to healthcare and productivity costs and to understanding whether developing targeted interventions will reduce these costs.

Family socioeconomic status and child executive functions: the roles of language, home environment, and single parenthood.

The association between family socioeconomic status (SES) and child executive functions is well-documented. However, few studies have examined the role of potential mediators and moderators. We studied the independent and interactive associations between family SES and single parenthood to predict child executive functions of inhibitory control, cognitive flexibility, and working memory and examined child expressive language abilities and family home environment as potential mediators of these associations. Sixty families from diverse SES backgrounds with a school-age target child (mean [SD] age = 9.9 [0.96] years) were evaluated. Child executive functioning was measured using a brief battery. The quality of the home environment was evaluated using the Home Observation for the Measurement of the Environment inventory. Family SES predicted the three child executive functions under study. Single parent and family SES were interactively associated with children's inhibitory control and cognitive flexibility; such that children from low SES families who were living with one parent performed less well on executive function tests than children from similarly low SES who were living with two parents. Parental responsivity, enrichment activities and family companionship mediated the association between family SES and child inhibitory control and working memory. This study demonstrates that family SES inequalities are associated with inequalities in home environments and with inequalities in child executive functions. The impact of these disparities as they unfold in the lives of typically developing children merits further investigation and understanding.

Socioeconomic predictors of health and development in middle childhood: variations by socioeconomic status measure and race.

BACKGROUND: Socioeconomically disadvantaged children have poorer physical and mental health and lower social and school/academic functioning compared to children with higher socioeconomic status (SES). These associations are not static but may vary by choice of SES indicator and child race/ethnicity. However, little is known about these associations in middle-childhood, a distinct and critical developmental period. We explore these associations in a small exploratory study designed to examine associations between SES and child developmental outcomes in middle childhood. MATERIALS AND METHODS: We recruited 60 families with a child between 8-12 years of age from the San Francisco Bay area September 2005-June 2006. The MacArthur Health and Behavior Questionnaire was used to assess health and adaptive functioning across four developmental domains: physical health, mental health, social functioning, and school/academic functioning. We examined a range of SES measures including continuous and categorical assessments of poverty, income, wealth, maternal and overall family educational attainment, subjective social status, and cumulative social risk. A series of multivariate ordinary least squares regressions was performed on the total sample and within race-specific groups. RESULTS: Although the long-recognized, graded relations among SES and outcomes were present, associations employing categorical representations of SES were far more pervasive; and stronger in magnitude. Wealth and highest degree earned in the family showed the strongest associations across virtually all health/functioning domains. Health and functioning was more strongly associated with educational attainment among Whites and financial resources among Blacks. Among Whites more wealth was associated with worse outcomes. CONCLUSIONS: Further research is needed to confirm the study findings. However, this study raises important questions about the measurement of SES for studying disparities in child health and developmental outcomes. This initial research suggests that improvements in health and functioning in middle childhood may require more significant status transitions; more targeted social interventions to address racial/ethnic disparities in child health and developmental outcomes; and a need to intervene on adversities facing affluent youth, a potentially hidden yet vulnerable group in middle childhood.

Subtypes of sleep disturbance: associations among symptoms, comorbidities, treatment, and medical costs.

Medical claims and survey data were used to evaluate patients with sleep disturbance lasting 1 year or more, and to identify subtypes of sleep disturbance using latent class analysis. Four subtypes were identified from the 1,374 patients. Subtypes differed on the number of sleep disturbance symptoms, presence of non-restorative sleep and comorbidities, degree of daytime impairment, and insomnia severity. The results from this study suggest that patient-reported symptoms of sleep disturbance, the frequency of symptoms, functional impairment, and comorbid conditions are important elements in distinguishing among groups of patients with varying degrees of sleep problems. These data provide evidence that the Insomnia Severity Index (ISI) varies accordingly with the frequency and resulting impairment of symptoms captured in the 4 clusters.

Association of insomnia severity and comorbid medical and psychiatric disorders in a health plan-based sample: Insomnia severity and comorbidities.

BACKGROUND: Insomnia is commonly associated with one or more comorbid illnesses. Data on the relationship between insomnia severity and comorbid disorders are still limited, especially with regard to the use of well-validated measures of insomnia severity. METHODS: A total of 2086 health plan enrollees, over-sampling for those with insomnia based on health claims, completed a telephone survey between April and June of 2006. Participants were categorized using four insomnia severity categories and compared on their administrative health claims' psychiatric and medical comorbidities. RESULTS: Controlling for age and gender, the odds ratio for having at least one psychiatric diagnosis was 5.04 (CI=3.24-7.84) for severe insomnia, 2.63 (CI=1.97-3.51) for moderate insomnia, and 1.7 (CI=1.30-2.23) for subthreshold insomnia compared with those with no insomnia. Similarly, the odds ratio for having treatment for at least one chronic disease was 2.83 (CI=1.84-4.35) for severe insomnia, 2.34 (CI=1.83-2.99) for moderate insomnia, and 1.55 (CI=1.25-1.92) for subthreshold insomnia compared with the no insomnia group. CONCLUSIONS: Increasing insomnia severity is associated with increased chronic medical and psychiatric illnesses. Further research is needed to better understand associations between insomnia severity and individual psychiatric and chronic medical comorbidities.