Assessing the economic burden of Alzheimer's disease patients first diagnosed by specialists.

BACKGROUND: It is not known if there is a differential impact on Alzheimer's disease (AD) diagnosis and outcomes if/when patients are diagnosed with cognitive decline by specialists versus non-specialists. This study examined the cost trajectories of Medicare beneficiaries initially diagnosed by specialists compared to similar patients who received their diagnosis in primary care settings. METHODS: Patients with ≥2 claims for AD were selected from de-identified administrative claims data for US Medicare beneficiaries (5 % random sample). The earliest observed diagnosis of cognitive decline served as the index date. Patients were required to have continuous Medicare coverage for ≥12 months pre-index (baseline) and ≥12 months following the first AD diagnosis, allowing for up to 3 years from index to AD diagnosis. Time from index date to AD diagnosis was compared between those diagnosed by specialists (i.e., neurologist, psychiatrist, or geriatrician) versus non-specialists using Kaplan-Meier analyses with log-rank tests. Patient demographics, Charlson Comorbidity Index (CCI) during baseline, and annual all-cause medical costs (reimbursed by Medicare) in baseline and follow-up periods were compared across propensity-score matched cohorts. RESULTS: Patients first diagnosed with cognitive decline by specialists (n = 2593) were younger (78.8 versus 80.8 years old), more likely to be male (40 % versus 34 %), and had higher CCI scores and higher medical costs at baseline than those diagnosed by non-specialists (n = 13,961). However, patients diagnosed by specialists had a significantly shorter time to AD diagnosis, both before and after matching (mean [after matching]: 3.5 versus 4.6 months, p < 0.0001). In addition, patients diagnosed by specialists had significantly lower average total all-cause medical costs in the first 12 months after their index date, a finding that persisted after matching ($19,824 versus $25,863, p < 0.0001). Total per-patient annual medical costs were similar for the two groups starting in the second year post-index. CONCLUSIONS: Before and after matching, patients diagnosed by a specialist had a shorter time to AD diagnosis and incurred lower costs in the year following the initial cognitive decline diagnosis. Differences in costs converged during subsequent years. This suggests that seeking care from specialists may yield more timely diagnosis, appropriate care and reduced costs among those with cognitive decline.

Medical costs of Alzheimer's disease misdiagnosis among US Medicare beneficiaries.

INTRODUCTION: Recent developments in diagnostic technology can support earlier, more accurate diagnosis of non-Alzheimer's disease (AD) dementias. METHODS: To evaluate potential economic benefits of early rule-out of AD, annual medical resource use and costs for Medicare beneficiaries potentially misdiagnosed with AD prior to their diagnosis of vascular dementia (VD) or Parkinson's disease (PD) were compared with that of similar patients never diagnosed with AD. RESULTS: Patients with prior AD diagnosis used substantially more medical services every year until their VD/PD diagnosis, resulting in incremental annual medical costs of approximately $9,500-$14,000. However, following their corrected diagnosis, medical costs converged with those of patients never diagnosed with AD. DISCUSSION: The observed correlation between timing of correct diagnosis and subsequent reversal in excess costs is strongly suggestive of the role of misdiagnosis of AD - rather than AD comorbidity - in this patient population. Our findings suggest potential benefits from earlier, accurate diagnosis.

Economic outcomes among Medicare patients receiving bioengineered cellular technologies for treatment of diabetic foot ulcers.

OBJECTIVE: To assess the real-world medical services utilization and associated costs of Medicare patients with diabetic foot ulcers (DFUs) treated with Apligraf (bioengineered living cellular construct (BLCC)) or Dermagraft (human fibroblast-derived dermal substitute (HFDS)) compared with those receiving conventional care (CC). METHODS: DFU patients were selected from Medicare de-identified administrative claims using ICD-9-CM codes. The analysis followed an 'intent-to-treat' design, with cohorts assigned based on use of (1) BLCC, (2) HFDS, or (3) CC (i.e., ≥1 claim for a DFU-related treatment procedure or podiatrist visit and no evidence of skin substitute use) for treatment of DFU in 2006-2012. Propensity score models were used to separately match BLCC and HFDS patients to CC patients with similar baseline demographics, wound severity, and physician experience measures. Medical resource use, lower-limb amputation rates, and total healthcare costs (2012 USD; from payer perspective) during the 18 months following treatment initiation were compared among the resulting matched samples. RESULTS: Data for 502 matched BLCC-CC patient pairs and 222 matched HFDS-CC patient pairs were analyzed. Increased costs associated with outpatient service utilization relative to matched CC patients were offset by lower amputation rates (-27.6% BLCC, -22.2% HFDS), fewer days hospitalized (-33.3% BLCC, -42.4% HFDS), and fewer emergency department visits (-32.3% BLCC, -25.7% HFDS) among BLCC/HFDS patients. Consequently, BLCC and HFDS patients had per-patient average healthcare costs during the 18-month follow-up period that were lower than their respective matched CC counterparts (-$5253 BLCC, -$6991 HFDS). LIMITATIONS: Findings relied on accuracy of diagnosis and procedure codes contained in the claims data, and did not account for outcomes and costs beyond 18 months after treatment initiation. CONCLUSION: These findings suggest that use of BLCC and HFDS for treatment of DFU may lower overall medical costs through reduced utilization of costly healthcare services.

Estimating the costs of opioid abuse and dependence from an employer perspective: a retrospective analysis using administrative claims data.

BACKGROUND: Opioid abuse and dependence is problematic across many age groups, including the working-age population and their dependents. Little is known, however, about the economic costs of opioid abuse/dependence imposed on employers, who pay for a substantial portion of healthcare costs through their contributions to employer-sponsored health insurance and are also affected by indirect costs such as those due to disability and workplace absenteeism. OBJECTIVE: To provide a comprehensive, current estimate of the economic burden of prescription opioid abuse/dependence to employers. METHODS: Administrative claims from beneficiaries covered by large self-insured companies throughout the USA were used to identify patients, including employees and dependents, who were diagnosed with opioid abuse and/or dependence ('abusers') between 2006 and 2012. Healthcare and work-loss costs for abusers were assessed over a 12-month period and compared with those for patients not diagnosed with abuse ('comparison patients'), using propensity score matching. RESULTS: 7,658 matched pairs of abusers and comparison patients were analysed. Relative to comparison patients, abusers had significantly higher annual healthcare resource utilization, leading to US$10,627 in per-patient incremental annual healthcare costs. Additionally, abusers had US$1,244 in excess annual work-loss costs. Together, this implies an employer burden for diagnosed abuse of US$1.71 per member per month. CONCLUSION: Opioid abuse/dependence impose a substantial economic burden on employers.

Burden of venous leg ulcers in the United States.

OBJECTIVE: To estimate the annual incremental per-patient and overall payer burden (2012USD) of venous leg ulcers (VLU) in the US. METHODS: Beneficiaries with and without VLU were identified using two de-identified insurance claims databases: aged 65+ from a 5% random sample of Medicare beneficiaries (2007-2010: n ∼ 2.3 million); and aged 18-64 from a privately-insured population (2007-2011: n ∼ 8.4 million). The index date was selected as the date of a VLU claim with no other VLU diagnoses in the preceding 12 months for the VLU cohort and as the date of a random medical claim for the non-VLU patients. These groups were matched using propensity scores to account for differences in demographics, comorbidities, resource utilization, and costs in the 12 month pre-index period. Medical resource use and costs incurred during the 12 month follow-up period were calculated for both payers. Drug costs and indirect work-loss due to disability and medically-related absenteeism were estimated for the privately-insured sample only. Annual VLU incidence rates were also estimated for both payers. RESULTS: Data for 58,672 matched VLU/non-VLU pairs of Medicare and 22,476 matched pairs of privately-insured patients were analyzed. Relative to matched non-VLU patients, VLU patients used more medical resources and incurred annual incremental medical costs of $6391 in Medicare ($18,986 vs $12,595), and $7030 ($13,653 vs $6623) in private insurance ($7086 including drug costs). Compared with non-VLU patients, privately-insured VLU patients had more days missed from work (14.0 vs 10.0), resulting in 29% higher work-loss costs (comparisons significant at p < 0.0001). The average annual incidence rate of VLU was 2.2% in Medicare and 0.5% in private insurance. LIMITATIONS: Findings did not account for out-of-pocket payments or other indirect costs (e.g., lost productivity), and relied on accuracy of diagnosis and procedure codes contained in claims data. CONCLUSION: These findings suggest an annual US payer burden of $14.9 billion.

Burden of diabetic foot ulcers for medicare and private insurers.

OBJECTIVE: To estimate the annual, per-patient incremental burden of diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS: DFU patients and non-DFU patients with diabetes (controls) were selected using two de-identified databases: ages 65+ years from a 5% random sample of Medicare beneficiaries (Standard Analytical Files, January 2007-December 2010) and ages 18-64 years from a privately insured population (OptumInsight, January 2007-September 2011). Demographics, comorbidities, resource use, and costs from the payer perspective incurred during the 12 months prior to a DFU episode were identified. DFU patients were matched to controls with similar pre-DFU characteristics using a propensity score methodology. Per-patient incremental clinical outcomes (e.g., amputation and medical resource utilization) and health care costs (2012 U.S. dollars) during the 12-month follow-up period were measured among the matched cohorts. RESULTS: Data for 27,878 matched pairs of Medicare and 4,536 matched pairs of privately insured patients were analyzed. During the 12-month follow-up period, DFU patients had more days hospitalized (+138.2% Medicare, +173.5% private), days requiring home health care (+85.4% Medicare, +230.0% private), emergency department visits (+40.6% Medicare, +109.0% private), and outpatient/physician office visits (+35.1% Medicare, +42.5% private) than matched controls. Among matched patients, 3.8% of Medicare and 5.0% of privately insured DFU patients received lower limb amputations. Increased utilization resulted in DFU patients having $11,710 in incremental annual health care costs for Medicare, and $16,883 for private insurance, compared with matched controls. Privately insured matched DFU patients incurred excess work-loss costs of $3,259. CONCLUSIONS: These findings document that DFU imposes substantial burden on public and private payers, ranging from $9-13 billion in addition to the costs associated with diabetes itself.