The cost of inpatient death associated with acute coronary syndrome.

BACKGROUND: No studies have addressed the cost of inpatient mortality during an acute coronary syndrome (ACS) admission. OBJECTIVE: Compare ACS-related length of stay (LOS), total admission cost, and total admission cost by day of discharge/death for patients who died during an inpatient admission with a matched cohort discharged alive following an ACS-related inpatient stay. METHODS: Medical and pharmacy claims (2009-2012) were used to identify admissions with a primary diagnosis of ACS from patients with at least 6 months of continuous enrollment prior to an ACS admission. Patients who died during their ACS admission (deceased cohort) were matched (one-to-one) to those who survived (survived cohort) on age, sex, year of admission, Chronic Condition Index score, and prior revascularization. Mean LOS, total admission cost, and total admission cost by the day of discharge/death for the deceased cohort were compared with the survived cohort. A generalized linear model with log transformation was used to estimate the differences in the total expected incremental cost of an ACS admission and by the day of discharge/death between cohorts. A negative binomial model was used to estimate differences in the LOS between the two cohorts. Costs were inflated to 2013 dollars. RESULTS: A total of 1,320 ACS claims from patients who died (n=1,320) were identified and matched to 1,319 claims from the survived patients (n=1,319). The majority were men (68%) and mean age was 56.7±6.4 years. The LOS per claim for the deceased cohort was 47% higher (adjusted incidence rate ratio: 1.47, 95% confidence interval: 1.37-1.57) compared with claims from the survived cohort. Compared with the survived cohort, the adjusted mean incremental total cost of ACS admission claims from the deceased cohort was US$43,107±US$3,927 (95% confidence interval: US$35,411-US$50,803) higher. CONCLUSION: Despite decreasing ACS hospitalizations, the economic burden of inpatient death remains high.

Factors predicting development of opioid use disorders among individuals who receive an initial opioid prescription: mathematical modeling using a database of commercially-insured individuals.

BACKGROUND: Prescription drug abuse in the United States and elsewhere in the world is increasing at an alarming rate with non-medical opioid use, in particular, increasing to epidemic proportions over the past two decades. It is imperative to identify individuals most likely to develop opioid abuse or dependence to inform large-scale, targeted prevention efforts. METHODS: The present investigation utilized a large commercial insurance claims database to identify demographic, mental health, physical health, and healthcare service utilization variables that differentiate persons who receive an opioid abuse or dependence diagnosis within two years of filling an opioid prescription (OUDs) from those who do not receive such a diagnosis within the same time frame (non-OUDs). RESULTS: When compared to non-OUDs, OUDs were more likely to: (1) be male (59.9% vs. 44.2% for non-OUDs) and younger (M=37.9 vs. 47.7); (2) have a prescription history of more opioids (1.7 vs. 1.2), and more days supply of opioids (M=272.5, vs. M=33.2; (3) have prescriptions filled at more pharmacies (M=3.3 per year vs. M=1.3); (4) have greater rates of psychiatric disorders; (5) utilize more medical and psychiatric services; and (6) be prescribed more concomitant medications. A predictive model incorporating these findings was 79.5% concordant with actual OUDs in the data set. CONCLUSIONS: Understanding correlates of OUD development can help to predict risk and inform prevention efforts.

Work absences and expenditures for employees with autoimmune inflammatory diseases.

OBJECTIVE: Economic burden was compared for employees with autoimmune inflammatory diseases (AutoIDs) who received anti-tumor necrosis factor (TNF) α agents, those who did not, and those with no AutoID. METHODS: Retrospective claims data analysis (2000-2006). Propensity analysis created two groups: (1) adult AutoID patients with anti-TNFα therapy (AutoID/anti-TNFα) matched to those with no anti-TNFα therapy (AutoID/non-anti-TNFα), and (2) non-AutoID patients (control) matched to all AutoID patients (AutoID). Indirect, direct, and total expenditures after controlling for various covariates were compared using regression analysis. RESULTS: Total direct and total expenditures were, respectively, $13,187 and $13,373 higher for AutoID/anti-TNFα group (n = 689) versus AutoID/non-anti-TNFα group (n = 2699). Indirect expenditures were not statistically different between the groups. AutoID- (n = 12,612) and control-group (n = 48,895) differences showed similar trends. CONCLUSIONS: These results provide useful information to employers about the cost burden associated with AutoIDs.

Burden of illness for an employed population with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) affects approximately 7% of Americans. COPD impacts productivity and forces 1 in 5 employees ages 45-65 years old to retire prematurely. Our objective was to quantify the direct and indirect costs of COPD in an employed population in the United States. A retrospective analysis using Thomson Reuters MarketScan commercial claims and Health and Productivity (HPM) databases (2000-2007) identified employees (ages 18-65 years) with ≥ 1 COPD medical claim, ≥ 6 month insurance eligibility pre and ≥ 12 months post diagnosis, and ≥ 12 months HPM data post diagnosis. COPD subjects were matched to non-COPD subjects using propensity scores to create a comparison group with similar characteristics. Differences in medical and pharmacy utilization and productivity (absence and short-term disability [STD] days) were examined using negative binomial regression, and cost differences using Heckman selection models. A total of 27,612 COPD patients were matched in a 1:1 ratio to 825,884 non-COPD patients; 80% were ages 36-65 years, and 59% were male. COPD employees had about twice the rate of emergency department visits and hospitalizations compared to non-COPD employees (P<0.0001). The rate of absence and STD days was approximately 1.5 times higher (P<0.0001) compared to non-COPD employees. Yearly direct and indirect expenditures were higher ($3609 and $909, respectively; P<0.0001) for COPD versus non-COPD employees. Excess utilization and associated costs of COPD to employers was quantified. By understanding these costs, employers may evaluate disease management programs and treatment to improve outcomes for employees with COPD. Improved treatment options may reduce the direct and indirect costs of COPD.

An evaluation of the impact of patient cost sharing for antihypertensive medications on adherence, medication and health care utilization, and expenditures.

OBJECTIVE: To assess the impact of patient cost-sharing for antihypertensive medications on the proportion of days covered (PDC) by antihypertensive medications, medical utilization, and health care expenditures among commercially insured individuals assigned to different risk categories. METHODS: Participants were identified from the Consolidated Health Cost Guidelines (CHCG) database (January 1, 2006-December 31, 2008) based on a diagnosis (index) claim for hypertension, continuous enrollment ≥12 months pre- and post-index, and no prior claims for antihypertensive medications. Participants were assigned to: low-risk group (no comorbidities), high-risk group (1+ selected comorbidities), or very high-risk group (prior hospitalization for 1+ selected comorbidities). The relationship between patient cost sharing and PDC by antihypertensive medications was assessed using standard linear regression models, controlling for risk group membership, and various demographic and clinical factors. The relationship between PDC and health care service utilization was subsequently examined using negative binomial regression models. RESULTS: Of the 28,688 study patients, 66% were low risk. The multivariate regression model supported a relationship between patient cost sharing per 30-day fill and PDC in the following year. For every US$1.00 increase in cost sharing, PDC decreased by 1.1 days (P < 0.0001). Significant predictors of PDC included high risk, older age, gender, Charlson Comorbidity Index score, geography, and total post-index insurer- and patient-paid costs. An increase in PDC was associated with a decrease in all-cause and hypertension-related inpatient, outpatient, and emergency room visits and medical, pharmacy, and total costs. CONCLUSIONS: The trend has been for managed care organizations and employers to require patients to bear a greater out-of-pocket burden for health care resources consumed. This study illustrates the potential adverse effects of higher patient cost sharing among patients with hypertension stratified by different risk levels. A decrease in PDC was predictive of higher resource utilization and health care costs, which should be of interest to payers and employers alike.

The $17.1 billion problem: the annual cost of measurable medical errors.

At a minimum, high-quality health care is care that does not harm patients, particularly through medical errors. The first step in reducing the large number of harmful medical errors that occur today is to analyze them. We used an actuarial approach to measure the frequency and costs of measurable US medical errors, identified through medical claims data. This method focuses on the analysis of comparative rates of illness, using mathematical models to assess the risk of occurrence and to project costs to the total population. We estimate that the annual cost of measurable medical errors that harm patients was $17.1 billion in 2008. Pressure ulcers were the most common measurable medical error, followed by postoperative infections and by postlaminectomy syndrome, a condition characterized by persistent pain following back surgery. A total of ten types of errors account for more than two-thirds of the total cost of errors, and these errors should be the first targets of prevention efforts.

Adverse drug reactions in hospital and ambulatory care settings identified using a large administrative database.

BACKGROUND: Previous studies are limited in sample size and number of sites for the detection and characterization of adverse drug reactions (ADRs) in ambulatory care and hospital settings. OBJECTIVE: To determine the prevalence and distribution of suspected ADRs according to demographic characteristics and drug classes for ambulatory care and hospitalized patients. METHODS: A cross-sectional evaluation of administrative data from 2002-2005, containing a maximum of 20 million Medicare and commercially insured patients in a year, was completed. Individuals with one or more claims suggesting an ADR were identified, using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) criteria referred to as a "suspected ADR." Frequency of ICD-9-CM codes consistent with suspected ADRs for the 4 years was calculated for hospital and ambulatory care settings, based on age ranges, comorbidities, and drug classes. RESULTS: Between 2002 and 2005, the average annual prevalence of suspected ADRs was 0.5%, with a total of 249,633 suspected ADRs during the 4 years. The mean age of hospitalized patients experiencing a suspected ADR was 12 years older than that of ambulatory care patients and 20 years older than that of the general database population. Diseases of the circulatory and endocrine/nutritional/metabolic systems rank among the top 5 comorbid conditions in hospitalized patients who had a suspected ADR. Injury and poisoning was the primary comorbidity in ambulatory patients. High-risk medications frequently associated with suspected ADRs in both settings were antineoplastic and anticoagulant agents. Other drug classes commonly associated with suspected ADRs in hospitalized patients were antihypertensives and diuretics. For the ambulatory care setting, drug classes frequently associated with suspected ADRs were antirheumatic and antiarteriosclerotic agents. CONCLUSIONS: ADR detection, using administrative data, revealed differences in age, comorbidities, and drug classifications between ambulatory care and hospital settings. The results can be used to develop focused prevention strategies and targeted surveillance for individuals most at risk for developing ADRs.

Categorization of infliximab dose changes and healthcare utilization and expenditures for patients with rheumatoid arthritis in commercially insured and Medicare-eligible populations.

OBJECTIVE: To evaluate how changes in infliximab dose influence resource utilization and expenditures for patients with rheumatoid arthritis (RA). RESEARCH DESIGN AND METHODS: A retrospective analysis using claims from January 1, 1999 through March 31, 2005 in the MedStat MarketScan databases for RA patients who had an increase, decrease, or no change in infliximab dose within 1 year of initiating therapy. Eligibility criteria included at least one claim with a diagnosis of RA and no biologic treatment within 6 months before the index infliximab claim, continuous health plan enrollment (commercial or Medicare) for 6 months before and 12 months after the index date, and three consecutive infliximab infusions. The index and final infliximab doses were estimated from claims data. RESULTS: Data were included for 1678 commercially insured patients and 616 Medicare-eligible patients; 45.4% and 39.3%, respectively, had an increase in dose, 24.7% and 43.2%, respectively, had a decrease in dose, and 29.9% and 17.5%, respectively, had no change in dose. Overall, resource utilization was higher in the increase-in-dose groups and lower in the no change-in-dose groups when compared with the decrease-in-dose groups for both cohorts. Medical costs were also highest for the increase-in-dose groups for both cohorts. Pharmacy expenditures for the no-change-in-dose groups were lower than the decrease-in-dose groups in both cohorts. CONCLUSIONS: An increase in dose was the most common dose change for the commercial cohort, while a decrease in dose was the most common dose change for the Medicare-eligible cohort. Patients with an increase in dose had the highest utilization and expenditures while those with no change in dose had the lowest levels. The nature of this utilization needs to be examined to better understand how dosing changes may influence medical utilization. Changes in dose were defined by the difference between the first and final doses and may not have captured changes in interim doses.

Cost effectiveness of community-based physical activity interventions.

BACKGROUND: Physical inactivity is associated with the increased risk of many chronic diseases. Such risks decrease with increases in physical activity. This study assessed the cost-effectiveness of population-wide strategies to promote physical activity in adults and followed disease incidence over a lifetime. METHODS: A lifetime cost-effectiveness analysis from a societal perspective was conducted to estimate the costs, health gains, and cost-effectiveness (dollars per quality-adjusted life year [QALY] gained, relative to no intervention) of seven public health interventions to promote physical activity in a simulated cohort of healthy U.S. adults stratified by age, gender, and physical activity level. Interventions exemplifying each of four strategies strongly recommended by the Task Force on Community Preventive Services were evaluated: community-wide campaigns, individually adapted health behavior change, community social-support interventions, and the creation of or enhanced access to physical activity information and opportunities. Each intervention was compared to a no-intervention alternative. A systematic review of disease burden by physical activity status was used to assess the relative risk of five diseases (coronary heart disease, ischemic stroke, type 2 diabetes, breast cancer, and colorectal cancer) across a spectrum of physical activity levels. Other data were obtained from clinical trials, population-based surveys, and other published literature. RESULTS: Cost-effectiveness ratios ranged between $14,000 and $69,000 per QALY gained, relative to no intervention. Results were sensitive to intervention-related costs and effect size. CONCLUSIONS: All of the evaluated physical activity interventions appeared to reduce disease incidence, to be cost-effective, and--compared with other well-accepted preventive strategies--to offer good value for money. The results support using any of the seven evaluated interventions as part of public health efforts to promote physical activity.