Inpatient Hospitalization Costs Associated with Birth Defects Among Persons Aged <65 Years - United States, 2019.

Changing treatments and medical costs necessitate updates to hospitalization cost estimates for birth defects. The 2019 National Inpatient Sample was used to estimate the service delivery costs of hospitalizations among patients aged <65 years for whom one or more birth defects were documented as discharge diagnoses. In 2019, the estimated cost of these birth defect-associated hospitalizations in the United States was $22.2 billion. Birth defect-associated hospitalizations bore disproportionately high costs, constituting 4.1% of all hospitalizations among persons aged <65 years and 7.7% of related inpatient medical costs. Updating estimates of hospitalization costs provides information about health care resource use associated with birth defects and the financial impact of birth defects across the life span and illustrates the need to determine the continued health care needs of persons born with birth defects to ensure optimal health for all.

The Fading of Protective Roots: A Multivariate Analysis of the Risk of Hypertension among Hispanics by Nativity.

OBJECTIVE: To examine the effects of Hispanic nativity on the risk and severity of hypertension relative to US-born non-Hispanic whites. METHODS: The analytic sample (n = 34,007) was comprised of cross-sectional data drawn from twenty years of the National Health and Nutrition Examination Survey, 1999-2018. RESULTS: Foreign-born Hispanics aged 65 years and older had a greater risk of severe hypertension compared to non-Hispanic Whites. When examined by length of residency in the US, elderly foreign-born Hispanics with less than 10 years of residency were at greater risk of hypertension and severe hypertension, while those with 20 or more years of residency had similar risks compared to non-Hispanic Whites. CONCLUSION: The "Hispanic Paradox" of better health despite lower socioeconomic status, was not observed in foreign-born or US-born Hispanics aged 65 years and older. Among elderly immigrants, those with fewer years of residency had the greatest hypertensive risk.

Preterm birth lifetime costs in the United States in 2016: An update.

The societal cost of preterm birth indicates potential economic gains from interventions that reduce the incidence of preterm birth. Changes in the epidemiology of preterm birth and healthcare costs require periodic updates to cost estimates. Previously reported incremental cost estimates for the United States in 2004 were updated. The discounted present value of the excess cost associated with prematurity for the 2016 US birth cohort was estimated to be $25.2 billion: $17.1 billion for medical care of persons born preterm, $2.0 billion for delivery care, $1.3 billion for early intervention and special education, and $4.8 billion in lost productivity due to associated disabilities in adults. The nominal and inflation-adjusted incremental costs per preterm birth increased by 26% and 4%, respectively, during 2004-2016. The aggregate cost decreased by 4%, associated with declines in overall births and the preterm birth rate and changes in the distribution by gestational age.

Provider Practice Competition and Adoption of Medicare's Oncology Care Model.

BACKGROUND: There is a concern that the Oncology Care Model (OCM), a voluntary bundled payment program, may incentivize mergers and acquisitions among physician practices leading to reduced competition and price increases. These concerns are heightened if OCM is preferentially adopted in competitive health care markets because it could result in reduced competition, but little is known about the characteristics of markets where OCM is adopted. OBJECTIVE: To measure the association between regional market competition among medical oncologists with the initial adoption of OCM. RESEARCH DESIGN: The Herfindahl-Hirschman Index (HHI), a measure of competition, was calculated for hospital referral regions (HRRs) using secondary data from the Centers for Medicare and Medicaid Services. The relationship between HHI and OCM adoption was assessed using a 2-part regression model adjusting for the market-level number of practices, physician density, average practice size, sociodemographic characteristics, and medical resources. A count model on all HRRs was also estimated to assess an overall effect. SUBJECTS: A total of 10,788 physicians in 3,537 practices who billed Medicare for oncology services in 2015. RESULTS: OCM was adopted in 114 (37%) of the 306 HRRs. We found that practices in competitive health care markets were more likely to adopt OCM than in noncompetitive markets. Two-part regression analysis indicated a nonlinear relationship between HHI and OCM adoption. Average practice size, number of practices in an HRR, and the hospital bed rate were positively associated with adoption, whereas the rate of full-time equivalent hospital employees to 1000 residents was negatively associated with adoption. CONCLUSIONS: OCM adoption was higher in HRRs with greater competition. Careful monitoring of market-level changes among OCM adopters should be undertaken to ensure that the benefits of the OCM outweigh the negative consequences of possible changes in competition.

The nexus between health and time use among racially and ethnically diverse women.

OBJECTIVES: Ethnic and racial health disparities have been well-documented in the scholarly literature. In recent years, evidence about time spent in physical (in)activity and its relationship to physical and mental health has also emerged. This study assesses if observed ethnic/racial health differences were associated with differences in time use. DESIGN: Our analyses utilized baseline data from 510 Utah women who enrolled in one of two community-based, participatory research intervention studies between 2012 and 2015. The distinct racial/ethnic groups included African immigrants, African Americans, Latinas, Native Hawaiians/Pacific Islanders, American Indians/Alaskan Natives, and rural White, Non-Latina women. In the baseline survey, respondents reported the typical time they spent in paid employment, television/movie viewing, physical activity, food preparation/clean-up, and sleep. Cluster analysis was used to identify seven distinct patterns of time use within these five activities. We related these time use patterns along with race/ethnicity, socio-demographics, and other potentially contributing health-related factors (e.g. smoking status) to two health outcomes: (1) self-reported health status, and (2) depression. RESULTS: Our time use clusters revealed heterogeneity by racial/ethnic groups, suggesting that some of the health effects that may have been previously ascribed to group membership should instead be attributed to (un)healthy patterns of time use. In particular, spending too much time in sedentary activities such as watching television/movies and too little time sleeping both linked to poor physical and mental health, independently of racial/ethnic group membership. CONCLUSIONS: Researchers and policy makers designing culturally sensitive physical activity health-related interventions should consider patterns of time use that are associated with poor health. Programs designed to improve sleep time and reduce sedentary television-viewing time may be as important as interventions designed to increase physical activity time. These broader patterns of time use mediated the relationships between race/ethnicity and physical and mental health for the women in our study.

Employer-Sponsored Plan Expenditures for Infants Born Preterm.

BACKGROUND: Care for infants born preterm or with major birth defects is costly. Specific estimates of financial burden for different payers are lacking, in part because use of administrative data to identify preterm infants and costs is challenging. METHODS: We used private health insurance claims data and billing codes to identify live births during 2013 and calculated first-year expenditures for employer-sponsored health plans for infants born preterm, both overall and stratified by major birth defects. RESULTS: We conservatively estimated that 7.7% of insured infants born preterm accounted for 37% of $2.0 billion spent by participating plans on the care of infants born during 2013. With a mean difference in plan expenditures of ∼$47 100 per infant, preterm births cost the included plans an extra $600 million during the first year of life. Extrapolating to the national level, we projected aggregate employer-sponsored plan expenditures of $6 billion for infants born preterm during 2013. Infants with major birth defects accounted for 5.8% of preterm births but 24.5% of expenditures during infancy. By using an alternative algorithm to identify preterm infants, it was revealed that incremental expenditures were higher: $78 000 per preterm infant and $14 billion nationally. CONCLUSION: Preterm births (especially in conjunction with major birth defects) represent a substantial burden on payers, and efforts to mitigate this burden are needed. In addition, researchers need to conduct studies using linked vital records, birth defects surveillance, and administrative data to accurately and longitudinally assess per-infant costs attributable to preterm birth and the interaction of preterm birth with major birth defects.

Costs, mortality, and hospital usage in relation to prenatal diagnosis in d-transposition of the great arteries.

BACKGROUND: The impact of prenatal diagnosis of d-transposition of the great arteries (dTGA) on health-care usage is largely unknown. We evaluated a population-based cohort to assess costs, mortality and inpatient encounters by whether dTGA was prenatally diagnosed or not. METHODS: The dTGA cases (born 1997-2011) identified at the Utah Birth Defect Network, which includes data on timing of diagnosis, were linked to statewide inpatient discharge data. We excluded preterm cases or cases with additional major heart defects. We evaluated hospitalizations and costs for infants (first year of life) and mothers (10 months before birth) using multivariable models adjusted for demographic and clinical risk factors. RESULTS: Of 119 cases, 14 (12%) were prenatally diagnosed. Birth weight, surgical complexity and extracardiac defects/syndromes were similar between groups. Of 7 deaths (6%), two occurred pre-intervention in postnatally diagnosed infants. Prenatal diagnosis was associated with more in-hospital days (estimate 13 additional days, p = 0.03) and higher mean costs for mothers ($4,141 vs $12,148) and infants (90,419 vs $49,576). Prenatal diagnosis independently predicted higher adjusted costs for the overall cohort ($22,570, p = 0.045). After excluding deaths, total costs were no longer significantly different. CONCLUSION: Mothers of prenatally diagnosed infants with dTGA had higher inpatient costs compared with those postnatally diagnosed. Costs trended higher for their infants, although were not significantly different. Linkage of population-based surveillance systems and outcome databases can be a powerful tool to further explore the complex relationship of prenatal diagnosis to costs and outcomes in other types of congenital heart diseases. Birth Defects Research 109:262-270, 2017. © 2017 Wiley Periodicals, Inc.

Medicaid Expenditures for Children Remaining at Home After a First Finding of Child Maltreatment.

BACKGROUND: Child maltreatment is associated with physical and mental health problems. The objective of this study was to compare Medicaid expenditures based on a first-time finding of child maltreatment by Child Protective Services (CPS). METHODS: This retrospective cohort study included children aged 0 to 14 years enrolled in Utah Medicaid between January 2007 and December 2009. The exposed group included children enrolled in Medicaid during the month of a first-time CPS finding of maltreatment not resulting in out-of-home placement. The unexposed group included children enrolled in Medicaid in the same months without CPS involvement. Quantile regression was used to describe differences in average nonpharmacy Medicaid expenditures per child-year associated with a first-time CPS finding of maltreatment. RESULTS: A total of 6593 exposed children and 39 181 unexposed children contributed 20 670 and 105 982 child-years to this analysis, respectively. In adjusted quantile regression, exposed children at the 50th percentile of health care spending had annual expenditures $78 (95% confidence interval [CI], 65 to 90) higher than unexposed children. This difference increased to $336 (95% CI, 283 to 389) and $1038 (95% CI, 812 to 1264) at the 75th and 90th percentiles of health care spending. Differences were higher among older children, children with mental health diagnoses, and children with repeated episodes of CPS involvement; differences were lower among children with severe chronic health conditions. CONCLUSIONS: Maltreatment is associated with increased health care expenditures, but these costs are not evenly distributed. Better understanding of the reasons for and outcomes associated with differences in health care costs for children with a history of maltreatment is needed.

Retrospective Assessment of Cost Savings From Prevention: Folic Acid Fortification and Spina Bifida in the U.S.

INTRODUCTION: Although fortification of food with folic acid has been calculated to be cost saving in the U.S., updated estimates are needed. This analysis calculates new estimates from the societal perspective of net cost savings per year associated with mandatory folic acid fortification of enriched cereal grain products in the U.S. that was implemented during 1997-1998. METHODS: Estimates of annual numbers of live-born spina bifida cases in 1995-1996 relative to 1999-2011 based on birth defects surveillance data were combined during 2015 with published estimates of the present value of lifetime direct costs updated in 2014 U.S. dollars for a live-born infant with spina bifida to estimate avoided direct costs and net cost savings. RESULTS: The fortification mandate is estimated to have reduced the annual number of U.S. live-born spina bifida cases by 767, with a lower-bound estimate of 614. The present value of mean direct lifetime cost per infant with spina bifida is estimated to be $791,900, or $577,000 excluding caregiving costs. Using a best estimate of numbers of avoided live-born spina bifida cases, fortification is estimated to reduce the present value of total direct costs for each year's birth cohort by $603 million more than the cost of fortification. A lower-bound estimate of cost savings using conservative assumptions, including the upper-bound estimate of fortification cost, is $299 million. CONCLUSIONS: The estimates of cost savings are larger than previously reported, even using conservative assumptions. The analysis can also inform assessments of folic acid fortification in other countries.

Using multiple sources of data for surveillance of postoperative venous thromboembolism among surgical patients treated in Department of Veterans Affairs hospitals, 2005-2010.

BACKGROUND: There are limitations to using administrative data to identify postoperative venous thromboembolism (VTE). We used a novel approach to quantify postoperative VTE events among Department of Veterans Affairs (VA) surgical patients during 2005-2010. METHODS: We used VA administrative data to exclude patients with VTE during 12 months prior to surgery. We identified probable postoperative VTE events within 30 and 90 days post-surgery in three settings: 1) pre-discharge inpatient, using a VTE diagnosis code and a pharmacy record for anticoagulation; 2) post-discharge inpatient, using a VTE diagnosis code followed by a pharmacy record for anticoagulation within 7 days; and 3) outpatient, using a VTE diagnosis code and either anticoagulation or a therapeutic procedure code with natural language processing (NLP) to confirm acute VTE in clinical notes. RESULTS: Among 468,515 surgeries without prior VTE, probable VTEs were documented within 30 and 90 days in 3,931 (0.8%) and 5,904 (1.3%), respectively. Of probable VTEs within 30 or 90 days post-surgery, 47.8% and 62.9%, respectively, were diagnosed post-discharge. Among post-discharge VTE diagnoses, 86% resulted in a VA hospital readmission. Fewer than 25% of outpatient records with both VTE diagnoses and anticoagulation prescriptions were confirmed by NLP as acute VTE events. CONCLUSION: More than half of postoperative VTE events were diagnosed post-discharge; analyses of surgical discharge records are inadequate to identify postoperative VTE. The NLP results demonstrate that the combination of VTE diagnoses and anticoagulation prescriptions in outpatient administrative records cannot be used to validly identify postoperative VTE events.

Surgical volume, hospital quality, and hospitalization cost in congenital heart surgery in the United States.

Hospital volume has been associated with improved outcomes in congenital cardiac surgery. However, the relationship between hospital volume and hospitalization cost remains unclear. This study examines the relationship between hospital surgical volume and hospitalization costs, while accounting for measures of quality, in children undergoing congenital heart surgery. A retrospective, repeated cross-sectional analysis was performed, using discharges from the 2006 and 2009 Kids' Inpatient Database. All pediatric admissions (<18 years) with a Risk Adjustment for Congenital Heart Surgery procedure and hospitalization cost/charge data were included. Multivariate, linear mixed regression models were run on hospitalization costs, with and without adjustment for indicators of quality (hospital mortality rate and complication rate). Both medium and high-volume hospitals (200-400 cases/year and >400 cases/year, respectively) were associated with lower odds of mortality but not occurrence of a complication. Hospital mortality was associated with the largest increase in hospitalization costs. High-volume hospitals (>400 cases/year) were associated with the lowest hospitalization costs per discharge ($37,775, p < 0.01) when compared to low-($43,270) and medium($41,085)-volume hospitals, prior to adjusting for quality indicators. However, when adjusting for hospital mortality rate, high-volume hospitals no longer demonstrated significant cost savings. When adjusting for hospital complication rate, high-volume hospitals continued to have the lowest hospitalization costs. High-volume hospitals are associated with a reduction in hospitalization costs that appear to be mediated through improvements in quality.

Organizational culture associated with provider satisfaction.

BACKGROUND: Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model. METHODS: This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey. RESULTS: Providers were most satisfied with quality of care (mean, 4.14; scale of 1-5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions. CONCLUSIONS: Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation.

OBJECTIVE: To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. DATA SOURCE/STUDY SETTING: An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. STUDY DESIGN: Convergent case study mixed methods design. DATA COLLECTION/EXTRACTION METHODS: Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. PRINCIPAL FINDINGS: Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. CONCLUSIONS: Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.

Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change.

PURPOSE: We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS: Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS: The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS: These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings.

PURPOSE: We examined quality, satisfaction, financial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODS: We measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, financial performance, and efficiency. RESULTS: Team function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected findings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the efficiency of visits, with some positive and some negative correlations depending on the outcome. CONCLUSIONS: Elements related to care teams and continuity appear to be key elements of CBD as they influence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refined analyses to identify causal associations.

A multivariate analysis of federally mandated school wellness policies on adolescent obesity.

PURPOSE: To evaluate the effects of school wellness policies mandated by the 2004 Child Nutrition and WIC Reauthorization Act on the prevalence of overweight and obesity among adolescents. METHODS: Multivariate logistic regressions, adjusted for clustering within school districts, were used to estimate the effects of district-level wellness policies on the odds of overweight and obesity among adolescents. The analyses were performed on a population-based sample obtained from the Utah Population Database, a compilation of vital characteristic, administrative, and genealogical records on all residents in Utah. Models controlled for individual, maternal, and familial characteristics, as well as characteristics of school district of residence. Self-reported body mass index was taken from drivers license data. RESULTS: Each additional component included in a district's wellness policy was associated with as much as: 3.2% lower odds in the prevalence of adolescent overweight (OR = .968; 95% CI = .941-.997), 2.5% lower odds of obesity (OR = .975; CI = .952-.997), and 3.4% lower odds of severe obesity (OR = .966; CI = .938-.995). Wellness policy components related to diet were significantly associated with lower body mass indexes across all three thresholds, whereas those related to physical activity had significant associations for lower odds of severe obesity only. CONCLUSION: Results suggest that school wellness policies can significantly reduce the risk of adolescent obesity. Further research should address specific policy components that are most effective in various populations, as well as the level of commitment that is required at both the school- and district-levels for sustained effect.

Health care expenditures of children and adults with spina bifida in a privately insured U.S. population.

BACKGROUND: We provide new estimates of medical care utilization and expenditures over the lifespan for persons living with spina bifida in the United States. Updated estimates are essential for calculations of lifetime costs and for economic evaluations of prevention and management strategies for spina bifida. METHODS: We analyzed data from the 2001-2003 MarketScan database on paid medical and prescription drug claims of persons covered by employer-sponsored health insurance in the United States. Medical care utilization and expenditures during 2003 were analyzed for persons with a diagnosis of spina bifida recorded during 2001-2003 who had 12 months of coverage in a fee-for-service health plan. To calculate expenditures during infancy, a separate analysis was performed for those born during 2002 with claims and expenditures data during the first 12 months of life. We compared medical expenditures for persons with and without spina bifida by age groups. RESULTS: Average incremental medical expenditures comparing patients with spina bifida and those without were $41,460 per year at age 0, $14,070 at ages 1-17, $13,339 at ages 18-44, and $10,134 at ages 45-64. Children ages 1-17 years with spina bifida had average medical expenditures 13 times greater than children without spina bifida. Adults with spina bifida had average medical expenditures three to six times greater than adults without spina bifida in this privately insured population. CONCLUSIONS: Although per capita medical care utilization and expenditures are highest among children, adults constitute an important and growing share of the population living with spina bifida.

Reevaluating the benefits of folic acid fortification in the United States: economic analysis, regulation, and public health.

Before a 1996 US regulation requiring fortification of enriched cereal-grain products with folic acid, 3 economic evaluations projected net economic benefits or cost savings of folic acid fortification resulting from the prevention of pregnancies affected by a neural tube defect. Because the observed decline in neural tube defect rates is greater than was forecast before fortification, the economic gains are correspondingly larger. Applying both cost-benefit and cost-effectiveness analytic techniques, we estimated that folic acid fortification is associated with annual economic benefit of 312 million dollars to 425 million dollars. The cost savings (net reduction in direct costs) were estimated to be in the range of 88 million dollars to 145 million dollars per year.