Disparities in the medical expenditures of patients with cancer and concomitant mental disorder: analyzing the effects of diagnosis sequence order.

BACKGROUND: Cancer is the leading cause of death in Taiwan. Medical expenditures related to cancer accounted for 44.8% of all major illness insurance claims in Taiwan. Prior research has indicated that the dual presence of cancer and mental disorder in patients led to increased medical burden. Furthermore, patients with cancer and concomitant mental disorder could incur as much as 50% more annual costs than those without. Although previous studies have investigated the utilization of patients with both diseases, the effects of morbidity sequence order on patient costs are, however, uncertain. This study explored medical expenditures linked with the comorbidity of cancer and mental disorder, with a focus on the impact of diagnosis sequence order. METHODS: This population-based retrospective matched cohort study retrieved patients with cancer and mental disorder (aged ≥ 20 years) from the Ministry of Health and Welfare Data Science Center 2005-2015 database. 321,045 patients were divided based on having one or both diseases, as well as on the sequence of mental disorder and cancer diagnosis. Study subjects were paired with comparison counterparts free of both diseases using Propensity Score Matching at a 1:1 ratio. Annual Cost per Patient Linear Model (with a log-link function and gamma distribution) was used to assess the average annual cost, covarying for socio-demographic and clinical factors. Binomial Logistic Regression was used to evaluate factors associated with the risk of high-utilization. RESULTS: The "Cancer only" group had higher adjusted mean annual costs (NT$126,198), more than 5-times that of the reference group (e^ß: 5.45, p < 0.001). However, after exclusion of patients with non-cancer and inclusion of diagnosis sequence order for patients with cancer and concomitant mental disorder, the post-cancer mental disorder group had the highest expenditures at over 13% higher than those diagnosed with only cancer on per capita basis (e^ß: 1.13, p < 0.001), whereas patients with cancer and any pre-existing mental disorder incurred lower expenditures than those with only cancer. The diagnosis of post-cancer mental disorder was significantly associated with high-utilization (OR = 1.24; 95% CI: 1.047-1.469). Other covariates associated with high-utilizer status included female sex, middle to old age, and late stage cancer. CONCLUSION: Presence of mental disorder prior to cancer had a diminishing effect on medical utilization in patients, possibly indicating low medical compliance or adherence in patients with mental disorder on initial treatments after cancer diagnosis. Patients with post-cancer mental disorder had the highest average annual cost. Similar results were found in the odds of reaching high-utilizer status. The follow-up of cancer treatment for patients with pre-existing mental disorders warrants more emphasis in an attempt to effectively allocate medical resources.

Pregnant theatre staff in orthopaedic operating rooms: An observational study.

PURPOSE: Trauma & Orthopaedic (T&O) surgery presents several occupational hazards to pregnant women and the unborn child. National bodies have produced guidelines to mitigate these risks as far as possible but individual trusts must be aware of them and implement them in their local policies. Our study aims to re-assess whether national guidelines for the protection of pregnant women are better adhered to nationally by providing a comparison to a previous study in 2018. METHODS: A national observational study of 146 NHS trusts in the UK was conducted. Each trust was asked to complete a freedom of information request regarding all orthopaedic guidelines relating to pregnant theatre staff, which specifically related to the protection of the mother and foetus from exposure to harmful activity in theatre. Compliance was ascertained by cross-checking local policies with national guidelines. RESULTS: 82/146 (52.0%) of NHS trusts responded to the Freedom of Information  request. 31/75 (41.3%) respondents followed Health and Safety Executive (HSE) guidance for New and Expectant Mothers with 17/75 (22.7%) following multiple national guidelines. 16/75 (21.3%) NHS trusts do not follow any national guidelines in protecting new and expectant mothers from occupational hazards in the orthopaedic theatre setting. CONCLUSIONS: Although an improvement has been made since 2018 in complying with national guidelines protecting new and expectant mothers from orthopaedic-related hazards, a sizeable proportion of NHS trusts do not comply with any national guidelines, putting employees at undue risk. There is a continued need for pregnant surgeons to be aware of and seek occupational health advice from dedicated professional bodies if the NHS trust does not provide specific guidance. Simultaneously, a sustained effort must be present to continue to inform NHS employers of their duty to protect new and expectant mothers and signpost them to relevant guidance.