Differences in healthcare costs over 10 years following discharge from military service by weight trajectory.

The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.

Economic Burden of Acute Gastroenteritis among Members of Integrated Healthcare Delivery System, United States, 2014-2016.

We conducted a large surveillance study among members of an integrated healthcare delivery system in Pacific Northwest of the United States to estimate medical costs attributable to medically attended acute gastroenteritis (MAAGE) on the day care was sought and during 30-day follow-up. We used multivariable regression to compare costs of MAAGE and non-MAAGE cases matched on age, gender, and index time. Differences accounted for confounders, including race, ethnicity, and history of chronic underlying conditions. Analyses included 73,140 MAAGE episodes from adults and 18,617 from children who were Kaiser Permanente Northwest members during 2014-2016. Total costs were higher for MAAGE cases relative to non-MAAGE comparators as were costs on the day care was sought and costs during follow-up. Costs of MAAGE are substantial relative to the cost of usual-care medical services, and much of the burden accrues during short-term follow-up.

Estimating the economic impact of acute coronary syndrome in New Zealand over time (ANZACS-QI 64): a national registry-based cost burden study.

OBJECTIVES: To estimate the changes in costs associated with acute coronary syndrome (ACS) admissions in New Zealand (NZ) public hospitals over a 12-year period. DESIGN: A cost-burden study of ACS in NZ was conducted from the NZ healthcare system perspective. SETTING: Hospital admission costs were estimated using relevant diagnosis-related groups and their costs for publicly funded casemix hospitalisations, and applied to 190 364 patients with ACS admitted to NZ public hospitals between 2007 and 2018 identified from routine national hospital datasets. Trends in the costs of index ACS hospitalisation, hospital admissions costs, coronary revascularisation and all-cause mortality up to 1 year were evaluated. All costs were presented as 2019 NZ dollars. PRIMARY OUTCOME MEASURES: Healthcare costs attributed to ACS admissions in NZ over time. RESULTS: Between 2007 and 2018, there was a 42% decrease in costs attributed to ACS (NZ$7.7 million (M) to NZ$4.4 M per 100 000 per year), representing a decrease of NZ$298 827 per 100 000 population per year. Mean admission costs associated with each admission declined from NZ$18 411 in 2007 to NZ$16 898 over this period (p<0.001) after adjustment for key clinical and procedural characteristics. These reductions were against a background of increased use of coronary revascularisation (23.1% (2007) to 38.1% (2018)), declining ACS admissions (366-252 per 100 000 population) and an improvement in 1-year survival post-ACS. Nevertheless, the total ACS cost burden remained considerable at NZ$237 M in 2018. CONCLUSIONS: The economic cost of hospitalisations for ACS in NZ decreased considerably over time. Further studies are warranted to explore the association between reductions in ACS cost burden and changes in the management of ACS.

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.

Cost-effectiveness of Cardiac Telerehabilitation With Relapse Prevention for the Treatment of Patients With Coronary Artery Disease in the Netherlands.

Importance: Cardiac telerehabilitation (CTR) has been found to be a safe and beneficial alternative to traditional center-based cardiac rehabilitation (CR) and might be associated with higher participation rates by reducing barriers to CR use. However, implementation of CTR interventions remains low, which may be owing to a lack of cost-effectiveness analyses of data from large-scale randomized clinical trials. Objective: To assess the cost-effectiveness of CTR with relapse prevention compared with center-based CR among patients with coronary artery disease. Design, Setting, and Participants: This economic evaluation performed a cost-utility analysis of data from the SmartCare-CAD (Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform) randomized clinical trial. The cost-effectiveness and utility of 3 months of cardiac telerehabilitation followed by 9 months of relapse prevention were compared with the cost-effectiveness of traditional center-based cardiac rehabilitation. The analysis included 300 patients with stable coronary artery disease who received care at a CR center serving 2 general hospitals in the Netherlands between May 23, 2016, and July 26, 2018. All patients were entering phase 2 of outpatient CR and were followed up for 1 year (until August 14, 2019). Data were analyzed from September 21, 2020, to September 24, 2021. Intervention: After baseline measurements were obtained, participants were randomly assigned on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group) using computerized block randomization. After 6 supervised center-based training sessions, patients in the intervention group continued training at home using a heart rate monitor and accelerometer. Patients uploaded heart rate and physical activity data and discussed their progress during a weekly video consultation with their physical therapist. After 3 months, weekly coaching was concluded, and on-demand coaching was initiated for relapse prevention; patients were instructed to continue using their wearable sensors and were contacted in cases of nonadherence to the intervention or reduced exercise or physical activity volumes. Main Outcomes and Measures: Quality-adjusted life-years were assessed using the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS), and cardiac-associated health care costs and non-health care costs were measured by health care consumption, productivity, and informal care questionnaires (the Medical Consumption Questionnaire, the Productivity Cost Questionnaire, and the Valuation of Informal Care Questionnaire) designed by the Institute for Medical Technology Assessment. Costs were converted to 2020 price levels (in euros) using the Dutch consumer price index (to convert to US dollars, euro values were multiplied by 1.142, which was the mean exchange rate in 2020). Results: Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life among patients receiving CTR vs center-based CR was comparable during the study according to the results of both utility measures (mean difference on EQ-5D-5L: -0.004; P = .82; mean difference on EQ-VAS: -0.001; P = .92). Intervention costs were significantly higher for CTR (mean [SE], €224 [€4] [$256 ($4)]) compared with center-based CR (mean [SE], €156 [€5] [$178 ($6)]; P < .001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], €4787 [€503] [$5467 ($574)] and center-based CR (mean [SE], €5507 [€659] [$6289 ($753)]; P = .36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], €20 495 [€ 2751] [$23 405 ($3142)] vs €24 381 [€3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-€3887 [-$4439]; P = .34). Conclusions and Relevance: In this economic evaluation, a CTR intervention with relapse prevention was likely to be cost-effective compared with center-based CR, suggesting that CTR maybe used as an alternative intervention for the treatment of patients with coronary artery disease. These results add to the evidence base in favor of CTR and may increase the implementation of CTR interventions in clinical practice.

Estimating the Theoretical Cost Implications of Funding New Drugs Considered Not to Be Cost-Effective.

This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland (€ 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be €108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.

Economic burden of highly active relapsing-remitting multiple sclerosis patients in the French national health insurance database.

BACKGROUND: As healthcare management of highly active-relapsing-remitting multiple sclerosis (HA-RRMS) patients is more complex than for the whole multiple sclerosis (MS) population, this study assessed the related economic burden from a National Health Insurance's (NHI's) perspective. RESEARCH DESIGN AND METHODS: Study based on French NHI databases, using individual data on billing and reimbursement of outpatient and hospital healthcare consumption, paid sick leave and disability pension, over 2010-2017. RESULTS: Of the 9,596 HA-RRMS adult patients, data from 7,960 patients were analyzed with at least 2 years of follow-up. Mean annual cost/patient was €29,813. Drugs represented 40% of the cost, hospital care 33%, disability pensions 9%, and all healthcare professionals' visits combined 8%. Among 3,024 patients under 60 years-old with disability pension, disability pension cost €7,168/patient/year. Among 3,807 patients with paid sick leave, sick leave cost €1,956/patient/year. Mean costs were €2,246/patient higher the first year and increased by €1,444 between 2010 and 2015, with a €5,188 increase in drug-related expenditures and a €634 increase in healthcare professionals' visits expenditures but a €4,529 decrease in hospital care expenditures. CONCLUSIONS: The cost of health care sick leaves, and disability pensions of HA-RRMS patients was about twice as high as previously reported cost of MS patients.

Direct costs of antineoplastic and supportive treatment for progressive multiple myeloma in a tax-based health system.

Aim: To estimate current real-world costs of drugs and supportive care for the treatment of multiple myeloma in a tax-based health system. Methods: Forty-one patients were included from a personalized medicine study (2016-2019). Detailed information was collected from patient journals and hospital registries to estimate the total and mean costs using inverse probability weighting of censored data. Results: Total observed (censored) costs for the 41 patients was €8.84 million during 125 treatment years, with antineoplastic drugs as the main cost driver (€5.6 million). Individual costs showed large variations. Mean 3-year cost per patient from first progression was €182,103 (€131,800-232,405). Conclusion: Prediction of real-world costs is hindered by the availability of detailed costing data. Micro-costing analyses are needed for budgeting and real-world evaluation of cost-effectiveness.

Lay abstract In recent years, there has been a dramatic improvement in the treatment of multiple myeloma due to the introduction of new drugs. These drugs have significantly increased survival but have also had an immense impact on healthcare budgets. In this study, we used detailed treatment information for multiple myeloma patients in combination with billing data from the hospital pharmacy at a Danish hospital to calculate individual cost histories for both drugs and supportive care. Using these data, we estimated the mean 3-year cost of a multiple myeloma patient to be €182.103, but we also found large variation between patients, causing an uncertainty of €50.000 in either direction. We believe that detailed costing studies, similar to the present one, are necessary for evaluation of cost-effectiveness of drugs in clinical practice.

Health and economic impact of the correct diagnosis of transthyretin cardiac amyloidosis in Spain.

Objective: To estimate the health and economic impact of the reduction in mortality and cardiovascular hospitalizations, associated with correct diagnosis of cardiac transthyretin amyloidosis (ATTR-CM), from the Spanish National Health System (NHS) perspective.Methods: A costs and effects analysis were performed (probabilistic Markov model) with time horizons between 1 and 15 years, comparing the correct diagnosis of ATTR-CM versus the non-diagnosis. Transition probabilities were obtained from the ATTR-ACT study (placebo arm) and from the literature. Costs and healthcare resources were obtained from Spanish sources (€ 2019) and from a panel of Spanish clinical experts.Results: After 1, 5, 10 and 15 years, the diagnosis of ATTR-CM would generate a gain of 0.031 (95%CI 0.025; 0.038); 0.387 (95%CI 0.329; 0.435); 0.754 (95%CI 0.678; 0.781) and 0.944 (95%CI 0.905; 0.983) life years per patient, respectively, with savings of € 212 (95%CI € -632; 633), € 2,289 (95%CI € 2,250; 2,517), € 2,859 (95%CI € 2,584; 3,149) and € 2,906 (95%CI € 2,669; 3,450) per patient, respectively, versus the non-diagnosis.Conclusions: Just by correctly diagnosing ATTR-CM, years of life would be gained, cardiovascular hospitalizations would be avoided, and savings would be generated for the NHS, compared to the non-diagnosis of the disease.

One-year direct costs of biological therapy in rheumatoid arthritis and its predictive factors: data from the Moroccan RBSMR registry.

The aim of the study was to estimate the annual direct costs of biological therapies in rheumatoid arthritis (RA), and to establish possible factors associated with those costs. The main data source was the Moroccan registry of biological therapies in rheumatic diseases (RBSMR Registry). We included patients with available 1-year data. Variables related to socio-economic status, disease and biological therapy were collected. Direct costs included prices of biologics, costs of infusions, and subcutaneous injections. Differences in costs across groups were tested by Mann-Whitney and Kruskal-Wallis tests. Correlations analysis was performed in search of factors associated with high costs. We included 197 rheumatoid arthritis patients. The mean age was 52.3 ± 11 years, with female predominance 86.8%. Receiving one of the following therapies: rituximab (n = 132), tocilizumab (n = 37), or TNF-blockers (n = 28). Median one-year direct costs per patient were €1665 [€1472-€9879]. The total annual direct costs were € 978,494. Rituximab, constituted 25.7% of the total annual budget. TNF-blockers and tocilizumab represented 27.3% and 47% of this overall budget, respectively. Although the costs were not significantly different in terms of gender or level of study, the insurance type significantly affected the cost estimation. A positive correlation was found between the annual direct cost and body mass index (r = 0.15, p = 0.04). In Morocco, a developing country, the annual direct costs of biological therapy are high. Our results may contribute to the development of strategies for better governance of these costs.

Development of a predictive model for integrated medical and long-term care resource consumption based on health behaviour: application of healthcare big data of patients with circulatory diseases.

BACKGROUND: Medical costs and the burden associated with cardiovascular disease are on the rise. Therefore, to improve the overall economy and quality assessment of the healthcare system, we developed a predictive model of integrated healthcare resource consumption (Adherence Score for Healthcare Resource Outcome, ASHRO) that incorporates patient health behaviours, and examined its association with clinical outcomes. METHODS: This study used information from a large-scale database on health insurance claims, long-term care insurance, and health check-ups. Participants comprised patients who received inpatient medical care for diseases of the circulatory system (ICD-10 codes I00-I99). The predictive model used broadly defined composite adherence as the explanatory variable and medical and long-term care costs as the objective variable. Predictive models used random forest learning (AI: artificial intelligence) to adjust for predictors, and multiple regression analysis to construct ASHRO scores. The ability of discrimination and calibration of the prediction model were evaluated using the area under the curve and the Hosmer-Lemeshow test. We compared the overall mortality of the two ASHRO 50% cut-off groups adjusted for clinical risk factors by propensity score matching over a 48-month follow-up period. RESULTS: Overall, 48,456 patients were discharged from the hospital with cardiovascular disease (mean age, 68.3 ± 9.9 years; male, 61.9%). The broad adherence score classification, adjusted as an index of the predictive model by machine learning, was an index of eight: secondary prevention, rehabilitation intensity, guidance, proportion of days covered, overlapping outpatient visits/clinical laboratory and physiological tests, medical attendance, and generic drug rate. Multiple regression analysis showed an overall coefficient of determination of 0.313 (p < 0.001). Logistic regression analysis with cut-off values of 50% and 25%/75% for medical and long-term care costs showed that the overall coefficient of determination was statistically significant (p < 0.001). The score of ASHRO was associated with the incidence of all deaths between the two 50% cut-off groups (2% vs. 7%; p < 0.001). CONCLUSIONS: ASHRO accurately predicted future integrated healthcare resource consumption and was associated with clinical outcomes. It can be a valuable tool for evaluating the economic usefulness of individual adherence behaviours and optimising clinical outcomes.

DRG-Oriented Mathematical Calculation Model and Method of Integrated Medical Service Cost.

In the context of the new round of medical and health reform, in order to alleviate the problem of "difficult to see a doctor and expensive to see a doctor," the state focuses on reducing the cost of medical services, so it puts forward the calculation and method research of medical costs. The purpose of this study is to calculate and predict the cost of medical services in a DRG-oriented integrated environment. In this study, activity-based costing and weighted moving average methods are used. First, basic data of medical services are collected, then all medical activities are confirmed and all service costs are collected, then a cost database is established, and a calculation model of medical costs is designed. Finally, calculation suggestions and optimization methods are put forward by analyzing the calculated data. The experimental results show that the actual demand of drugs predicted by the general moving average method is relatively insufficient, with the maximum error of 41%, the minimum of 5%, and the average error of 19.8%; the maximum error of drug demand predicted by the weighted moving average method is 24%, the minimum is 2%, and the average is 15.4%. It can be concluded that the prediction effect of the weighted moving average method is better than that of the ordinary moving average method, which plays a good and effective role in the prediction of medical cost. The activity-based costing method is more detailed and organized for the cost calculation and classification of medical services. It provides a certain value for the effective management and control of medical service cost.

Spillover effects of mandatory hip and knee replacement surgery bundles in medicare.

BACKGROUND: Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking. OBJECTIVE: To evaluate the association between CJR participation and changes in outcomes among privately insured individuals. DESIGN, SETTING, PARTICIPANTS: We used 2013-2017 Health Care Cost Institute claims for 418,016 privately insured individuals undergoing joint replacement in 75 CJR and 121 Non-CJR markets. Multivariable generalized linear models with hospital and market random effects and time fixed effects were used to analyze the association between CJR participation and changes in outcomes. MAIN OUTCOMES AND MEASURES: Total episode spending, discharge to institutional post-acute care, and quality (e.g., surgical complications, readmissions). RESULTS: Patients in CJR and Non-CJR markets did not differ in total episode spending (difference of -$157, 95% CI -$1043 to $728, p = 0.73) or discharge to institutional post-acute care (difference of -1.1%, 95% CI -3.2%-1.0%, p = 0.31). Similarly, patients in the two groups did not differ in quality or other utilization outcomes. Findings were generally similar in stratified and sensitivity analyses. CONCLUSIONS: There was a lack of evidence of cost or utilization spillovers from CJR to privately insured individuals. There may be limits in the ability of certain value-based payment reforms to drive broad changes in care delivery and patient outcomes.

Integrating E-Prescribing and Pharmacy Claims Data for Predictive Modeling: Comparing Costs and Utilization of Health Plan Members Who Fill Their Initial Medications with Those Who Do Not.

BACKGROUND: Nonfilling of prescribed medications is a worldwide problem of serious concern. Studies of health care costs and utilization associated with medication nonadherence frequently rely on claims data and usually focus on patients with specific conditions. Past studies also have little agreement on whether higher medication costs associated with higher adherence can reduce downstream health care consumption. OBJECTIVES: To (a) compare the characteristics between people with and without complete medication initiations from a general population and (b) quantify the effect of medication initiation on health care utilization and expenditures with propensity score weighting. METHODS: We conducted a retrospective cohort study using 2012 and 2013 electronic health records (EHR) and insurance claims data from an integrated health care delivery network. We included 43,097 eligible primary care patients in the study. Annual medication fill rates of initial prescriptions in 2012 were defined as the number of filled prescriptions from claims divided by the number of e-prescriptions from EHRs, while excluding all refills. A claim was considered filled if (a) EHR and claims records were from the same drug class; (b) claims occurred between the date of a current EHR order and that of the next EHR order of the same class; and (c) the maximum fill rate was 100%. The 6 annual outcomes included total costs, medical costs, pharmacy costs, being a high-cost "outlier" (in top 5%), having 1 or more hospitalizations, and having 1 or more emergency department (ED) visits. Individuals were classified as either having completed all medication initiations (100% annual filling rate for initiations) or not. We used propensity score weighting to control for baseline differences between complete and incomplete initial fillers. We adopted linear and logistic regressions to model costs and binary utilization indicators for the same year (concurrently) and next year (prospectively). RESULTS: Approximately 42% of the study sample had complete medication initiations (100% filling rate), while the remaining 58% had incomplete initiations. Individuals who fully filled initial prescriptions had lower comorbidity burden and consumed fewer health care resources. After applying propensity score weighting and controlling for variables such as the number of prescription orders, patients with complete medication initiations had lower overall and medical costs, concurrently and prospectively (e.g., $751 and $252 less for annual total costs). Complete medication initiation fillers were also less likely to have concurrent health care utilization (OR = 0.78, 95% CI = 0.68-0.90 for hospitalization; OR = 0.77, 95% CI = 0.72-0.82 for ED admissions) but no difference in prospective utilization other than for ED visits (OR = 0.93, 95% CI = 0.87-0.99). CONCLUSIONS: Identifying the subpopulation of patients with incomplete medication initiations (i.e., filling less than 100% of initial prescriptions) is a pragmatic approach for population health management programs to align resources and potentially contain cost and utilization. DISCLOSURES: No outside funding supported this study. This study applied the Adjusted Clinical Group (ACG) case-mix/risk adjustment methodology, developed at Johns Hopkins Bloomberg School of Public Health. Although ACGs are an important aspect of this study, the goal of the study was not to directly assess or evaluate the methodology. The Johns Hopkins University receives royalties for nonacademic use of software based on the ACG methodology. Chang, Kharrazi, and Weiner receive a portion of their salary support from this revenue. Chang is also a part-time consultant for Monument Analytics, a health care consultancy whose clients include the life sciences industry, as well as plaintiffs in opioid litigation. Alexander is past Chair of FDA's Peripheral and Central Nervous System Advisory Committee; has served as a paid advisor to IQVIA; is a co-founding Principal and equity holder in Monument Analytics; and is a member of OptumRx's National P&T Committee. These arrangements have been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. The other authors have nothing to disclose.

The Burden of Cervical Cancer in Korea: A Population-Based Study.

This study used the Korean National Health Insurance (NHI) claims database from 2011 to 2017 to estimate the incidence and the incidence-based cost of cervical cancer and carcinoma in situ of cervix uteri (CIS) in Korea. The primary outcome was the direct medical cost per patient not diagnosed with cervical cancer (C53) or CIS (D06) 2 years prior to the index date in the first year after diagnosis. A regression analysis was conducted to adjust for relevant covariates. The incidence of cervical cancer tended to decrease from 2013 to 2016, while that of CIS increased. In particular, the incidence rate of CIS in women in their 20 s and 30 s increased by 56.8% and 28.4%, respectively, from 2013 to 2016. The incidence-based cost of cervical cancer and CIS was USD 13,058 and USD 2695 in 2016, respectively, which increased from 2013. Multivariate regression analysis suggested that age was the most influential variable of the cost in both patient groups, and the cost was highest in those aged over 60, i.e., the medical cost was significantly lower in younger women than their older counterparts. These findings suggest that targeting younger women in cervical cancer prevention is a reasonable option from both economic and public health perspectives.

Treatment patterns and direct medical costs among patients with advanced hepatocellular carcinoma.

AIMS: This study assessed the real-world United States (US) treatment patterns and the associated economic burden in patients diagnosed with advanced hepatocellular carcinoma (HCC). METHODS: The MarketScan database was used to identify patients newly diagnosed with HCC who received systemic therapy between 2011 and 2018 and continuously enrolled for ≥6 months (baseline period) prior and ≥1 month following HCC diagnosis. Treatment patterns (systemic and locoregional therapy), healthcare resource utilization, and costs were reported during follow-up. RESULTS: The final sample included 1580 patients (median age, 61; 78% male; median follow up, 8.7 months). The most common first line of therapy (LOT) was sorafenib (78%). The median time from HCC diagnosis to start of sorafenib was 43 days, and the median duration of sorafenib therapy was 60 days. Only 17% of patients received second LOT, and non-sorafenib treatment use increased to 66% (mostly chemotherapy combination). Transarterial chemoembolization was the most commonly observed locoregional therapy prior to the first LOT. The multivariable-adjusted average all-cause total cost among sorafenib treated patients was $17,642 (95% CI: $16,711-$18,558) per-patient per-month), of which $11,393 were HCC-specific. CONCLUSIONS: In patients who received first-line therapy for HCC, the duration of therapy was short (potentially due to progression or tolerability). Most patients did not continue to second-line therapy. Despite the short duration of therapy, HCC patients still incur a high economic burden, and there is a need for more effective and tolerable treatments.

Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study.

OBJECTIVE: The objective of this investigation was to compare the value of primary spine care (PSC) with usual care for management of patients with spine-related disorders (SRDs) within a primary care setting. METHODS: We retrospectively examined existing patient encounter data at 3 primary care sites within a multi-clinic health system. Designated clinicians serve in the role as PSC as the initial point of contact for spine patients, coordinate, and follow up for the duration of the episode of care. A PSC may be a chiropractor, physical therapist, or medical or osteopathic physician who has been trained to provide primary care for patients with SRDs. The PSC model of care had been introduced at site I (Lebanon, New Hampshire); sites II (Bedford, New Hampshire) and III (Nashua, New Hampshire) served as control sites where patients received usual care. To evaluate cost outcomes, we employed a controlled quasi-experimental design for analysis of health claims data. For analysis of clinical outcomes, we compared clinical records for PSC at site I and usual care at sites II and III, all with reference to usual care at site I. We examined clinical encounters occurring over a 24-month period, from February 1, 2016 through January 31, 2018. RESULTS: Primary spine care was associated with reduced total expenditures compared with usual care for SRDs. At site I, average per-patient expenditure was $162 in year 1 and $186 in year 2, compared with site II ($332 in year 1; $306 in year 2) and site III ($467 in year 1; $323 in year 2). CONCLUSION: Among patients with SRDs included in this study, implementation of the PSC model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.

The relationship between integrated pediatric psychology and primary care visit length, revenue, content over 24 months.

Introduction: Integrating behavioral health providers into pediatric primary care to provide behavioral health (BH) services is both effective and efficient; however, the impact of pediatric integrated services on the operational and financial outcomes of primary care provider (PCP) visits has not been thoroughly investigated. The present study examined whether length of practice integration predicts the relationship between BH content addressed in a PCP visit, visit length, and revenue generation. Method: A total of 1,209 pediatric encounters with 25 PCPs across 7 primary care offices in a predominantly rural health system were abstracted for the presence or absence of BH content, visit length, duration of integration, and revenue. χ2 analyses and the generalized linear model framework were used to address the study objectives. Results: Integration was associated with more PCP visits with a BH topic discussed at 6-11 months of integration but not at 14-24 months. Visits with a BH topic were longer than medical-only visits and shorter when a practice was integrated for 6-11 months but not at 14-24 months of integration. Public insurance and integration were associated with lower revenue generation per minute. Visit content was not associated with PCP revenue. Discussion: Results suggest a relationship between integration and the operational and financial outcomes of PCP visits. This study shows that initial efficiencies or improvements (e.g., time, cost, content) associated with integrating BH may be lost over time. Future studies should evaluate sustainability in relation to program impact. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System.

BACKGROUND: Medication therapy management (MTM) was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries. Even though the term "MTM" was first used in 2003, pharmacists have provided similar services since the term "pharmaceutical care" was introduced in 1990. Fairview Health Services, a large integrated health care system, implemented a standardized pharmaceutical care service system in 1998, naming it a pharmaceutical care-based MTM practice in 2006. OBJECTIVE: To present the clinical, economic, and humanistic outcomes of 10 years of delivering MTM services to patients in a health care delivery system. METHODS: Data from MTM services provided to 9,068 patients and documented in electronic therapeutic records were retrospectively analyzed over the 10-year period from September 1998 to September 2008 in 1 health system with 48 primary care clinics. Patients eligible for MTM services were aged 21 years or older and either paid for MTM out of pocket or met their health care payer's criteria for MTM reimbursement; the criteria varied for Medicaid, Medicare, and commercially insured enrollees. All MTM was delivered face to face. Health data extracted from the electronic therapeutic record by the present study's investigators included patient demographics, medication list, medical conditions, drug therapy problems identified and addressed, change in clinical status, and pharmacist-estimated cost savings. The clinical status assessment was a comparison of the first and most recent MTM visit to measure whether the patient achieved the goals of therapy for each medical condition (e.g., the blood pressure of a patient with diabetes and hypertension will be less than 130/80 millimeters mercury [mmHg] in 1 month; the patient with allergic rhinitis will be relieved of his complaints of nasal congestion, runny nose, and eye itching within 5 days). Goals were set according to evidence-based literature and patient-specific targets determined cooperatively by pharmacists, patients, and physicians. Cost-savings calculations represented MTM pharmacists' estimates of medical services (e.g., office visits, laboratory services, urgent care visits, emergency room visits) and lost work time avoided by the intervention. All short-term (3-month) estimated health care savings that resulted from addressing drug therapy problems were analyzed. The expenses of these avoided services were calculated using the health system's contracted rates for services provided in the last quarter of 2008. The return on investment (ROI) was calculated by dividing the pharmacist-estimated savings by the cost of MTM services in 2008 (number of MTM encounters times the average cost of an MTM visit). The humanistic impact of MTM services was assessed using the results from the second patient satisfaction survey administered in 2008 (new patients seen from January through December 2008) for the health system's MTM program. RESULTS: A total of 9,068 patient records were in the documentation system as of September 30, 2008. During the 10-year period, there were 33,706 documented encounters (mean 3.7 encounters per patient). Of 38,631 drug therapy problems identified and addressed by MTM pharmacists, the most frequent were a need for additional drug therapy (n = 10,870, 28.1%) and subtherapeutic dosage (n = 10,100, 26.1%). In the clinical status assessment of the 12,851 medical conditions in 4,849 patients who were not at goal when they enrolled in the program, 7,068 conditions (55.0%) improved, 2,956 (23.0%) were unchanged, and 2,827 (22.0%) worsened during the course of MTM services. Pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter) and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 per $1 in MTM administrative costs. In the patient satisfaction survey, 95.3% of respondents agreed or strongly agreed that their overall health and well-being had improved because of MTM. CONCLUSION: Pharmacist estimates of the impact of an MTM program in a large integrated health care system suggest that the program was associated with improved clinical outcomes and cost savings. Patient satisfaction with the program was high. DISCLOSURES: There was no external funding for this manuscript. The 3 authors are employees of Fairview Pharmacy Services. Ramalho de Oliveira had primary responsibility for the concept and design, writing, and revision of the manuscript, with the assistance of Brummel and Miller. Ramalho de Oliveira performed the data collection, and all 3 authors shared equally in data interpretation.

Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge.

Importance: Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity. Objective: To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system. Design, Setting, and Participants: This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020. Exposures: Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed). Main Outcomes and Measures: The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes. Results: In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses. Conclusions and Relevance: In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.