Patterns of Medical Care Cost by Service Type for Patients With Recurrent and De Novo Advanced Cancer.

OBJECTIVES: There is limited knowledge about the cost patterns of patients who receive a diagnosis of de novo and recurrent advanced cancers in the United States. METHODS: Data on patients who received a diagnosis of de novo stage IV or recurrent breast, colorectal, or lung cancer between 2000 and 2012 from 3 integrated health systems were used to estimate average annual costs for total, ambulatory, inpatient, medication, and other services during (1) 12 months preceding de novo or recurrent diagnosis (preindex) and (2) diagnosis month through 11 months after (postindex), from the payer perspective. Generalized linear regression models estimated costs adjusting for patient and clinical factors. RESULTS: Patients who developed a recurrence <1 year after their initial cancer diagnosis had significantly higher total costs in the preindex period than those with recurrence ≥1 year after initial diagnosis and those with de novo stage IV disease across all cancers (all P < .05). Patients with de novo stage IV breast and colorectal cancer had significantly higher total costs in the postindex period than patients with cancer recurrent in <1 year and ≥1 year (all P < .05), respectively. Patients in de novo stage IV and those with recurrence in ≥1 year experienced significantly higher postindex costs than the preindex period (all P < .001). CONCLUSIONS: Our findings reveal distinct cost patterns between patients with de novo stage IV, recurrent <1-year, and recurrent ≥1-year cancer, suggesting unique care trajectories that may influence resource use and planning. Future cost studies among patients with advanced cancer should account for de novo versus recurrent diagnoses and timing of recurrence to obtain estimates that accurately reflect these care pattern complexities.

Estimating the Impact of Diabetes Mellitus on Worker Productivity Using Self-Report, Electronic Health Record and Human Resource Data.

OBJECTIVE: We assessed the relationship between diabetes mellitus (DM) and measures of worker productivity, direct health care costs, and costs associated with lost productivity (LP) among health care industry workers across two integrated health care systems. METHODS: We used data from the Value Based Benefit Design Health and Wellness Study Phase II (VBD), a prospective study of employees surveyed across health systems. Survey and health care utilization data were linked to estimate LP and health care utilization costs. RESULTS: Mean marginal lost productive time per week was 0.56 hours higher for respondents with DM. Mean adjusted monthly total health care utilization costs were $467 higher for respondents with DM. CONCLUSION: The impact of DM is reflected in higher rates of LP and higher indirect costs for employers related to LP and higher health care resource use.

Medical Care Costs Associated With Cancer in Integrated Delivery Systems.

Background: The high economic burden of cancer is projected to continue growing. Cost-of-care estimates are key inputs for comparative effectiveness and economic analyses that aim to inform policies associated with cancer care. Existing estimates are based largely on SEER-Medicare data in the elderly, leaving a knowledge gap regarding costs for patients aged <65 years. Methods: We estimated total and net medical care costs using data on individuals diagnosed with breast, colorectal, lung, or prostate cancer (n=45,522) and noncancer controls (n=314,887) enrolled in 1 of 4 participating health plans. Net costs were defined as the difference in mean total costs between patients with cancer and controls. The phase-of-care approach and Kaplan-Meier Sample Average method were used to estimate mean total and net 1- and 5-year costs (in 2015 US dollars) by cancer site, stage at diagnosis, and age group (<65 and ≥65 years). Results: Total and net costs were consistently highest for lung cancer and lowest for prostate cancer. Net costs were higher across all cancer sites for patients aged <65 years than those aged ≥65 years. Medical care costs for all cancers increased with advanced stage at diagnosis. Conclusions: This study improves understanding of medical care costs for the 4 most common invasive cancers in the United States. Higher costs among patients aged <65 years highlight limitations of relying on SEER-Medicare data alone to understand the national burden of cancer, whereas higher costs for patients with advanced-stage cancer underscore the importance of early detection to curtail high long-term costs. These cost estimates can be used in the development and evaluation of interventions and policies across the cancer care continuum.

Relationship between cardiovascular risk and lipid testing in one health care system: a retrospective cohort study.

BACKGROUND: The US Preventive Services Taskforce (USPSTF) recommends routine lipid screening beginning age 35 for men [1]. For women age 20 and older, as well as men age 20-34, screening is recommended if cardiovascular risk factors are present. Prior research has focused on underutilization but not overuse of lipid testing. The objective is to document over- and under-use of lipid testing in an insured population of persons at low, moderate and high cardiovascular disease (CVD) risk for persons not already on statins. METHODS: The study is a retrospective cohort study that included all adults without prior CVD who were continuously enrolled in a large integrated healthcare system from 2005 to 2010. Measures included lipid test frequency extracted from administrative data and Framingham cardiovascular risk equations applied using electronic medical record data. Five year lipid testing patterns were examined by age, sex and CVD risk. Generalized linear models were used to estimate the relative risk for over testing associated with patient characteristics. RESULTS: Among males and females for whom testing is not recommended, 35.8 % and 61.5 % received at least one lipid test in the prior 5 years and 8.4 % and 24.4 % had two or more. Over-testing was associated with age, race, comorbidity, primary care use and neighborhood income. Among individuals at moderate and high-risk (not already treated with statins) and for whom screening is recommended, between 21.4 % and 25.1 % of individuals received no screening in the prior 5 years. CONCLUSIONS: Based on USPSTF lipid screening recommendations, this study documents substantial over-testing among individuals with low CVD risk and under-testing among individuals with moderate to high-risk not already on statins. Opportunity exists to better focus lipid screening efforts appropriate to CVD risk.

Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH.

PURPOSE: Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes. METHODS: We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008-2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters. RESULTS: The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%-1.29%) and 2.74% (95% CI, 2.70%-2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P<.001). CONCLUSIONS: Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.

Positron emission tomography and stage migration in head and neck cancer.

IMPORTANCE: Since 2001, there has been a rapid adoption of positron emission tomography (PET) for diagnosis and American Joint Committee on Cancer (AJCC) staging of head and neck cancer (HNC) without data describing improved clinical outcomes. OBJECTIVE: To determine the association between increased use of PET and stage and/or survival for patients with HNC in the managed care environment. DESIGN, SETTING, AND PARTICIPANTS: Adult patients diagnosed as having HNC (n = 958) from 2000 to 2008 at 4 integrated health systems were identified via tumor registries linked to administrative data. The AJCC stage distribution, patient and treatment characteristics, and survival between pre-PET era (2000-2004) vs PET era (2005-2008) and use of PET vs no use of PET during the PET era were compared. The AJCC stages were categorized to represent localized (stage I or II), locally advanced (stage III, IVA, or IVB), and metastatic (stage IVC) disease. INTERVENTIONS: Treatments were determined by billing codes for surgery, radiation treatment, and chemotherapy. MAIN OUTCOMES AND MEASURES: The primary outcome for this study was the use of PET. Secondary outcomes included treatment received and 2-year survival. A logit model estimated the effects of PET on diagnosis of locally advanced disease. Kaplan-Meier estimates described overall survival differences between PET and non-PET. Cox regression evaluated the association of PET on survival in patients with locally advanced disease. RESULTS: An association between PET and locally advanced disease was found (odds ratio, 2.86 [95% CI, 1.90-4.29) (P < .001). Two-year overall survival for patients with locally advanced disease with and without PET was 52% and 32%, respectively (P = .004), but there was no difference for all stages (P = .69). On Cox proportional hazard regression, PET had no association with survival in patients with locally advanced disease (hazard ratio, 1.208 [95% CI, 0.778-1.877]) (P = .40). CONCLUSIONS AND RELEVANCE: The increasing use of PET among patients with HNC is associated with a greater number of patients with higher-stage disease and a dilution of the population with higher-stage disease with patients who have a better prognosis. Thus, the improved survival in patients with locally advanced disease likely reflects selection bias and stage migration. Further research on PET use among patients with HNC is necessary to determine if it results in improved treatment for individual patients.

Specialty use among patients with treated hypertension in a patient-centered medical home.

BACKGROUND: Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use. OBJECTIVE: To describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation. DESIGN: One-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods. PATIENTS: Adults aged 18-85 years with treated hypertension. INTERVENTION: System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009. MAIN MEASURES: Resource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties. KEY RESULTS: Compared to baseline, the study population averaged 7% fewer adjusted specialty visits during implementation (P < 0.001) and 4% fewer adjusted specialty visits in the first post-implementation year (P = 0.02). Patients were 12% less likely to have any cardiology visits during implementation and 13% less likely during the first post-implementation year (P < 0.001). In interaction analysis, patients with low morbidity had at least 27% fewer specialty visits during each of 3 years following baseline (P < 0.001); medium morbidity patients had 9% fewer specialty visits during implementation (P < 0.001) and 5% fewer specialty visits during the first post-implementation year (P = 0.007); high morbidity patients had 3% (P = 0.05) and 5% (P = 0.009) higher specialty use during the first and second post-implementation years, respectively. CONCLUSIONS: Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients.

Outcomes among chronically ill adults in a medical home prototype.

OBJECTIVES: To compare quality, utilization, and cost outcomes for patients with selected chronic illnesses at a patient-centered medical home (PCMH) prototype site with outcomes for patients with the same chronic illnesses at 19 nonintervention control sites. STUDY DESIGN: Nonequivalent pretest-posttest control group design. METHODS: PCMH redesign results were investigated for patients with preexisting diabetes, hypertension, and/or coronary heart disease. Data from automated databases were collected for eligible enrollees in an integrated healthcare delivery system. Multivariable regression models tested for adjusted differences between PCMH patients and controls during the baseline and follow-up periods. Dependent measures under study included clinical processes and, outcomes, monthly healthcare utilization, and costs. RESULTS: Compared with controls over 2 years, patients at the PCMH prototype clinic had slightly better clinical outcome control in coronary heart disease (2.20 mg/dL lower mean low-density lipoprotein cholesterol; P <.001). PCMH patients changed their patterns of primary care utilization, as reflected by 86% more secure electronic message contacts (P <.001), 10% more telephone contacts (P = .003), and 6% fewer in-person primary care visits (P <.001). PCMH patients had 21% fewer ambulatory care-sensitive hospitalizations (P <.001) and 7% fewer total inpatient admissions (P = .002) than controls. During the 2-year redesign, we observed 17% lower inpatient costs (P <.001) and 7% lower total healthcare costs (P <.001) among patients at the PCMH prototype clinic. CONCLUSIONS: A clinic-level population-based PCMH redesign can decrease downstream utilization and reduce total healthcare costs in a subpopulation of patients with common chronic illnesses.

Impact of deductibles on initiation and continuation of psychotherapy for treatment of depression.

OBJECTIVE: To estimate the impact of deductibles on the initiation and continuation of psychotherapy for depression. DATA SOURCES/STUDY SETTING: Data from health care encounters and claims from Group Health Cooperative, a large integrated health care system in Washington State, was merged with information from a centralized behavioral health triage call center to conduct study analyses. STUDY DESIGN: A retrospective observational design using a hierarchical logistic regression model was used to estimate initiation and continuation probabilities for use of psychotherapy, adjusting for key sociodemographic/economic factors and prior use of behavioral health services relevant to individual decisions to seek mental health care. DATA COLLECTION/EXTRACTION METHODS: Analyses were based on merged datasets on patient enrollment, insurance benefits, use of mental health and general medical services and information collected by a triage specialist at a centralized behavioral health call center. PRINCIPAL FINDINGS: Among individuals with unmet deductibles between $100 and $500, we found a statistically significant lower likelihood of making an initial visit, but there was no statistically significant effect on making an initial or subsequent visit among individuals that had met their deductible. CONCLUSIONS: Unmet deductibles appear to influence the likelihood of initiating psychotherapy for treating depression.

How are the costs of care for medical falls distributed? The costs of medical falls by component of cost, timing, and injury severity.

PURPOSE OF THE STUDY: To examine the components of cost that drive increased total costs after a medical fall over time, stratified by injury severity. DESIGN AND METHODS: We used 2004-2007 cost and utilization data for persons enrolled in an integrated care delivery system. We used a longitudinal cohort study design, where each individual provides 2-3 years of administrative data grouped into 3-month intervals relative to an index date. We identified 8,969 medical fallers through International Classification of Diseases, 9th Revision, codes and E-Codes and used 8,956 nonfaller controls, identified through age and gender frequency matching. Total costs were partitioned into 7 components: inpatient, outpatient, emergency, radiology, pharmacy, postacute care, and "other." RESULTS: The large increase in costs after a hospitalized fall is mainly associated with inpatient and postacute care components. The spike in costs after a nonhospitalized fall is attributable to outpatient and "other" (e.g., ambulatory surgery or community health services) components. Hospitalized fallers' inpatient, emergency, postacute care, outpatient, and radiology costs are not always greater than those for nonhospitalized fallers. IMPLICATIONS: Components associated with increased costs after a medical fall vary over time and by injury severity. Future studies should compare if delivering certain acute and postacute health services improve health and reduce cost trajectories after a medical fall more than others. Additionally, since the older adult population and the problem of falls are growing, health care delivery systems should develop standardized methodology to monitor medical fall rates.

Impact on seniors of the patient-centered medical home: evidence from a pilot study.

PURPOSE: To assess the impact on health care cost and quality among seniors of a patient-centered medical home (PCMH) pilot at Group Health Cooperative, an integrated health care system in Washington State. DESIGN AND METHODS: A prospective before-and-after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health. Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics. Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics that were selected for their similarities in organization and patient composition to the pilot clinic. RESULTS: After adjusting for baseline, seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales. Seniors in the PCMH clinic had significantly greater quality outcomes over time, but this difference was not significant relative to control. PCMH patients used more e-mail, phone, and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions. At 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs. IMPLICATIONS: A PCMH redesign can be associated with improvements in patient experience and quality without increasing overall cost.

Cost of breast-related care in the year following false positive screening mammograms.

OBJECTIVE: We sought to estimate the direct cost, from the perspective of the health insurer or purchaser, of breast-care services in the year following a false positive screening mammogram compared with a true negative examination. DESIGN: We identified 21,125 women aged 40 to 80 years enrolled in an integrated healthcare delivery system in Washington State, who participated in screening mammography between January 1, 1998 and July 30, 2002. Pathology and cancer registry data were used to identify breast cancer diagnoses in the year following the screening mammogram. A positive examination was defined as a Breast Imaging Reporting and Data System assessment of 0, 4, or 5. Women with a positive screening mammogram but no breast cancer diagnosed within 1 year were classified as false positives. We used diagnostic and procedure codes in automated health plan data to identify services received in the year following the screening mammogram. Medicare reimbursement rates were applied to all services. We used ordinary least-squares linear regression to estimate the difference in costs following a false positive versus true negative screening mammogram. RESULTS: False positive results occurred in 9.9% of women; most false positives (87.3%) were followed by breast imaging only. The mean cost of breast-care following a false positive mammogram was $527. This was $503 (95% confidence interval, $490-$515) more than the cost of breast-care services for true negative women. CONCLUSIONS: The direct costs for breast-related procedures following false positive screening mammograms may contribute substantially to US healthcare spending.

A longitudinal analysis of total 3-year healthcare costs for older adults who experience a fall requiring medical care.

OBJECTIVES: To compare longitudinal changes in healthcare costs between fallers admitted to the hospital at the time of the fall (admitted), those not admitted to the hospital (nonadmitted), and nonfaller controls; test hypotheses related to differences in mean costs between and within these groups over time; and estimate the costs attributable to falling. DESIGN: Longitudinal cohort. SETTING: Group Health Cooperative of Puget Sound. PARTICIPANTS: Seven thousand nine hundred ninety-three nonadmitted fallers, 976 admitted fallers, and 8,956 nonfallers aged 67 and older enrolled in an integrated healthcare delivery system. Fallers were identified according to fall-related E-Codes and International Classification of Diseases, Ninth Revision codes recorded between January 1, 2004, and December 31, 2006. Nonfallers were frequency matched on age group and sex. MEASUREMENTS: Quarterly costs during a 3-year period were modeled using generalized estimating equations. Covariates included index age, sex, RxRisk (a comorbidity adjuster), fall status, time, and interactions between fall status and time. RESULTS: Cost differences between the faller cohorts and nonfallers were greatest in quarters closest to the fall (all P<.01) and persisted throughout the entire year of follow-up. Although nonfaller costs increased with time, faller cohort costs increased more quickly (all P<.01). For admitted fallers, 92% of costs incurred in the quarter of the fall were estimated to be attributable to falling ($27,745 of $30,038, P<.001). CONCLUSION: Falls for which medical attention are sought resulted in higher costs than for nonfallers for up to 12 months after a fall, particularly for falls requiring hospitalization. Prevention efforts should focus on reducing fall-related injuries requiring hospitalization because they produce the highest excess costs and have a higher likelihood of 1-year mortality.

Changes in health care costs over time following the cessation of intimate partner violence.

BACKGROUND: Research has documented greater health care costs attributable to intimate partner violence (IPV) among women during and after exposure. However, no studies have determined whether health care costs for abused women return to baseline levels at some point after their abuse ceases. OBJECTIVE: We examine whether health care costs among women exposed to IPV converge with those of non-abused women during a 10-year period following the end of exposure. DESIGN: Retrospective cohort analysis. SETTING: Group Health Cooperative, a large integrated health care system in the Pacific Northwest. PARTICIPANTS: Random sample of English-speaking women aged 18-64 enrolled within Group Health and who participated in a telephone survey between June 2003 and August 2005. MEASUREMENTS: Total health care costs over an 11-year period from January 1, 1992 to December 31, 2002 were compiled using automated health plan data and comparisons made among women exposed to IPV since age 18 and those who never experienced IPV. IPV included physical, sexual, or psychological violence involving an intimate partner, and was assessed using five questions from the Behavioral Risk Factor Surveillance System. RESULTS: Relative to women with no IPV history, total health care costs were significantly higher during IPV exposure, costs that were sustained for 3 years following the end of exposure. By the 4th year following the end of exposure to IPV, health care costs among IPV-exposed women were similar to non-abused women, and this pattern held for the remainder of the 10-year study period. CONCLUSIONS: Policy makers should consider the ongoing needs of victims following abuse exposure. Interventions to reduce the prevalence of IPV or to mitigate the impact of IPV have the potential to reduce the rate of growth of health care costs.

Association of cardiometabolic risk factors and prevalent cardiovascular events.

BACKGROUND: Although cardiovascular disease causes substantial morbidity and mortality, how individual and groups of risk factors contribute to cardiovascular outcomes is incompletely understood. This study evaluated cardiometabolic risk factors and their relationship to prevalent diagnosis of acute myocardial infarction (AMI) and stroke. METHODS: We used retrospective data from 3 integrated health-care systems that systematically collect and store detailed patient-level data. Adult enrollees were eligible for inclusion if they had all of the following clinical measurements: weight, height, blood pressure, high density lipoproteins, triglycerides, and fasting blood glucose or evidence of diabetes from July 1, 2003, to June 30, 2005. We used National Cholesterol Education Program Adult Treatment Panel III guidelines to determine qualifying levels for cardiometabolic risk factors. RESULTS: A total of 170,648 persons met the inclusion/exclusion criteria; 11,757 had no qualifying risk factors, 25,684 had 1, 38,176 had 2, and 95,031 had 3 or more risk factors. Compared to those without risk factors, persons with any 1 risk factor were 2.21 (95% confidence interval [CI], 1.78-2.74) times more likely to have had a diagnosis of AMI or stroke. The risk increased to 2.79 (95% CI, 2.26-3.42) for persons with 2, 3.45 (95% CI, 2.80-4.24) for persons with 3, 4.35 (95% CI, 3.54-5.35) for persons with 4, and 5.73 (95% CI, 4.65-7.07) for persons with 5 risk factors. The highest risk was conferred by having the combination of risk factors of diabetes, hypertension, and dyslipidemia, with or without weight risk. CONCLUSIONS: This study demonstrates a direct association between an increasing number of cardiometabolic risk factors and prevalent diagnosis of AMI and stroke. The combination of risk factors conferring the highest risk was diabetes, hypertension, and dyslipidemia.

Evaluation of the group health cooperative access initiative: study design challenges in estimating the impact of a large-scale organizational transformation.

The Institute of Medicine argues that poorly designed delivery systems are a major cause of low-quality care in the United States but does not present methods for evaluating whether its recommendations, when implemented by a health care organization, actually improve quality of care. We describe how time-series study designs using individual-level longitudinal data can be applied to address methodological challenges in our evaluation of the impact of the Group Health Cooperative "Access Initiative," an integrated set of 7 "patient-centered" reforms in its integrated delivery system that are consistent with the Institute of Medicine's recommendations. The methods may be generalizable to evaluating similar reforms in other integrated delivery systems with representative patient and physician data sources.

Intimate partner violence among men prevalence, chronicity, and health effects.

CONTEXT: The breadth and depth of intimate partner violence (IPV) experienced by men have not been fully documented. OBJECTIVES: To describe the prevalence, chronicity, and severity of IPV, and the health outcomes associated with IPV, in adult men with healthcare insurance. DESIGN: A retrospective telephone cohort study conducted from 2003 to 2005. The setting was an integrated healthcare system in Washington State and Idaho. PARTICIPANTS: English-speaking men aged 18 and older (N=420) enrolled in the healthcare system for 3 or more years. MAIN OUTCOME MEASURES: Physical, psychological, and sexual IPV were assessed using five questions from the Behavioral Risk Factor Surveillance Survey. Health was measured using the Short Form-36, version 2 (SF-36v2) survey, the Center for Epidemiological Studies Depression Scale, and the National Institute of Mental Health Presence of Symptoms Survey. RESULTS: Men experienced IPV at a rate of 4.6% in the past year, 10.4% in the past 5 years, and 28.8% over their lifetimes. While overall rates of physical and nonphysical IPV were similar, men aged 18-55 were twice as likely to be recently abused (14.2%, SE=2.6%) than were men aged 55 and older (5.3%, SE=1.6%). Abuse was typically nonviolent or mildly violent, occurred on multiple occasions, and was initiated by only one intimate partner. Compared to men with no IPV, older men who experienced IPV had more depressive symptoms (prevalence ratios=2.61 and 2.80 for nonphysical and physical abuse) and had lower SF-36v2 mental health subscales (range=-3.21 to -5.86). CONCLUSIONS: Men experience IPV at moderate rates, and poor mental health outcomes are associated with such experiences.

Health care utilization and costs associated with childhood abuse.

BACKGROUND: Physical and sexual childhood abuse is associated with poor health across the lifespan. However, the association between these types of abuse and actual health care use and costs over the long run has not been documented. OBJECTIVE: To examine long-term health care utilization and costs associated with physical, sexual, or both physical and sexual childhood abuse. DESIGN: Retrospective cohort. PARTICIPANTS: Three thousand three hundred thirty-three women (mean age, 47 years) randomly selected from the membership files of a large integrated health care delivery system. MEASUREMENTS: Automated annual health care utilization and costs were assembled over an average of 7.4 years for women with physical only, sexual only, or both physical and sexual childhood abuse (as reported in a telephone survey), and for women without these abuse histories (reference group). RESULTS: Significantly higher annual health care use and costs were observed for women with a child abuse history compared to women without comparable abuse histories. The most pronounced use and costs were observed for women with a history of both physical and sexual child abuse. Women with both abuse types had higher annual mental health (relative risk [RR] = 2.07; 95% confidence interval [95%CI] = 1.67-2.57); emergency department (RR = 1.86; 95%CI = 1.47-2.35); hospital outpatient (RR = 1.35 = 95%CI = 1.10-1.65); pharmacy (incident rate ratio [IRR] = 1.57; 95%CI = 1.33-1.86); primary care (IRR = 1.41; 95%CI = 1.28-1.56); and specialty care use (IRR = 1.32; 95%CI = 1.13-1.54). Total adjusted annual health care costs were 36% higher for women with both abuse types, 22% higher for women with physical abuse only, and 16% higher for women with sexual abuse only. CONCLUSIONS: Child abuse is associated with long-term elevated health care use and costs, particularly for women who suffer both physical and sexual abuse.

Concordance of population-based estimates of mammography screening.

OBJECTIVE: Estimates of adherence to mammography screening guidelines vary, in part, due to lack of consensus on defining adherence. This study estimated adherence to repeat (two successive on-time screenings) and regular screening (three or more successive screenings) and evaluated the impact of varying operational definitions and evaluation periods. METHODS: The study included women aged 50-80 without a history of breast cancer who: were on a biennial screening cycle and due for a screening mammogram between 1995 and 1996; underwent screening (index date) in response to a reminder letter; and belonged to Group Health, an integrated health care delivery system in Washington State, for 6 or more years after the index date. Automated records provided information on enrollment, health care utilization, and procedures. RESULTS: Among 1336 women, 67-82% experienced a repeat screen. Adherence to regular screening over the 6-year evaluation period was 42-84%--and higher with longer allowable intervals between screenings, when definitions did not require on-schedule screenings, when intervals were reset after a diagnostic mammogram, and for shorter evaluation periods. CONCLUSION: Estimates of adherence to screening guidelines varied by the operational definition of "success" and time period of evaluation. Consensus in definitions and terminology is needed to compare evaluations.

Changes in health care costs before and after smoking cessation.

Previous research on health care costs among former smokers suggests that quitters incur greater health care costs for up to 4 years after cessation compared with continuing smokers. However, little is known about the relationship between health care costs and utilization in the periods before as well as after cessation. The present study used a retrospective cohort design with automated health plan and primary data to examine the health care costs and clinical experiences before and after smoking cessation among former smokers compared with a sample of continuing smokers. Subjects were a random sample of adults (aged 25 and older) whose smoking status was identified by a physician during a primary care visit to the Group Health Cooperative (GHC), a nonprofit, integrated health care delivery system in western Washington state. Total direct health care costs among former smokers began to rise in the quarter prior to cessation and were significantly greater (p < .001) than those of continuing smokers in the quarter immediately following cessation. This difference dissipated within one quarter following cessation. We replicated the postquit cost spike among former smokers found by other research and showed that this spike dissipated within the first year postquit. Smoking cessation did not result in sustained cost increases among former smokers.