Implications of Payment for Acute Myocardial Infarctions as a 90-Day Bundled Single Episode of Care: A Cost of Illness Analysis.

OBJECTIVES: Evaluate the cost of illness associated with the 90-day period following acute myocardial infarction (AMI) and the implication of care pathway (percutaneous coronary intervention [PCI] vs medical management [MM]), in order to assess the potential financial risk incurred by providers for AMI as an episode of care. PERSPECTIVE: Reimbursement payment systems for acute care episodes are shifting from 30-day to 90-day bundled payment models. Since follow-up care and readmissions beyond the early days/weeks post-AMI are common, financial risk may be transferred to providers. SETTING: AMI hospitalization Centers for Medicare & Medicaid Services (CMS) standard analytical files between 10/1/2015 and 9/30/2016 were reviewed. METHODS: Included patients were Medicare beneficiaries with a primary diagnosis of AMI subsequently treated with either PCI or MM. Payments were standardized to remove geographic variation and separated into reimbursements for services during the hospitalization and from discharge to 90 days post-discharge. Results were stratified by Medicare Severity Diagnosis Related Groups (MS-DRGs) individually and grouped between patients treated with MM and PCI. Risk-adjusted likelihood of utilization of post-acute nursing care and all-cause readmission was assessed by logistic regression. RESULTS: A total of 96,546 patients were included in the analysis. The highest total mean payment (US$32,714) was for MS-DRG 248 (PCI with non-drug-eluting stent with major complication or comorbidity). Total payments were similar between MM and PCI patients, but MM patients incurred the majority of costs in the post-acute period after discharge, with the converse true for PCI patients. MM without catheterization was associated with a twofold increase in risk of requiring post-acute nursing care and 90-day readmission versus PCI (odds ratio [95% confidence interval]: 2.01 [1.92-2.11] and 2.17 [2.08-2.27]). Smaller hospital size, diabetes, peripheral arterial disease, prior AMI, and multivessel disease were predictors of higher healthcare utilization. CONCLUSIONS: MS-DRGs associated with the lowest reimbursements (and presumably, lowest costs of inpatient care) incur the highest post-discharge expenditures. As the CMS Bundled Payment for Care Improvement and similar programs are implemented, there will be a need to account for heterogeneous post-discharge care costs. Video abstract (MP4 274659 KB).

Around 805,000 heart attacks occur annually in the US. With an average age over 65 years, many heart attack patients qualify for Medicare health insurance. Under Medicare, hospitals (or 'providers') receive reimbursements for the cost of care associated with 'acute care episodes' (e.g., heart attacks) as a 'bundled' payment. The bundled reimbursements are typically based on pre-defined prices, with hospitals paying the difference if actual costs exceed these. Reimbursements are typically given for care costs from the initial heart attack through to hospital discharge and care in the 30-day post-discharge period. However, recently introduced reimbursement models such as BPCI Advanced have moved to expand this to 90 days. Since follow-up care and additional cardiovascular readmissions are common beyond 30 days, extension of the reimbursement period to 90 days could increase financial risk to hospitals/providers if these additional costs are not included in reimbursements. To assess the potential impact of this, we investigated the cost of illness for heart attack and the implication of type of care: medical management (standard medication given after heart attack) vs. percutaneous coronary intervention (PCI; standard medication plus a non-surgical procedure to widen heart blood vessels). We found that 90-day costs after heart attack are substantial regardless of type of care. We found that post-discharge costs were generally high, but higher for medically managed patients than those receiving PCI. Our analysis also suggests Medicare disease classifications associated with lowest payments for heart attack (and presumably, lowest hospitalization costs) are associated with the highest post-discharge expenditures. Overall, our study suggests that new payment models should account for variable post-discharge care costs, and new therapies are needed to reduce additional events, readmissions, and associated costs in heart attack patients.

A review of the use and effectiveness of digital health technologies in patients with asthma.

OBJECTIVE: A new generation of digital health technologies (DHT) offers the opportunity to improve adherence and asthma control. Recent literature was reviewed to summarize the use of technological aids and evaluate their impact on health outcomes in patients with asthma. DATA SOURCES: PubMed and Embase were searched to identify articles published over the past 5 years (2013 to 2017). STUDY SELECTIONS: All records were judged for eligibility by 2 independent reviewers; 28 articles met the inclusion criteria. RESULTS: Interactive websites were the most frequently evaluated type of DHT (50% of all studies), followed by mobile apps in adult patient cohorts. Relatively few studies assessed electronic monitoring devices, phone calls, or text messaging. Among the 16 studies that focused on children, most interventions that used interactive websites (n = 8) showed at least some benefit, although results varied based on the specific outcome. Twelve studies focused on adults, with interventions using interactive websites (n = 6) reporting results that were generally less consistent compared with the pediatric studies. The 6 studies that assessed mobile apps with adult patients reported consistent benefits across a range of outcomes, including medication adherence and asthma control. CONCLUSION: Most interventions reported at least some benefit, although results varied based on the specific outcome. Overall, technology that included more interactive features, such as website-based daily diary entries and apps that provided real-time feedback, was associated with increased asthma control, as was the case for multidimensional interventions that combined the use of several complementary types of DHT.

Meta-analysis and indirect treatment comparison of lipegfilgrastim with pegfilgrastim and filgrastim for the reduction of chemotherapy-induced neutropenia-related events.

Background Granulocyte colony-stimulating factors are effective at reducing the risk and duration of neutropenia. The current meta-analysis compared the neutropenia-related efficacy and safety of lipegfilgrastim to those of pegfilgrastim and filgrastim. Methods Embase was searched for trials examining the efficacy/safety of lipegfilgrastim, pegfilgrastim, or filgrastim. Outcomes included febrile neutropenia, severe neutropenia, duration of severe neutropenia, time to recovery of absolute neutrophil count, and incidence of bone pain. Direct comparisons were made using random-effects models. No trials directly compared lipegfilgrastim and filgrastim. Indirect comparisons were made between lipegfilgrastim and filgrastim with pegfilgrastim as the common comparator. Results This meta-analysis included a total of 5769 patients from 24 studies. Over all cycles, lipegfilgrastim showed a lower, nonsignificant risk of febrile neutropenia compared with pegfilgrastim. Lipegfilgrastim has a lower risk of febrile neutropenia versus filgrastim but was also not statistically significant. The risk ratio for severe neutropenia in cycle 1 was 0.80, a 20% reduction in favor of lipegfilgrastim. For cycles 2-4, the risk ratio was 0.53 (0.35, 0.79) for lipegfilgrastim versus pegfilgrastim. The risk of severe neutropenia in cycles 2-4 was also significantly lower for lipegfilgrastim (risk ratio 0.45, 0.27, 0.75, respectively). No significant differences were found for febrile neutropenia and severe neutropenia in cycle 1. However, in cycles 2-4, lipegfilgrastim was associated with significant and clinically meaningful reductions in risk of severe neutropenia versus either pegfilgrastim or filgrastim. Conclusions Compared with pegfilgrastim or filgrastim, lipegfilgrastim has a statistically significantly lower absolute neutrophil count recovery time; however, differences in duration of severe neutropenia and bone pain were nonsignificant.

Clinical features of adolescents with chronic idiopathic or spontaneous urticaria: Review of omalizumab clinical trials.

BACKGROUND: Adults and adolescents were included in 3 phase 3 omalizumab trials in chronic idiopathic urticaria (CIU): ASTERIA I, ASTERIA II, and GLACIAL. OBJECTIVE: To describe the baseline clinical profile of adolescent patients with CIU enrolled in the omalizumab trials to add to the limited literature available on CIU in this population. METHODS: Data for patient demographics, baseline clinical disease characteristics, medical history, and previous CIU medication information (not efficacy assessments) from phase 3 omalizumab trials were pooled and descriptive statistical analyses performed for adolescent (12 to <18 years old) and adult (≥18 years old) subgroups. Inferential analysis was inappropriate, partly because of small sample size in the adolescent subgroup. RESULTS: The pooled population of 975 patients with CIU included 39 adolescents (4.0%). Demographics of adolescents and adults with CIU were similar, but compared with adults, fewer adolescents had positive Chronic Urticaria Index test results. Baseline clinical disease characteristics were also similar between the subgroups, with the number of previous CIU medications slightly lower in adolescents compared with adults. Medical history and existing conditions in adolescents tended to be more allergy than cardiovascular related, and fewer experienced angioedema compared with adults. CONCLUSION: Pooled data indicate differences in baseline demographic and clinical characteristics between adult and adolescent patient subgroups. This finding helps augment our understanding of the clinical profile of CIU in adolescents, but larger-scale studies in this population are warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifiers: NCT01287117 (ASTERIA I), NCT01292473 (ASTERIA II), and NCT01264939 (GLACIAL).

Patient-reported impact of chronic urticaria compared with psoriasis in theUnited States.

PURPOSE: Data are lacking on the burden of chronic idiopathic urticaria (CIU) versus other dermatologic conditions. This analysis compared the burden of chronic urticaria (CU, proxy for CIU) with psoriasis. METHODS: Data from CU (N = 747) and psoriasis patients (N = 5107) came from 2010 to 2012 US National Health and Wellness Surveys. Outcomes included SF-12v2/SF-36v2 mental and physical component summary scores (MCS and PCS, respectively) and other health/activity-related measures. RESULTS: MCS score was 44.7 for CU, and 48.2, 44.7 and 44.3 for mild/moderate/severe psoriasis, respectively (US norm = 50). PCS score was 43.8 for CU, and 46.5, 44.1 and 40.3 for mild/moderate/severe psoriasis. Health utility score was 0.67 for CU, and 0.72, 0.67 and 0.65 for mild/moderate/severe psoriasis. More CU patients reported depression (39%), anxiety (42%) and sleep difficulties (50%) than psoriasis patients (any severity). Overall work impairment was 29% for CU, and 19%, 26% and 31% for mild/moderate/severe psoriasis. Activities impairment was 39% for CU, and 28%, 37% and 43% for mild/moderate/severe psoriasis. CU and psoriasis patients had frequent healthcare visits. CONCLUSIONS: Patients with CU had impaired mental/physical health and work/non-work activities, similar to moderate-to-severe psoriasis patients. Results suggest that better disease management of CU is needed. This analysis should also reflect the significant burden of CIU.

Improving Quality of Acute Asthma Care in US Hospitals: Changes Between 1999-2000 and 2012-2013.

BACKGROUND: Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS). METHODS: This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS. RESULTS: The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs 800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 (P < .001). However, during 2012-2013, wide variability in guideline concordance of acute asthma care remained across hospitals, with the greatest variation in provision of individualized written action plan at discharge (SD, 36). Guideline concordance was significantly lower in Midwestern and Southern hospitals compared with Northeastern hospitals. After adjusting for severity, patients who received care perfectly concordant with the guidelines had significantly shorter hospital LOS (-14% [95% CI, -23 to -4]; P = .009). CONCLUSIONS: Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.

Association of Guideline-concordant Acute Asthma Care in the Emergency Department With Shorter Hospital Length of Stay: A Multicenter Observational Study.

OBJECTIVES: The objectives were to determine whether guideline-concordant emergency department (ED) management of acute asthma is associated with a shorter hospital length of stay (LOS) among patients hospitalized for asthma. METHODS: A multicenter chart review study of patients aged 2-54 years who were hospitalized for acute asthma at one of the 25 U.S. hospitals during 2012-2013. Based on level A recommendations from national asthma guidelines, we derived four process measures of ED treatment before hospitalization: inhaled ß-agonists, inhaled anticholinergic agents, systemic corticosteroids, and lack of methylxanthines. The outcome measure was hospital LOS. RESULTS: Among 854 ED patients subsequently hospitalized for acute asthma, 532 patients (62%) received care perfectly concordant with the four process measures in the ED. Overall, the median hospital LOS was 2 days (interquartile range = 1-3 days). In the multivariable negative binomial model, patients who received perfectly concordant ED asthma care had a significantly shorter hospital LOS (-17%, 95% confidence interval [CI] = -27% to -5%, p = 0.006), compared to other patients. In the mediation analysis, the direct effect of guideline-concordant ED asthma care on hospital LOS was similar to that of primary analysis (-16%, 95% CI = -27% to -5%, p = 0.005). By contrast, the indirect effect mediated by quality of inpatient asthma care was not significant, indicating that the effect of ED asthma care on hospital LOS was mediated through pathways other than quality of inpatient care. CONCLUSION: In this multicenter observational study, patients who received perfectly concordant asthma care in the ED had a shorter hospital LOS. Our findings encourage further adoption of guideline-recommended emergency asthma care to improve patient outcomes.

Effect of chronic urticaria on US patients: analysis of the National Health and Wellness Survey.

BACKGROUND: Chronic idiopathic (also called spontaneous) urticaria (CIU/CSU) is the most common form of chronic urticaria and has been associated with impairment to health outcomes, although the effect has never been assessed using a nationally representative sample in the United States. OBJECTIVES: To assess the burden of CIU/CSU from the patients' perspective in terms of health related quality of life, impairment to work and nonwork activities, and health care resource use. METHODS: Data were obtained from the US National Health and Wellness Survey. Current use of a prescription for the treatment of chronic hives was used as a proxy for CIU/CSU. Patients with CIU/CSU in the proxy group were matched 1:4 to respondents without chronic hives using survey year, sex, age, and race. Generalized linear models were adjusted for comorbidities, smoking, body mass index, and health insurance status. Outcome measures included the Medical Outcomes Study 12-Item and 36-Item Short Form Health Surveys; self-reported depression, anxiety, and sleep difficulties; the Work Productivity and Activity Impairment questionnaire, and health care resource use. RESULTS: After matching and adjustment for covariates, those currently using a prescription for chronic hives had mental component summary scores 5.7 points lower, physical component summary scores 6.5 points lower, and health utility scores 0.11 points lower than controls, as well as higher adjusted odds of reporting depression, anxiety, and sleep difficulties. Mean adjusted work impairment was approximately double in prescription-treated chronic hives relative to controls, as was frequency of health care visits. CONCLUSION: Chronic hives substantially affects quality of life, nonwork activities, capacity to work, and health care use, providing further evidence of a high burden of CIU/CSU across multiple health outcomes and unmet need for effective treatment.

Underuse of guideline-recommended long-term asthma management in children hospitalized to the intensive care unit: a multicenter observational study.

BACKGROUND: Despite the significant burden of childhood asthma, little is known about prevention-oriented management before and after hospitalizations for asthma exacerbation. OBJECTIVE: To investigate the proportion and characteristics of children admitted to the intensive care unit (ICU) for asthma exacerbation and the frequency of guideline-recommended outpatient management before and after the hospitalization. METHODS: A 14-center medical record review study of children aged 2 to 17 years hospitalized for asthma exacerbation during 2012-2013. Primary outcome was admission to the ICU; secondary outcomes were 2 preventive factors: inhaled corticosteroid (ICS) use and evaluation by asthma specialists in the pre- and posthospitalization periods. RESULTS: Among 385 children hospitalized for asthma, 130 (34%) were admitted to the ICU. Risk factors for ICU admission were female sex, having public insurance, a marker of chronic asthma severity (ICS use), and no prior evaluation by an asthma specialist. Among children with ICU admission, guideline-recommended outpatient management was suboptimal (eg, 65% were taking ICSs at the time of index hospitalization, and 19% had evidence of a prior evaluation by specialist). At hospital discharge, among children with ICU admission who had not previously used controller medications, 85% were prescribed ICSs. Furthermore, 62% of all children with ICU admission were referred to an asthma specialist during the 3-month posthospitalization period. CONCLUSION: In this multicenter study of US children hospitalized with asthma exacerbation, one-third of children were admitted to the ICU. In this high-risk group, we observed suboptimal pre- and posthospitalization asthma care. These findings underscore the importance of continued efforts to improve prevention-oriented asthma care at all clinical encounters.

Children and Adults With Frequent Hospitalizations for Asthma Exacerbation, 2012-2013: A Multicenter Observational Study.

BACKGROUND: Earlier studies reported that many patients were frequently hospitalized for asthma exacerbation. However, there have been no recent multicenter studies to characterize this patient population with high morbidity and health care utilization. OBJECTIVE: To examine the proportion and characteristics of children and adults with frequent hospitalizations for asthma exacerbation. METHODS: A multicenter chart review study of patients aged 2 to 54 years who were hospitalized for asthma exacerbation at 1 of 25 hospitals across 18 US states during the period 2012 to 2013 was carried out. The primary outcome was frequency of hospitalizations for asthma exacerbation in the past year (including the index hospitalization). RESULTS: The cohort included 369 children (aged 2-17 years) and 555 adults (aged 18-54 years) hospitalized for asthma exacerbation. Over the 12-month period, 36% of the children and 42% of the adults had 2 or more (frequent) hospitalizations for asthma exacerbation. Among patients with frequent hospitalizations, guideline-recommended outpatient management was suboptimal. For example, among adults, 32% were not on inhaled corticosteroids at the time of index hospitalization and 75% had no evidence of a previous evaluation by an asthma specialist. At hospital discharge, among adults with frequent hospitalizations who had used no controller medications previously, 37% were not prescribed inhaled corticosteroids. Likewise, during a 3-month postdischarge period, 64% of the adults with frequent hospitalizations were not referred to an asthma specialist. Although the proportion of patients who did not receive these guideline-recommended outpatient care appeared higher in adults, these preventive measures were still underutilized in children; for example, 38% of the children with frequent hospitalizations were not referred to asthma specialist after the index hospitalization. CONCLUSIONS: This multicenter study of US patients hospitalized with asthma exacerbation demonstrated a disturbingly high proportion of patients with frequent hospitalizations and ongoing evidence of suboptimal longitudinal asthma care.

Health economics and outcomes research fellowship practices reviewed.

The guidelines for health economics and outcomes research (HEOR) fellowship training programs devised by the American College of Clinical Pharmacy (ACCP) and the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) suggest that continuous improvements are made to ensure that postgraduate training through didactic and professional experiences prepare fellows for HEOR research careers. The HEOR Fellowship Program at Novartis Pharmaceuticals Corporation was standardized to enhance the fellows' HEOR research understanding and align professional skill sets with the ACCP-ISPOR Fellowship Program Guidelines. Based on feedback from an internal task force comprised of HEOR employees and current and former fellows, the HEOR Fellowship Program was normatively and qualitatively assessed to evaluate the current curricular program. Fellowship program activities were instituted to ensure that the suggested minimum level requirements established by the guidelines were being met. Research opportunities enabling fellows to work hand-in-hand with other fellows and HEOR professionals were emphasized. Curricular enhancements in research methodology and professional training and development, and materials for a structured journal club focusing on specific methodological and HEOR research topics were developed. A seminar series (e.g., creating SMART Goals, StrengthsFinder 2.0) and professional courses (e.g., ISPOR short courses, statistics.com) were included to enhance the fellows' short- and long-term professional experience. Additional program attributes include an online reference library developed to enrich the current research facilities and a Statistical Analysis Software training program. Continuously assessing and updating HEOR fellowship programs keeps programs up-to-date in the latest HEOR concepts and approaches used to evaluate health care, both professionally and educationally.

Costs and health care resource utilization among chronic obstructive pulmonary disease patients with newly acquired pneumonia.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for lung infections and other pathologies (eg, pneumonia); however, few studies have evaluated the impact of pneumonia on health care resource utilization and costs in this population. The purpose of this study was to estimate health care resource utilization and costs among COPD patients with newly acquired pneumonia compared to those without pneumonia. METHODS: A retrospective claims analysis using Truven MarketScan(®) Commercial and Medicare databases was conducted. COPD patients with and without newly acquired pneumonia diagnosed between January 1, 2004 and September 30, 2011 were identified. Propensity score matching was used to create a 1:1 matched cohort. Patient demographics, comorbidities (measured by Charlson Comorbidity Index), and medication use were evaluated before and after matching. Health care resource utilization (ie, hospitalizations, emergency room [ER] and outpatient visits), and associated health care costs were assessed during the 12-month follow-up. Logistic regression was conducted to evaluate the risk of hospitalization and ER visits, and gamma regression models and two-part models compared health care costs between groups after matching. RESULTS: In the baseline cohort (N=467,578), patients with newly acquired pneumonia were older (mean age: 70 versus [vs] 63 years) and had higher Charlson Comorbidity Index scores (3.3 vs 2.6) than patients without pneumonia. After propensity score matching, the pneumonia cohort was nine times more likely to have a hospitalization (odds ratio; 95% confidence intervals [CI] =9.2; 8.9, 9.4) and four times more likely to have an ER visit (odds ratio; 95% CI =4.4; 4.3, 4.5) over the 12-month follow-up period compared to the control cohort. The estimated 12-month mean hospitalization costs ($14,353 [95% CI: $14,037-$14,690]), outpatient costs ($6,891 [95% CI: $6,706-$7,070]), and prescription drug costs ($1,104 [95% CI: $1,054-$1,142]) were higher in the pneumonia cohort than in the control cohort. CONCLUSION: This study demonstrated elevated health care resource use and costs in patients with COPD after acquiring pneumonia compared to those without pneumonia.

Group-based trajectory modeling to assess adherence to biologics among patients with psoriasis.

BACKGROUND: Proportion of days covered (PDC), a commonly used adherence metric, does not provide information about the longitudinal course of adherence to treatment over time. Group-based trajectory model (GBTM) is an alternative method that overcomes this limitation. METHODS: The statistical principles of GBTM and PDC were applied to assess adherence during a 12-month follow-up in psoriasis patients starting treatment with a biologic. The optimal GBTM model was determined on the basis of the balance between each model's Bayesian information criterion and the percentage of patients in the smallest group in each model. Variables potentially predictive of adherence were evaluated. RESULTS: In all, 3,249 patients were included in the analysis. Four GBTM adherence groups were suggested by the optimal model, and patients were categorized as demonstrating continuously high adherence, high-then-low adherence, moderate-then-low adherence, or consistently moderate adherence during follow-up. For comparison, four PDC groups were constructed: PDC Group 4 (PDC ≥75%), PDC Group 3 (25%≤ PDC <50%), PDC Group 2 (PDC <25%), and PDC Group 1 (50%≤ PDC <75%). Our findings suggest that the majority of patients (97.9%) from PDC Group 2 demonstrated moderate-then-low adherence, whereas 96.4% of patients from PDC Group 4 showed continuously high adherence. The remaining PDC-based categorizations did not capture patients with uniform adherence behavior based on GBTM. In PDC Group 3, 25.3%, 17.2%, and 57.5% of patients exhibited GBTM-defined consistently moderate adherence, moderate-then-low adherence, or high-then-low adherence, respectively. In PDC Group 1, 70.8%, 23.6%, and 5.7% of patients had consistently moderate adherence, high-then-low adherence, and continuously high adherence, respectively. Additional analyses suggested GBTM-based categorization was best predicted by patient age, sex, certain comorbidities, and particular drug use. CONCLUSION: GBTM is a more appropriate way to model dynamic behaviors and offers researchers an alternative to more traditional drug adherence measurements.

Health care utilization and costs among patients with AD with and without dysphagia.

OBJECTIVE: To assess health care utilization and associated costs among patients with Alzheimer disease (AD), with and without dysphagia. METHODS: MarketScan Commercial and Medicare databases were analyzed. Patients with a diagnosis of AD with and without dysphagia between October 2006 and September 2010 were included. Acetylcholinesterase inhibitor usage, the number of outpatient and emergency room (ER) visits and hospitalizations, and associated health care costs were assessed. All variables were measured 1 year after the initial diagnosis of AD at the patient level. Patients with dysphagia were matched to patients without dysphagia using propensity score-matching (PSM) methods. Regression models were conducted to compare utilization and costs between the 2 groups. RESULTS: A total of 485 patients with dysphagia and 8492 patients without dysphagia were included. Before matching, patients with dysphagia were older (81.1 vs. 79.8 y), and had higher Charlson Comorbidity Index scores (2.4 vs. 1.7). After matching, all baseline covariates were not statistically different between the 2 groups. Multivariate regression results showed that patients with dysphagia had a higher likelihood of all-cause hospitalizations [odds ratio (OR)=2.26, 95% confidence interval (CI)=1.70-2.99, P=0.001] and all-cause ER visits (OR=1.45, 95% CI=1.12-1.87, P=0.007) compared with patients without dysphagia; they also had a higher likelihood for AD-related hospitalizations and ER visits. The difference in all-cause total health care, ER, and hospitalization costs between patients with and without dysphagia were $3620 (95% CI=$2863-$4375), $258 (95% CI=$241-$274), and $3547 (95% CI=$3325-$3770), respectively. CONCLUSIONS: This study suggests that patients with AD and dysphagia have higher health care utilization and costs compared with patients without dysphagia.

Direct and indirect costs of sleep disturbances and residual symptoms in patients treated for depression: analysis of a nationwide cross sectional survey.

OBJECTIVE: To assess the relationship between inadequate response to depression treatment and sleep disturbances, work productivity loss, and resource utilization. METHODS: Adults reporting antidepressant use for more than 90 days (n = 6116) in the 2009 US National Health and Wellness Survey were categorized as non-, partial-, or complete responders to depression treatment. Multivariable analyses, adjusting for patient characteristics and comorbidities, examined the association of treatment response with sleep disturbances (including possible mediation), productivity, and resource use. RESULTS: Partial- and nonresponders, versus complete responders, experienced greater sleep disturbance, productivity loss, and resource use. Mediation results were consistent with the possibility that sleep disturbances predicted inadequate treatment response, which led to greater resource use. CONCLUSIONS: Sleep disturbances are prevalent in depression and associated with increased resource use. Appropriate management, including antidepressants that alleviate sleep disturbances, may improve functional and economic outcomes.

A patient perspective of the impact of medication side effects on adherence: results of a cross-sectional nationwide survey of patients with schizophrenia.

BACKGROUND: Antipsychotic medications often have a variety of side effects, however, it is not well understood how the presence of specific side effects correlate with adherence in a real-world setting. The aim of the current study was to examine the relationship between these variables among community-dwelling patients with schizophrenia. METHODS: Data were analyzed from a 2007-2008 nationwide survey of adults who self-reported a diagnosis of schizophrenia and were currently using an antipsychotic medication (N = 876). The presence of side effects was defined as those in which the patient reported they were at least "somewhat bothered". Adherence was defined as a score of zero on the Morisky Medication Adherence Scale. To assess the relationship between side effects and adherence, individual logistic regression models were fitted for each side effect controlling for patient characteristics. A single logistic regression model assessed the relationship between side effect clusters and adherence. The relationships between adherence and health resource use were also examined. RESULTS: A majority of patients reported experiencing at least one side effect due to their medication (86.19%). Only 42.5% reported complete adherence. Most side effects were associated with a significantly reduced likelihood of adherence. When grouped as side effect clusters in a single model, extra pyramidal symptoms (EPS)/agitation (odds ratio (OR) = 0.57, p = 0.0007), sedation/cognition (OR = 0.70, p = 0.033), prolactin/endocrine (OR = 0.69, p = 0.0342), and metabolic side effects (OR = 0.64, p = 0.0079) were all significantly related with lower rates of adherence. Those who reported complete adherence to their medication were significantly less likely to report a hospitalization for a mental health reason (OR = 0.51, p = 0.0006), a hospitalization for a non-mental health reason (OR = 0.43, p = 0.0002), and an emergency room (ER) visit for a mental health reason (OR = 0.60, p = 0.008). CONCLUSIONS: Among patients with schizophrenia, medication side effects are highly prevalent and significantly associated with medication nonadherence. Nonadherence is significantly associated with increased healthcare resource use. Prevention, identification, and effective management of medication-induced side effects are important to maximize adherence and reduce health resource use in schizophrenia.

Resource utilization and costs associated with insomnia treatment in patients with major depressive disorder.

OBJECTIVE: To estimate resource utilization and costs associated with insomnia treatment among newly treated patients with major depressive disorder (MDD). METHOD: Data from the MarketScan(®) Research Databases (Commercial Claims and Encounters, Medicare Supplemental and Coordination of Benefits, and Health and Productivity Management) were analyzed. Patients aged ≥ 18 years with a first prescription claim for an antidepressant between January 1, 2006, and December 31, 2007 (index date), were included in the analysis if they had ≥ 1 MDD diagnosis (ICD-9-CM criteria) in the 12 months prior to the claim and 24 months of continuous insurance coverage. Patients were categorized into 2 groups on the basis of the presence or absence of insomnia medication during the 12 months following the index date. Multivariate analyses were conducted to compare all-cause and MDD-related hospitalization and emergency room (ER) visits and costs in the year following the index date between patients with and without insomnia medication. Covariates for adjustment included age, gender, region, health plan type, baseline comorbidities, and health care utilization. RESULTS: The total sample size was 87,461 newly treated MDD patients with a mean (SD) age of 43.5 (15.1) years; 67% were women. Among newly treated patients, 10,339 (11.8%) took insomnia medication. Patients taking insomnia medication were significantly more likely to be hospitalized (OR = 1.84, 95% CI = 1.73-1.96 for all cause; OR = 1.50, 95% CI = 1.43-1.57 for MDD related; P < .0001) and to have ER visits (OR = 4.25, 95% CI = 3.65-4.95 for all cause; OR = 2.51, 95% CI = 2.24-2.81 for MDD related; P < .0001) than the patients not taking insomnia medication. Adjusted all-cause health care costs were $3,918 (95% CI = $3,599-$4,290) higher and MDD-related health care costs were $537 (95% CI = $492-$586) higher in the insomnia medication cohort compared with controls in the 12-months following the index date. Patients taking insomnia medication had $1,162 more indirect costs for short-term disability compared to the control group (95% CI = $746-$1,684). CONCLUSIONS: The use of insomnia medications in newly treated patients with MDD appears to be associated with increased health care resource utilization and higher total and depression-related direct and indirect medical costs.

The cost of seasonal respiratory illnesses in Australian children: the dominance of patient and family costs and implications for vaccine use.

Respiratory viral infections are one of the next group of diseases likely to be targeted for prevention in childhood by the use of vaccines. To begin collecting necessary epidemiology and cost information about the illnesses caused by these viruses, we conducted a prospective cohort study in 118 Melbourne children between 12 and 71 months of age during winter and spring 2001. We were interested in calculating an average cost per episode of community-managed acute respiratory disease, in identifying the key cost drivers of such illness, and to identify the proportion of costs borne by the patient and family. There were 202 community-managed influenza-like illnesses identified between July and December 2001, generating 89 general practitioner visits, and 42 antibiotic prescriptions. The average cost of community-managed episodes (without hospitalisation) was dollar 241 (95% CI dollar 191 to dollar 291), with the key cost drivers being carer time away from usual activities caring for the ill child (70% of costs), use of non-prescription medications (5.4%), and general practice visits (5.0%). The patient and family met 87 per cent of total costs. The lowest average cost occurred in households from the highest income bracket. Acute respiratory illness managed in the community is common, with the responsibility for meeting the cost of episodes predominantly borne by the patient and family in the form of lost productivity. These findings have implications for preventive strategies in children, such as the individual use of, or implementation of public programs using, currently available vaccines against influenza and vaccines under development against other viral respiratory pathogens.