A Satellite Account for Health in the United States.

This paper develops a satellite account for the US health sector and measures productivity growth in health care for the elderly population between 1999 and 2012. We measure the change in medical spending and health outcomes for a comprehensive set of 80 conditions. Medical care has positive productivity growth over the time period, with aggregate productivity growth of 1.5% per year. However, there is significant heterogeneity in productivity growth. Care for cardiovascular disease has had very high productivity growth. In contrast, care for people with musculoskeletal conditions has been costly but has not led to improved outcomes.

Attributing medical spending to conditions: A comparison of methods.

To understand the cost burden of medical care it is essential to partition medical spending into conditions. Two broad strategies have been used to measure disease-specific spending. The first attributes each medical claim to the condition that physicians list as its cause. The second decomposes total spending for a person over a year to their cumulative set of health conditions. Traditionally, this has been done through regression analysis. This paper has two contributions. First, we develop a new cost attribution method to attribute spending to conditions using a more flexible attribution approach, based on propensity score analysis. Second, we compare the propensity score approach to the claims-based approach and the regression approach in a common set of beneficiaries age 65 and older in the 2009 Medicare Current Beneficiary Survey. Our estimates show that the three methods have important differences in spending allocation and that the propensity score model likely offers the best theoretical and empirical combination.

Explaining The Slowdown In Medical Spending Growth Among The Elderly, 1999-2012.

We examined trends in per capita spending for Medicare beneficiaries ages sixty-five and older in the United States in the period 1999-2012 to determine why spending growth has been declining since around 2005. Decomposing spending by condition, we found that half of the spending slowdown was attributable to slower growth in spending for cardiovascular diseases. Spending growth also slowed for dementia, renal and genitourinary diseases, and aftercare for people with acute illnesses. Using estimates from the medical literature of the impact of pharmaceuticals on acute disease, we found that roughly half of the reduction in major cardiovascular events was attributable to medications controlling cardiovascular risk factors. Despite this substantial cost-saving improvement in cardiovascular health, additional opportunities remain to lower spending through disease prevention and control.

Comparison of trends in US health-related quality of life over the 2000s using the SF-6D, HALex, EQ-5D, and EQ-5D visual analog scale versus a broader set of symptoms and impairments.

BACKGROUND: A number of instruments have been developed to measure health-related quality of life (HRQoL), differing in the health domains covered and their scoring. Although few such measures have been consistently included in US national health surveys over time, the surveys have included data on a broad range of symptoms and impairments, which enables the tracking of population health trends. OBJECTIVES: To compare trends in HRQoL as measured using existing instruments versus using a broader range of symptoms and impairments collected in multiple years of nationally representative data. DATA AND MEASURES: Data were from the 2000-2010 Medical Expenditure Panel Survey, which is nationally representative of the noninstitutionalized US population. Level of and trends in HRQoL derived from a broad range of survey symptoms and impairments (SSI) was compared with HRQoL from the SF-6D, the HALex, and, between 2000 and 2003, the EuroQol-5D (EQ-5D) and EQ-5D Visual Analog Scale. RESULTS: Trends in HRQoL were similar using different measures. The SSI scores correlated 0.66-0.80 with scores from other measures and mean SSI scores were between those of other measures. Scores from all HRQoL measures declined similarly with increasing age and with the presence of comorbid conditions. CONCLUSIONS: Measuring HRQoL using a broader range of symptoms and impairments than those in a single instrument yields population health trends similar to those from other measures while making maximum use of existing data and providing rich detail on the factors underlying change.

US trends in quality-adjusted life expectancy from 1987 to 2008: combining national surveys to more broadly track the health of the nation.

OBJECTIVES: We used data from multiple national health surveys to systematically track the health of the US adult population. METHODS: We estimated trends in quality-adjusted life expectancy (QALE) from 1987 to 2008 by using national mortality data combined with data on symptoms and impairments from the National Medical Expenditure Survey (1987), National Health Interview Survey (1987, 1994-1995, 1996), Medical Expenditure Panel Survey (1992, 1996, 2000-2008), National Nursing Home Survey (1985, 1995, and 1999), and Medicare Current Beneficiary Survey (1992, 1994-2008). We decomposed QALE into changes in life expectancy, impairments, symptoms, and smoking and body mass index. RESULTS: Years of QALE increased overall and for all demographic groups-men, women, Whites, and Blacks-despite being slowed by increases in obesity and a rising prevalence of some symptoms and impairments. Overall QALE gains were large: 2.4 years at age 25 years and 1.7 years at age 65 years. CONCLUSIONS: Understanding and consistently tracking the drivers of QALE change is central to informed policymaking. Harmonizing data from multiple national surveys is an important step in building this infrastructure.

Active surveillance compared with initial treatment for men with low-risk prostate cancer: a decision analysis.

CONTEXT: In the United States, 192,000 men were diagnosed as having prostate cancer in 2009, the majority with low-risk, clinically localized disease. Treatment of these cancers is associated with substantial morbidity. Active surveillance is an alternative to initial treatment, but long-term outcomes and effect on quality of life have not been well characterized. OBJECTIVE: To examine the quality-of-life benefits and risks of active surveillance compared with initial treatment for men with low-risk, clinically localized prostate cancer. DESIGN AND SETTING: Decision analysis using a simulation model was performed: men were treated at diagnosis with brachytherapy, intensity-modulated radiation therapy (IMRT), or radical prostatectomy or followed up by active surveillance (a strategy of close monitoring of newly diagnosed patients with serial prostate-specific antigen measurements, digital rectal examinations, and biopsies, with treatment at disease progression or patient choice). Probabilities and utilities were derived from previous studies and literature review. In the base case, the relative risk of prostate cancer-specific death for initial treatment vs active surveillance was assumed to be 0.83. Men incurred short- and long-term adverse effects of treatment. PATIENTS: Hypothetical cohorts of 65-year-old men newly diagnosed as having clinically localized, low-risk prostate cancer (prostate-specific antigen level <10 ng/mL, stage ≤T2a disease, and Gleason score ≤6). MAIN OUTCOME MEASURE: Quality-adjusted life expectancy (QALE). RESULTS: Active surveillance was associated with the greatest QALE (11.07 quality-adjusted life-years [QALYs]), followed by brachytherapy (10.57 QALYs), IMRT (10.51 QALYs), and radical prostatectomy (10.23 QALYs). Active surveillance remained associated with the highest QALE even if the relative risk of prostate cancer-specific death for initial treatment vs active surveillance was as low as 0.6. However, the QALE gains and the optimal strategy were highly dependent on individual preferences for living under active surveillance and for having been treated. CONCLUSIONS: Under a wide range of assumptions, for a 65-year-old man, active surveillance is a reasonable approach to low-risk prostate cancer based on QALE compared with initial treatment. However, individual preferences play a central role in the decision whether to treat or to pursue active surveillance.

Forecasting the effects of obesity and smoking on U.S. life expectancy.

BACKGROUND: Although increases in obesity over the past 30 years have adversely affected the health of the U.S. population, there have been concomitant improvements in health because of reductions in smoking. Having a better understanding of the joint effects of these trends on longevity and quality of life will facilitate more efficient targeting of health care resources. METHODS: For each year from 2005 through 2020, we forecasted life expectancy and quality-adjusted life expectancy for a representative 18-year-old, assuming a continuation of past trends in smoking (based on data from the National Health Interview Survey for 1978 through 1979, 1990 through 1991, 1999 through 2001, and 2004 through 2006) and past trends in body-mass index (BMI) (based on data from the National Health and Nutrition Examination Survey for 1971 through 1975, 1988 through 1994, 1999 through 2002, and 2003 through 2006). The 2003 Medical Expenditure Panel Survey was used to examine the effects of smoking and BMI on health-related quality of life. RESULTS: The negative effects of increasing BMI overwhelmed the positive effects of declines in smoking in multiple scenarios. In the base case, increases in the remaining life expectancy of a typical 18-year-old are held back by 0.71 years or 0.91 quality-adjusted years between 2005 and 2020. If all U.S. adults became nonsmokers of normal weight by 2020, we forecast that the life expectancy of an 18-year-old would increase by 3.76 life-years or 5.16 quality-adjusted years. CONCLUSIONS: If past obesity trends continue unchecked, the negative effects on the health of the U.S. population will increasingly outweigh the positive effects gained from declining smoking rates. Failure to address continued increases in obesity could result in an erosion of the pattern of steady gains in health observed since early in the 20th century.

The impact of symptoms and impairments on overall health in US national health data.

OBJECTIVE: To assess the effects on overall self-rated health of the broad range of symptoms and impairments that are routinely asked about in national surveys. DATA: We use data from adults in the nationally representative Medical Expenditure Panel Survey (MEPS) 2002 with validation in an independent sample from MEPS 2000. METHODS: Regression analysis is used to relate impairments and symptoms to a 100-point self-rating of general health status. The effect of each impairment and symptom on health-related quality of life (HRQOL) is estimated from regression coefficients, accounting for interactions between them. RESULTS: Impairments and symptoms most strongly associated with overall health include pain, self-care limitations, and having little or no energy. The most prevalent are moderate pain, severe anxiety, moderate depressive symptoms, and low energy. Effects are stable across different waves of MEPS, and questions cover a broader range of impairments and symptoms than existing health measurement instruments. CONCLUSIONS: This method makes use of the rich detail on impairments and symptoms in existing national data, quantifying their independent effects on overall health. Given the ongoing availability of these data and the shortcomings of traditional utility methods, it would be valuable to compare existing HRQOL measures to other methods, such as the one presented herein, for use in tracking population health over time.

The value of medical interventions for lung cancer in the elderly: results from SEER-CMHSF.

BACKGROUND: Lung cancer is the leading source of cancer mortality and spending. However, the value of spending on the treatment of lung cancer has not been conclusively demonstrated. The authors evaluated the value of medical care between 1983 and 1997 for nonsmall cell lung cancer in the elderly US population. METHODS: The authors used Surveillance, Epidemiology, and End Results (SEER) data to calculate life expectancy after diagnosis over the period 1983 to 1997. Direct costs for nonsmall cell lung cancer detection and treatment were determined by using Part A and Part B reimbursements from the Continuous Medicare History Sample File (CMHSF) data. The CMHSF and SEER data were linked to calculate lifetime treatment costs over the time period of interest. RESULTS: Life expectancy improved minimally, with an average increase of approximately 0.60 months. Total lifetime lung cancer spending rose by approximately $20,157 per patient in real, ie, adjusted for inflation, 2000 dollars from the early 1980s to the mid-1990s, for a cost-effectiveness ratio of $403,142 per life year (LY). The cost-effectiveness ratio was $143,614 for localized cancer, $145,861 for regional cancer, and $1,190,322 for metastatic cancer. CONCLUSIONS: The cost-effectiveness ratio for nonsmall cell lung cancer was higher than traditional thresholds used to define cost-effective care. The most favorable results were for persons diagnosed with early stage cancer. These results suggested caution when encouraging more intensive care for lung cancer patients without first considering the tradeoffs with the costs of this therapy and its potential effects on mortality and/or quality of life.

Utilities for prostate cancer health states in men aged 60 and older.

PURPOSE: We sought to measure utilities for prostate cancer health states in older men. METHODS: A total of 162 men aged 60 years or older (52% of whom had been diagnosed with prostate cancer) provided standard gamble utilities for 19 health states associated with prostate cancer or its treatment using an interactive, computer-based utility assessment program. Demographics and experience with specific health states were examined as predictors of ratings using ordinary least squares regression analysis. RESULTS: Mean utilities ranged from 0.67 to 0.84 for living with symptom-free cancer under conservative management ("watchful waiting") and from 0.71 to 0.89 for symptoms occurring with treatment (prostatectomy, radiation, and hormone ablation). For long-term treatment complications, bowel problems (0.71) were rated as significantly worse than impotence (0.89), urinary difficulty (0.88), or urinary incontinence (0.83). Combinations of these conditions were rated as significantly worse than individual component states. Men who had experienced impotence or urinary incontinence rated these states as slightly better than men who had not experienced the specific problems. CONCLUSIONS: Both "watchful waiting" and treatment complications from prostate cancer treatments can have large impacts on quality of life. Mean ratings are important for use in policy-making and cost-effectiveness analyses. Variation in ratings across patients suggests that mean scores do not reflect individual preferences and that shared decision-making may be best for clinical decisions.

Do out-of-pocket health expenditures rise with age among older Americans?

PURPOSE: Relationships are examined between age and out-of-pocket costs for different health goods and services among the older population. DESIGN AND METHODS: Age patterns in health service use and out-of-pocket costs are examined by use of the 1990 Elderly Health Supplement to the Panel Study of Income Dynamics (N = 1,031, age 66+). Multivariate regression is used to examine how age effects are mediated by health, insurance, and socioeconomic variables. RESULTS: Although long-term care expenditures increased with age, out-of-pocket costs for most other services did not. Total out-of-pocket costs increased with age only when nursing home costs were included. Increases with age in hospital and prescription costs were explained by declining health. Patterns of service use suggested reduced access to discretionary care among the oldest old. IMPLICATIONS: Although expenditures did not increase with age for most services, the high personal cost for nursing home care among the oldest old underlines the need for increased efforts to support them in the community. Greater spending by those in poor health highlights the importance of preventing age-related health conditions and their complications. Improved access to discretionary care among the oldest old may help to reduce the need for care in higher cost settings. The high prevalence of out-of-pocket prescription spending across the age range provides impetus for current efforts to reduce these costs.

Treatment options for localized prostate cancer: quality-adjusted life years and the effects of lead-time.

OBJECTIVES: The purposes of this study were to estimate the difference in quality-adjusted life-years between conservative management and prostatectomy or radiotherapy (RT) by clinical Gleason score (2 to 4, 5 to 6, 7, and 8 to 10) for patients aged 55 years and older with clinically localized prostate cancer and to adjust for and explore the effects of lead-time. For localized prostate cancer, it is not known whether treatment (prostatectomy or RT) results in longer quality-adjusted survival than conservative management. Observed survival benefits after treatment may be biased by the lead-time resulting from early diagnosis with prostate-specific antigen screening. METHODS: A Markov simulation was developed, and transition probabilities were derived from a review of published studies. Utility weights were measured in male volunteers older than 60 years. Estimates of disease progression during conservative management were adjusted for lead-time. Sensitivity analyses were performed on all parameters (including estimates for lead-time). RESULTS: For Gleason score 2 to 4 cancer, conservative management yielded the greatest number of quality-adjusted life-years. For Gleason score 5 to 6 cancer, any of the options appeared beneficial, depending on the estimates for disease progression. For Gleason score 7 to 10 cancer, prostatectomy and RT resulted in more quality-adjusted life-years than conservative management; with a lead-time adjustment of greater than 10 years, the outcomes with conservative management and prostatectomy were similar. The choice between prostatectomy and RT was sensitive to estimates of disease progression after treatment. CONCLUSIONS: Conservative management is a reasonable option for Gleason score 2 to 4 cancer and for some patients with Gleason score 5 to 6 cancer. Prostatectomy or RT is recommended for Gleason score 7 to 10 cancer. The survival benefits after treatment were not explained by the lead-time alone.