Halogenated aliphatic and phenolic disinfection byproducts in chlorinated and chloraminated dairy wastewater: Occurrence and ecological risk evaluation.

The increasing demand for dairy products has led to the production of a large amount of wastewater in dairy plants, and disinfection is an essential treatment process before wastewater discharge. Disinfection byproducts (DBPs) in disinfected dairy wastewater may negatively influence the aquatic organisms in receiving water. During chlorine and chloramine disinfection of dairy wastewater, the concentrations of aliphatic DBPs increased from below the detection limits to 485.1 µg/L and 26.6 µg/L, respectively. Brominated and iodinated phenolic DBPs produced during chlor(am)ination could further react with chlorine/chloramine to be transformed. High level of bromide in dairy wastewater (12.9 mg/L) could be oxidized to active bromine species by chlorine/chloramine, promoting the formation of highly toxic brominated DBPs (Br-DBPs), and they accounted for 80.3% and 71.1% of the total content of DBPs in chlorinated and chloraminated dairy wastewater, respectively. Moreover, Br-DBPs contributed 49.9-75.9% and 34.2-96.4% to the cumulative risk quotient of DBPs in chlorinated and chloraminated wastewater, respectively. The cumulative risk quotient of DBPs on green algae, daphnid, and fish in chlorinated wastewater was 2.8-11.4 times higher than that in chloraminated wastewater. Shortening disinfection time or adopting chloramine disinfection can reduce the ecological risks of DBPs.

High efficiency removal of organic and inorganic iodine with ferrate[Fe(VI)] through oxidation and adsorption.

I- is a halogen species existing in natural waters, and the transformation of organic and inorganic iodine in natural and artificial processes would impact the quality of drinking water. Herein, it was found that Fe(VI) could oxidize organic and inorganic iodine to IO3-and simultaneously remove the resulted IO3- through Fe(III) particles. For the river water, wastewater treatment plant (WWTP) effluent, and shale gas wastewater treated by 5 mg/L of Fe(VI) (as Fe), around 63 %, 55 % and 71 % of total iodine (total-I) had been removed within 10 min, respectively. Fe(VI) was superior to coagulants in removing organic and inorganic iodine from the source water. Adsorption kinetic analysis suggested that the equilibrium adsorption amount of I- and IO3- were 11 and 10.1 µg/mg, respectively, and the maximum adsorption capacity of IO3- by Fe(VI) resulted Fe(III) particles was as high as 514.7 µg/mg. The heterogeneous transformation of Fe(VI) into Fe(III) effectively improved the interaction probability of IO3- with iron species. Density functional theory (DFT) calculation suggested that the IO3- was mainly adsorbed in the cavity (between the γ-FeOOH shell and γ-Fe2O3 core) of Fe(III) particles through electrostatic adsorption, van der Waals force and hydrogen bond. Fe(VI) treatment is effective for inhibiting the formation of iodinated disinfection by-products in chlor(am)inated source water.

Highly Efficient Utilization of Ferrate(VI) Oxidation Capacity Initiated by Mn(II) for Contaminant Oxidation: Role of Manganese Species.

Manganese ion [Mn(II)] is a background constituent existing in natural waters. Herein, it was found that only 59% of bisphenol A (BPA), 47% of bisphenol F (BPF), 65% of acetaminophen (AAP), and 49% of 4-tert-butylphenol (4-tBP) were oxidized by 20 µM of Fe(VI), while 97% of BPA, 95% of BPF, 96% of AAP, and 94% of 4-tBP could be oxidized by the Fe(VI)/Mn(II) system [20 µM Fe(VI)/20 µM Mn(II)] at pH 7.0. Further investigations showed that bisphenol S (BPS) was highly reactive with reactive iron species (RFeS) but was sluggish with reactive manganese species (RMnS). By using BPS and methyl phenyl sulfoxide (PMSO) as the probe compounds, it was found that reactive iron species contributed primarily for BPA oxidation at low Mn(II)/Fe(VI) molar ratios (below 0.1), while reactive manganese species [Mn(VII)/Mn(III)] contributed increasingly for BPA oxidation with the elevation of the Mn(II)/Fe(VI) molar ratio (from 0.1 to 3.0). In the interaction of Mn(II) and Fe(VI), the transfer of oxidation capacity from Fe(VI) to Mn(III), including the formation of Mn(VII) and the inhibition of Fe(VI) self-decay, improved the amount of electron equivalents per Fe(VI) for BPA oxidation. UV-vis spectra and dominant transformation product analysis further revealed the evolution of iron and manganese species at different Mn(II)/Fe(VI) molar ratios.

A Literature Review of Productivity Loss Associated with Hypertension in the United States.

A literature review of peer-reviewed articles published 2000-2019 was conducted to determine the types and extent of hypertension-associated productivity loss among adults in the United States. All monetary outcomes were standardized to 2019 $ by using the Employment Cost Index. Twenty-seven articles met the inclusion criteria. Nearly half of the articles (12 articles) presented monetary outcomes of productivity loss. Absenteeism (14 articles) and presenteeism (8 articles) were most frequently assessed. Annual absenteeism was estimated to cost more than $11 billion, nationally controlling for sociodemographic characteristics. The annual additional costs per person were estimated at $63 for short-term disability, $72-$330 for absenteeism, and $53-$156 for presenteeism, controlling for participant characteristics; and may be as high as $2362 for absenteeism and presenteeism when considered in combination. The annual additional time loss per person was estimated as 1.3 days for absenteeism, controlling for common hypertension comorbidities, including stroke and diabetes; and 15.6 days for work and home productivity loss combined, controlling for sociodemographic characteristics. The loss from absenteeism alone might be more than 20% of the total medical expenditure of hypertension. Although the differences in estimation methods and study populations make it challenging to synthesize the costs across the studies, this review provides detailed information on the various types of productivity loss. In addition, the ways in which methods could be standardized for future research are discussed. Accounting for the costs from productivity loss can help public health officials, health insurers, employers, and researchers better understand the economic burden of hypertension.

Medicaid Medical Costs Associated with Hypertension by Diabetes Status among Women in Alabama.

Though a high proportion of Medicaid population in Alabama are women, little is known about their economic burdens of diabetes and hypertension. We used Alabama Medicaid claims data of 16,107 female enrollees aged 19-64 years to estimate per-capita total annual medical costs of hypertension by diabetes status. Hypertension prevalence was 60.0% and 17.3% among those with and without diabetes. The estimated annual medical cost for enrollees with hypertension was $6,689 (in 2017 $), of which $2,369 was associated with having hypertension. The hypertension-associated excess costs were $2,646 and $2,378 for enrollees with and without diabetes. All subgroups such as Blacks and those with Charlson Comorbidity Index ≥ 1, had higher medical costs when they had a combination of hypertension and diabetes compared with having diabetes without hypertension. Hypertension and diabetes increased medical costs substantially, and the findings can inform decision makers about effective resource utilizations for prevention and treatment strategies.

Medical expenditures for hypertensive disorders during pregnancy that resulted in a live birth among privately insured women.

OBJECTIVE: To estimate the excess maternal health services utilization and direct maternal medical expenditures associated with hypertensive disorders during pregnancy and one year postpartum among women with private insurance in the United States. STUDY DESIGN: We used 2008-2014 IBM MarketScan® Commercial Databases to identify women aged 15-44 who had a pregnancy resulting in live birth during 1/1/09-12/31/13 and were continuously enrolled with non-capitated or partially capitated coverage from 12 months before pregnancy through 12 months after delivery. Hypertensive disorders identified by diagnosis codes were categorized into three mutually exclusive types: preeclampsia and eclampsia, chronic hypertension, and gestational hypertension. Multivariate negative binomial and generalized linear models were used to estimate service utilization and expenditures, respectively. MAIN OUTCOME MEASURES: Per person excess health services utilization and medical expenditures during pregnancy and one year postpartum associated with hypertensive disorders (in 2014 US dollars). RESULTS: Women with preeclampsia and eclampsia, chronic hypertension, and gestational hypertension had $9,389, $6,041, and $2,237 higher mean medical expenditures compared to women without hypertensive disorders ($20,252), respectively (ps < 0.001). One-third (36%) of excess expenditure associated with hypertensive disorders during pregnancy was attributable to outpatient services. CONCLUSIONS: Hypertensive disorders during pregnancy were associated with significantly higher health services utilization and medical expenditures among privately insured women with hypertensive disorders. Medical expenditures varied by types of hypertensive disorders. Stakeholders can use this information to assess the potential economic benefits of interventions that prevent these conditions or their complications.

Weekend Effect on in-Hospital Mortality for Ischemic and Hemorrhagic Stroke in US Rural and Urban Hospitals.

INTRODUCTION: Previous studies have reported a "weekend effect" on stroke mortality, whereby stroke patients admitted during weekends have a higher risk of in-hospital death than those admitted during weekdays. AIMS: We aimed to investigate whether patients with different types of stroke admitted during weekends have a higher risk of in-hospital mortality in rural and urban hospitals in the US. METHODS: We used data from the 2016 National Inpatient Sample and used logistic regression to assess in-hospital mortality for weekday and weekend admissions among stroke patients aged 18 and older by stroke type (ischemic or hemorrhagic) and rural or urban status. RESULTS: Crude stroke mortality was higher in weekend admissions (p <0.001). After adjusting for confounding variables, in-hospital mortality among hemorrhagic stroke patients was significantly greater (22.0%) for weekend admissions compared to weekday admissions (20.2%, p = 0.009). Among rural hospitals, the in-hospital mortality among hemorrhagic stroke patients was also greater among weekend admissions (36.9%) compared to weekday admissions (25.7%, p = 0.040). Among urban hospitals, the mortality of hemorrhagic stroke patients was 21.1% for weekend and 19.6% for weekday admissions (p = 0.026). No weekend effect was found among ischemic stroke patients admitted to rural or urban hospitals. CONCLUSIONS: Our results help to understand mortality differences in hemorrhagic stroke for weekend vs. weekday admissions in urban and rural hospitals. Factors such as density of care providers, stroke centers, and patient level risky behaviors associated with the weekend effect on hemorrhagic stroke mortality need further investigation to improve stroke care services and reduce weekend effect on hemorrhagic stroke mortality.

Association Between Cost-Related Medication Nonadherence and Hypertension Management Among US Adults.

BACKGROUND: Medication nonadherence is an important element of uncontrolled hypertension. Financial factors frequently contribute to nonadherence. The objective of this study was to examine the association between cost-related medication nonadherence (CRMN) and self-reported antihypertensive medication use and self-reported normal blood pressure among US adults with self-reported hypertension. METHODS: Participants with self-reported hypertension from the 2017 National Health Interview Survey were included (n = 7,498). CRMN was defined using standard questions. Hypertension management included: (i) self-reported current antihypertensive medication use and (ii) self-reported normal blood pressure within the past 12 months. Adjusted prevalence and prevalence ratios of hypertension management indicators among those with and without CRMN were estimated. RESULTS: Overall, 10.7% reported CRMN, 83.6% reported current antihypertensive medication use, and 67.4% reported normal blood pressure within past 12 months. Adjusted percentages of current antihypertensive medication use (88.6% vs. 82.9%, P < 0.001) and self-reported normal blood pressure (69.8% vs. 59.5%, P = 0.002) were higher among those without CRMN compared with those with CRMN. Adjusted prevalence ratios showed that, compared with those with CRMN, those without CRMN were more likely to report current antihypertensive medication use (odds ratio = 1.08, 95% confidence interval 1.04-1.12) and self-reported normal blood pressure (1.15 (1.07-1.23)). CONCLUSIONS: Among US adults with self-reported hypertension, those without CRMN were more likely to report current antihypertensive medication use and normal blood pressure within the past 12 months. Financial barriers to medication adherence persist and impact hypertension management.

The uses and expenses of antihypertensive medications among hypertensive adults.

BACKGROUND: The literature lacks information about the use and cost of prescribed antihypertensive medications, especially by the type and class of medication prescribed. OBJECTIVE: This study investigated the uses and expenses of antihypertensive medications among hypertensive adults in the United States. METHODS: Using the 2014-2015 Medical Expenditure Panel Survey data, adult men and nonpregnant women aged 18 or older who had a diagnosis code of hypertension and used any prescribed antihypertensive medication were included in the study (n = 10,971). Adults with hypertension who were using a single antihypertensive medication were defined as single medication users, and those using two or more medications were defined as multiple medication users. Medications were classified into angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), thiazide-type diuretics (TDs), ß-blockers (BBs), and others. The average annual total antihypertensive medication expenses and the expenditures of each medication class were estimated by using generalized linear models with a log link and gamma distribution and were adjusted to 2015 US dollars. RESULTS: Among 10,971 hypertensive adults, 4759 (44.1%) were single medication users, and 6212 (55.9%) were multiple medication users. The average annual total cost for antihypertensive medications was $336 per person (95% confidence interval [CI] = $319-$353); $199 (95% CI = $177-$221) for single medication users and $436 (95% CI = $413-$459) for multiple medication users. The average annual costs for each medication class were estimated at $438 (95% CI = $384-$492) for ARBs and $49 for TDs (95% CI = $44-$55). CONCLUSIONS: Users of multiple medications incurred more than twice the expense than single medication users. When comparing classes of medications, the cost for ARBs was the highest, whereas the cost for TDs was the lowest. This information can be used in evaluating the cost-effectiveness of antihypertension therapies.

Association Between Medicaid Coverage and Income Status on Health Care Use and Costs Among Hypertensive Adults After Enactment of the Affordable Care Act.

BACKGROUND: Hypertension is highly prevalent among the low-income population in the United States. This study assessed the association between Medicaid coverage and health care service use and costs among hypertensive adults following the enactment of the Patient Protection and Affordable Care Act (ACA), by income status level. METHODS: A nationally representative sample of 2,866 nonpregnant hypertensive individuals aged 18-64 years with income up to 138% of the federal poverty level (FPL) were selected from the 2014 and 2015 Medical Expenditure Panel Survey. Regression analyses were performed to examine the association of Medicaid coverage with outpatient (outpatient visits and prescription medication fills), emergency, and acute health care service use and costs among those potentially eligible for Medicaid by income status-the very low-income (FPL ≤ 100%) and the moderately low-income (100% > FPL ≤ 138%). RESULTS: Among the study population, 70.1% were very low-income and 29.9% were moderately low-income. Full-year Medicaid coverage was higher among the very low-income group (41.0%) compared with those moderately low-income (29.1%). For both income groups, having full-year Medicaid coverage was associated with increased health care service use and higher overall annual medical costs ($13,085 compared with $7,582 without Medicaid); costs were highest among moderately low-income patients ($17,639). CONCLUSION: Low-income individuals with hypertension, who were potentially newly eligible for Medicaid under the ACA may benefit from expanded Medicaid coverage by improving their access to outpatient services that can support chronic disease management. However, to realize decreases in medical expenditures, efforts to decrease their use of emergency and acute care services are likely needed.

Understanding cost data collection tools to improve economic evaluations of health interventions.

Micro-costing data collection tools often used in literature include standardized comprehensive templates, targeted questionnaires, activity logs, on-site administrative databases, and direct observation. These tools are not mutually exclusive and are often used in combination. Each tool has unique merits and limitations, and some may be more applicable than others under different circumstances. Proper application of micro-costing tools can produce quality cost estimates and enhance the usefulness of economic evaluations to inform resource allocation decisions. A common method to derive both fixed and variable costs of an intervention involves collecting data from the bottom up for each resource consumed (micro-costing). We scanned economic evaluation literature published in 2008-2018 and identified micro-costing data collection tools used. We categorized the identified tools and discuss their practical applications in an example study of health interventions, including their potential strengths and weaknesses. Sound economic evaluations of health interventions provide valuable information for justifying resource allocation decisions, planning for implementation, and enhancing the sustainability of the interventions. However, the quality of intervention cost estimates is seldom addressed in the literature. Reliable cost data forms the foundation of economic evaluations, and without reliable estimates, evaluation results, such as cost-effectiveness measures, could be misleading. In this project, we identified data collection tools often used to obtain reliable data for estimating costs of interventions that prevent and manage chronic conditions and considered practical applications to promote their use.

Expansion Of Telestroke Services Improves Quality Of Care Provided In Super Rural Areas.

Telestroke is a telemedicine intervention that facilitates communication between stroke centers and lower-resourced facilities to optimize acute stroke management. Using administrative claims data, we assessed trends in telestroke use among fee-for-service Medicare beneficiaries with acute ischemic stroke and the association between providing telestroke services and intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy use, mortality, and medical expenditures, by urban versus rural county of residence in the period 2008-15. The proportion of ischemic stroke cases receiving telestroke increased from 0.4 to 3.8 per 1,000 cases, with usage highest among younger, male, non-Hispanic white, and patients in rural or super rural areas (super rural is the bottom quartile of rural areas. Compared with patients receiving usual care, those receiving telestroke had greater IV tPA and mechanical thrombectomy use regardless of county type, while those in super rural counties had lower thirty-day all-cause mortality. Despite increased telestroke use, rural patients remained less likely than urban patients to receive IV tPA. The findings suggest that telestroke service expansion efforts have increased, especially in rural and super rural counties, and have improved outcomes.

A Systematic Review of Economic Evidence on Community Hypertension Interventions.

CONTEXT: Effective community-based interventions are available to control hypertension. It is important to determine the economics of these interventions. EVIDENCE ACQUISITION: Peer-reviewed studies from January 1995 through December 2015 were screened. Interventions were categorized into educational interventions, self-monitoring interventions, and screening interventions. Incremental cost-effectiveness ratios were summarized by types of interventions. The review was conducted in 2016. EVIDENCE SYNTHESIS: Thirty-four articles were included in the review (16 from the U.S., 18 from other countries), including 25 on educational interventions, three on self-monitoring interventions, and six on screening interventions. In the U.S., five (31.3%) studies on educational interventions were cost saving. Among the studies that found the interventions cost effective, the median incremental costs were $62 (range, $40-$114) for 1-mmHg reduction in systolic blood pressure (SBP) and $13,986 (range, $6,683-$58,610) for 1 life-year gained. Outside the U.S., educational interventions cost from $0.62 (China) to $29 (Pakistan) for 1-mmHg reduction in SBP. Self-monitoring interventions, evaluated in the U.S. only, cost $727 for 1-mmHg reduction in SBP and $41,927 for 1 life-year gained. For 1 quality-adjusted life-year, screening interventions cost from $21,734 to $56,750 in the U.S., $613 to $5,637 in Australia, and $7,000 to $18,000 in China. Intervention costs to reduce 1 mmHg blood pressure or 1 quality-adjusted life-year were higher in the U.S. than in other countries. CONCLUSIONS: Most studies found that the three types of interventions were either cost effective or cost saving. Quality of economic studies should be improved to confirm the findings.

Cost-effectiveness Analyses of Antihypertensive Medicines: A Systematic Review.

CONTEXT: Hypertension affects one third of the U.S. adult population. Although cost-effectiveness analyses of antihypertensive medicines have been published, a comprehensive systematic review across medicine classes is not available. EVIDENCE ACQUISITION: PubMed, Embase, Cochrane Library, and Health Technology Assessment were searched to identify original cost-effectiveness analyses published from 1990 through August 2016. Results were summarized by medicine class: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), thiazide-type diuretics, ß-blockers, and others. Incremental cost-effectiveness ratios (ICERs) were adjusted to 2015 U.S. dollars. EVIDENCE SYNTHESIS: Among 76 studies reviewed, 14 compared medicines with no treatment, 16 compared medicines with conventional therapy, 29 compared between medicine classes, 13 compared within medicine class, and 11 compared combination therapies. All antihypertensives were cost effective compared with no treatment (ICER/quality-adjusted life year [QALY]=dominant-$19,945). ARBs were more cost effective than CCBs (ICER/QALY=dominant-$13,016) in nine comparisons, whereas CCBs were more cost effective than ARBs (ICER/QALY=dominant) in two comparisons. ARBs were more cost effective than ACEIs (ICER/QALY=dominant-$34,244) and ß-blockers (ICER/QALY=$1,498-$18,137) in all eight comparisons. CONCLUSIONS: All antihypertensives were cost effective compared with no treatment. ARBs appeared to be more cost effective than CCBs, ACEIs, and ß-blockers. However, these latter findings should be interpreted with caution because these findings are not robust due to the substantial variability across the studies, including study settings and analytic models, changes in the cost of generic medicines, and publication bias.

Prevalence and Medical Costs of Chronic Diseases Among Adult Medicaid Beneficiaries.

INTRODUCTION: This review summarizes the current literature for the prevalence and medical costs of noncommunicable chronic diseases among adult Medicaid beneficiaries to inform future program design. METHODS: The databases MEDLINE and CINAHL were searched in August 2016 using keywords, including Medicaid, health status, and healthcare cost, to identify original studies that were published during 2000-2016, examined Medicaid as an independent population group, examined prevalence or medical costs of chronic conditions, and included adults within the age group 18-64 years. The review and data extraction was conducted in Fall 2016-Spring 2017. Disease-related costs (costs specifically to treat the disease) and total costs (all-cause medical costs for a patient with the disease) are presented separately. RESULTS: Among the 29 studies selected, prevalence estimates for enrollees aged 18-64 years were 8.8%-11.8% for heart disease, 17.2%-27.4% for hypertension, 16.8%-23.2% for hyperlipidemia, 7.5%-12.7% for diabetes, 9.5% for cancer, 7.8%-19.3% for asthma, 5.0%-22.3% for depression, and 55.7%-62.1% for one or more chronic conditions. Estimated annual per patient disease-related costs (2015 U.S. dollars) were $3,219-$4,674 for diabetes, $3,968-$6,491 for chronic obstructive pulmonary disease, and $989-$3,069 for asthma. Estimated hypertension-related costs were $687, but total costs per hypertensive beneficiary ranged much higher. Estimated total annual healthcare costs were $29,271-$51,937 per beneficiary with heart failure and $11,446-$20,585 per beneficiary with schizophrenia. Costs among beneficiaries with cancer were $29,384-$46,194 for the 6 months following diagnosis. CONCLUSIONS: These findings could help inform the evaluation of interventions to prevent and manage noncommunicable chronic diseases and their potential to control costs among the vulnerable Medicaid population.

Medical Expenditures Associated With Hypertension in the U.S., 2000-2013.

INTRODUCTION: Trends of prevalence, treatment, and control of hypertension have been documented in the U.S., but changes in medical expenditures associated with hypertension over time have not been evaluated. This study analyzed these expenditures during 2000-2013 among U.S. adults. METHODS: Data from the Medical Expenditure Panel Survey were analyzed in 2016. The study population was non-institutionalized men and non-pregnant women aged ≥18 years. Hypertension was defined as ever been diagnosed with hypertension or currently taking antihypertensive medications. Medical expenditures included all payments to medical care providers. Expenditures associated with hypertension were estimated by two-part regression models and adjusted into 2015 U.S. dollars. Controlling variables included sociodemographic characteristics, marital status, insurance, region, smoking status, weight status, health status, and comorbidities. Trends were analyzed using joinpoint method. RESULTS: Total per-person annual expenditures associated with hypertension in 2000-2001 ($1,399) were not significantly different from those in 2012-2013 ($1,494) (average annual percent change [AAPC]= -0.6%, p=0.794), but annual national spending increased significantly from $58.7 billion to $109.1 billion (AAPC=8.3%, p=0.015), mainly because of the increase in the number of people treated for hypertension. Per-person outpatient payments were 22.7% higher in 2012-2013 than in 2000-2001 ($416 vs $322, p<0.05; AAPC=0.8%, p-trend=0.826). Payments for prescription medications took up a larger proportion of the medical expenditures associated with hypertension, compared to payments for outpatient or other services (33%-46%). CONCLUSIONS: During 2000-2013, annual national medical expenditures associated with hypertension increased significantly. Preventing hypertension could alleviate hypertension-associated economic burden.

Comorbidity Status and Annual Total Medical Expenditures in U.S. Hypertensive Adults.

INTRODUCTION: The purpose of this study is to investigate comorbidity status and its impact on total medical expenditures in non-institutionalized hypertensive adults in the U.S. METHODS: Data from the 2011-2014 Medical Expenditure Panel Survey were used. Patients were included if they had a diagnosis code for hypertension, were aged ≥18 years, and were not pregnant during the study period (N=26,049). The Elixhauser Comorbidity Index was modified to add hypertension-related comorbidities. The outcome variable was annual total medical expenditures, and a generalized linear model regression (gamma distribution with a log link function) was used. All costs were adjusted to 2014 U.S. dollars. RESULTS: Based on the modified Elixhauser Comorbidity Index, 14.0% of patients did not have any comorbidities, 23.0% had one, 24.4% had two, and 38.7% had three or more. The five most frequent comorbidities were hyperlipidemia, diabetes, rheumatoid arthritis, depression, and chronic pulmonary disease. Estimated mean annual total medical expenditures were $3,914 (95% CI=$3,456, $4,372) for those without any comorbidity; $5,798 (95% CI=$5,384, $6,213) for those with one comorbidity; $8,333 (95% CI=$7,821, $8,844) for those with two comorbidities; and $13,920 (95% CI=$13,166, $14,674) for those with three or more comorbidities. Of the 15 most frequent comorbidities, the condition with the largest impact on expenditures for an individual person was congestive heart failure ($7,380). Hypertensive adults with stroke, coronary heart disease, diabetes, renal diseases, and hyperlipidemia had expenditures that were $6,069, $6,046, $5,039, $4,974, and $4,851 higher, respectively, than those without these conditions. CONCLUSIONS: Comorbidities are highly prevalent among hypertensive adults, and this study shows that each comorbidity significantly increases annual total medical expenditures.

Annual Total Medical Expenditures Associated with Hypertension by Diabetes Status in U.S. Adults.

INTRODUCTION: Hypertension and diabetes, both independent risk factors for cardiovascular disease, often coexist. The hypertension-increased medical expenditures by diabetes status is unclear, however. This study estimated annual total medical expenditures in U.S. adults by hypertension and diabetes status. METHODS: The study population consisted of 40,746 civilian, non-institutionalized adults aged ≥18 years who participated in the 2013 or 2014 Medical Expenditure Panel Survey. The authors separately estimated hypertension-increased medical expenditures using two-part econometric and generalized linear models for the total; diabetes (n=4,396); and non-diabetes (n=36,250) populations and adjusted the results into 2014 U.S. dollars. Data were analyzed in 2017 and estimated the hypertension-increased medical expenditures by type of medical service and payment source. RESULTS: The prevalence of hypertension was 34.9%, 78.3%, and 30.1% for the total, diabetes, and non-diabetes populations, respectively. The respective mean unadjusted annual per capita medical expenditures were $5,225, $12,715, and $4,390. After controlling for potential confounders, hypertension-increased expenditures were $2,565, $4,434, and $2,276 for total, diabetes, and non-diabetes populations, respectively (all p<0.001). The hypertension-increased expenditure was highest for inpatient stays among the diabetes population ($1,730, p<0.001), and highest for medication among the non-diabetes population ($687, p<0.001). By payment source, Medicare ranked first in hypertension-increased expenditures for the diabetes ($2,753) and second for the non-diabetes ($669) populations (both p<0.001). CONCLUSIONS: Hypertension-increased medical expenditures were substantial and varied by medical service type and payment sources. These findings may be useful as inputs for cost- effectiveness evaluations of hypertension interventions by diabetes status.

Medical Expenditures Associated With Diabetes in Myocardial Infarction and Ischemic Stroke Patients.

INTRODUCTION: The coexistence of diabetes among people with acute myocardial infarction (AMI) or acute ischemic stroke (AIS) is common. However, little is known about the extent of excess medical expenditures associated with having diabetes among AMI and AIS patients. METHODS: Data on 3,307 AMI patients and 2,460 AIS patients aged ≥18 years from the 2008 to 2014 Medical Expenditure Panel Survey were analyzed. Per capita annual medical expenditures associated with diabetes were separately estimated by healthcare components with generalized linear models and two-part models. Excess expenditure associated with diabetes is the difference between estimated expenditure conditional on having both diabetes and AMI (or AIS) and the estimated expenditure conditional on having AMI (or AIS) but not diabetes. All expenditures were adjusted to 2014 U.S. dollars. The analysis was conducted in 2017. RESULTS: Per capita annual total excess expenditures associated with diabetes were $5,117 (95% CI=$4,989, $5,243) for AMI patients and $5,734 (95% CI=$5,579, $5,887) for AIS patients. Of the total excess expenditures, prescription drugs accounted for 40% among AMI patients and 42% among AIS patients. Higher expenditures associated with diabetes were explained more by higher volume of utilization than higher per unit expenditures. CONCLUSIONS: Excess expenditures associated with diabetes were substantial among both AMI and AIS patients. These results highlight the needs for both prevention and better management of diabetes among AMI and AIS patients, which in turn may lower the financial burden of treating these conditions.