Relationship of hemoglobin A1c, age of diabetes diagnosis, and ethnicity to clinical outcomes and medical costs in a computer-simulated cohort of persons with type 2 diabetes.

OBJECTIVE: To project the impact of maintaining long-term glycemic control (i.e., a sustained reduction in glycosylated hemoglobin (hemoglobin A1c [HbA1c]) on the lifetime incidence and direct medical costs of complications in persons with type 2 diabetes. STUDY DESIGN, PATIENTS, AND METHODS: Computer simulation of hypothetical patient cohorts using a published model developed by the National Institutes of Health. RESULTS: Across all HbA1c levels, Hispanics had the highest and whites had the lowest complication rates. With lower maintained HbA1c, the absolute decrease in complication rates was greatest and the reduction in direct medical expenditures was highest among Hispanics (18% vs 15% for blacks and 12% for whites). Complication rates and costs were most dramatically reduced when lower levels of HbA1c were maintained among persons with a younger age at diagnosis. CONCLUSIONS: Maintaining long-term glycemic control reduces complication rates and costs for medical care for all ethnic groups regardless of age at diagnosis. Relatively greater benefit is achieved by interventions targeting Hispanics and younger, newly diagnosed persons.

Cost-effectiveness of the conventional papanicolaou test with a new adjunct to cytological screening for squamous cell carcinoma of the uterine cervix and its precursors.

OBJECTIVE: To estimate costs and outcomes of conventional annual Papanicolaou (Pap) test screening compared with biennial Pap test plus speculoscopy (PPS) screening for cervical neoplasms. DESIGN: A Markov model compared cost-effectiveness and outcomes of annual Pap tests with biennial PPS. The model includes direct costs of screening, diagnostic testing, and treatment for squamous intraepitheial lesions and invasive cancers; indirect costs (eg, lost productivity because of cervical cancer); and newer management practices, including human papillomavirus DNA testing. PATIENTS: Women aged 18 to 64 years. INTERVENTION: Screening for cervical neoplasms with either annual Pap smear test or biennial PPS. MAIN OUTCOME MEASURE: Marginal cost per life-year gained. RESULTS: The probability of women having squamous intraepithelial lesions, cervical cancer, or death from cervical cancer was lower among women undergoing PPS biennially. A total of 12 additional days of life per woman was gained with biennial PPS during the 47-year model period. Total average cumulative direct medical costs per patient were $1419 for biennial PPS compared with $1489 for annual Pap tests. Total costs, including direct medical costs and indirect costs, were $2185 for PPS compared with $3179 for Pap tests alone. Increased savings and patient outcomes were observed in high-risk populations. CONCLUSION: Our simulations indicate that biennial screening with PPS is expected to provide cost savings for women older than 18 years compared with annual Pap test screening, especially for those in high-risk populations.

Challenges and directions for Medicare ESRD payment policy.

Since the inception of the ESRD program in 1973, Medicare has been challenged to provide access to high-quality care to beneficiaries with ESRD while trying to contain program payments. Despite implementing policies to control the growth in spending for outpatient dialysis and shifting the risk of certain ESRD beneficiaries to private payers, annual ESRD program payments have grown faster than overall Medicare spending. Some stakeholders contend that these policies have adversely affected beneficiaries' access to high-quality care. Refining the payment systems for caring for beneficiaries with ESRD in traditional Medicare and managed care plans may provide some respite to the growth in ESRD program spending in the short-term. In the long run, ESRD program spending may not be effectively controlled until changes are made in the delivery of health care services to this population.

Unequal access to cadaveric kidney transplantation in California based on insurance status.

OBJECTIVE: To assess the impact of insurance status on access to kidney transplantation among California dialysis patients. STUDY SETTING: California Medicare and Medicaid dialysis populations. STUDY DESIGN: All California ESRD dialysis patients under age 65 eligible for Medicare or Medicaid in 1991 (n = 9,102) took part in this cohort analytic study. DATA COLLECTION: Medicare and California Medicaid Program data were matched to the Organ Procurement and Transplantation Network Kidney Wait List files. PRINCIPAL FINDINGS: Only 31.4 percent of California Medicaid dialysis patients were placed on the kidney transplant waiting list compared to 38.8 percent and 45.0 percent of dually eligible Medicate/Medicaid and Medicare patients, respectively. Compared to the Medicaid population, Medicare enrollees were more likely to be placed on the kidney transplant waiting list (adjusted Relative Risk [RR] = 2.10, Confidence Interval [CI] 1.68, 2.62) as were dually eligible patients (RR = 1.54, CI 1.24, 1.91). Once on the waiting list, however, Medicare enrollment did not influence the adjusted median waiting time to acquire a first cadaveric transplant (p > .05). CONCLUSIONS: California dialysis patients excluded from Medicare coverage, who are disproportionately minority, female, and poor, are much less likely to enter the U.S. transplant system. We hypothesize that patient concerns with potential subsequent loss of insurance coverage as well as cultural and educational barriers are possible explanatory factors. Once in the system, however, insurance status does not influence receipt of a cadaveric renal transplant.

Association between antihypertensive drug use and hypoglycemia: a case-control study of diabetic users of insulin or sulfonylureas.

Antihypertensive drugs are commonly prescribed for the treatment of patients with both diabetes and hypertension. However, the role of selected agents in the development of hypoglycemia remains controversial. The main objective of this study was to evaluate the effect of antihypertensive agents on the risk of hypoglycemia in diabetic patients receiving insulin or sulfonylurea therapy. A matched case-control study was conducted using Pennsylvania Medicaid data. Five control subjects, matched for sex and age, with no reported medical condition of hypoglycemia, were randomly selected for each case patient admitted for hypoglycemia in 1993, resulting in a total of 404 cases and 1375 controls. With these sample sizes, we were able to detect a difference of 10% (P < 0.05) for our primary outcome measure, hospitalization for hypoglycemia. The relative risk of hypoglycemia was estimated using an unconditional logistic regression. The risk of hypoglycemia was 5.5 times greater (95% confidence interval [CI], 4.0 to 7.6) in insulin versus sulfonylurea users and was not influenced by use of angiotensin-converting enzyme (ACE) inhibitors overall. However, use of the ACE inhibitor enalapril was associated with an increased risk of hypoglycemia (odds ratio, 2.4; 95% CI, 1.1 to 5.3) in sulfonylurea users, suggesting that analyzing the unintended side effects of a class of drugs can sometimes mask the adverse effects of individual drugs. Use of beta-blockers was not associated with an increased risk of hypoglycemia, providing further empiric evidence that beta-blockers are an appropriate treatment for persons with concomitant diabetes and hypertension. Per capita health care costs were approximately 3 times higher in patients hospitalized for hypoglycemia compared with controls (P < 0.05). Hospitalization for hypoglycemia is expensive and may be prevented with appropriate monitoring of diabetic patients taking selected antihypertensive agents such as enalapril.

Direct expenditures for the treatment of allergic rhinoconjunctivitis in 1996, including the contributions of related airway illnesses.

BACKGROUND: Previous estimates of the national economic burden of allergic rhinoconjunctivitis (AR/AC) have relied on data analyses in which AR/AC was the primary International Classification of Diseases-ninth revision-Clinical Modification (ICD-9-CM)-coded diagnosis. These studies ignore the costs when AR/AC was a secondary diagnosis to other disorders such as asthma and sinusitis. OBJECTIVE: We sought to determine the national direct cost of illness for AR/AC. METHODS: An expert panel used the Delphi technique to estimate the proportion of visits coded by other primary ICD-9-CM diagnoses in which AR/AC was a significant secondary comorbid condition. The costs of this proportion were deemed to be "attributable" to AR/AC and were added to the costs when allergic rhinitis and allergic conjunctivitis were the primary diagnoses. RESULTS: The cost when AR/AC was the primary diagnosis was $1.9 billion (in 1996 dollars). The cost when AR/AC was a secondary diagnosis was estimated at $4.0 billion, giving an estimate of $5.9 billion for the overall direct medical expenditures attributable to AR/AC. Outpatient services (63%, $3.7 billion), medications (25%, $1.5 billion), and inpatient services (12%, $0.7 billion) accounted for the expenditures. Children 12 years and younger accounted for $2.3 billion (38.0%). CONCLUSION: Upper airway allergy is an expensive disease process because of its readily apparent manifestations as AR/AC and its contribution to other airway disorders.

Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders.

BACKGROUND: There have been no recent assessments of the economic burden of sinusitis in the peer-reviewed literature. OBJECTIVE: We sought to estimate the 1996 total direct health care expenditures for the treatment of sinusitis. METHODS: This study determined (1) direct expenditures of medical and surgical encounters in which sinusitis was the primary diagnosis and (2) attributable expenditures when related airway diseases were the primary diagnosis and sinusitis was a comorbid condition. An expert panel used the Delphi consensus-building technique to determine the proportions for the latter. RESULTS: Overall health care expenditures attributable to sinusitis in 1996 were estimated at $5.8 billion, of which $1.8 billion (30.6%) was for children 12 years or younger. A primary diagnosis of acute or chronic sinusitis accounted for 58.7% of all expenditures ($3.5 billion). About 12% each of the costs for asthma and chronic otitis media and eustachian tube disorders were attributed to diagnosis and treatment of comorbid sinusitis. Nearly 90% of all expenditures ($5.1 billion) were associated with ambulatory or emergency department services. CONCLUSION: The economic burden of sinusitis in the United States is significant. However, the limitations of this type of evaluation suggest the $5.8 billion amount may be an underestimate of the true direct costs.

The cost of Medicaid-covered services provided to disabled adults with neurologic disorders: implications for managed care.

OBJECTIVES: To estimate the mean annual per capita cost of care provided to disabled adult Medicaid recipients with neurologic conditions and to compare mean annual costs for disabled adult Medicaid recipients with those of nondisabled adult Medicaid recipients. STUDY DESIGN: Medicaid eligibility and claims files for all of calendar year 1993 were obtained from the state of Pennsylvania. Mean annual per capita costs are mean Medicaid expenditures on claims filed for Medicaid-covered services and pharmaceuticals provided in 1993 to full-year eligible Medicaid recipients. PATIENTS AND METHODS: Disabled adults aged 18 to 64 years with one or more of several neurologic conditions were identified from medical diagnoses (International Classification of Diseases, 9th Revision codes) reported on claims. A comparison group of nondisabled adults was chosen from the Medicaid Eligibility File. Annual costs were estimated for a wide range of specific services as well as for 3 broad service categories. RESULTS: There were large differences between disabled and nondisabled adults in mean annual per capita costs of acute care and other medical services ($4142 vs $1451), rehabilitation and support services ($3835 vs $235), and pharmaceuticals ($1116 vs $382). Mean costs also differed significantly among persons with different neurologic conditions. The mean annual per capita cost for all services was $5368 for adults with epilepsy and $19,356 for those with a spinal cord injury. All differences are statistically significant (P < .001). CONCLUSIONS: States may want to separately capitate rehabilitation and support services given the large differences in the magnitude and relative distribution of costs for disabled and nondisabled Medicaid recipients.

Psychiatric illness in patients with end-stage renal disease.

PURPOSE: We sought to determine the prevalence of psychiatric illness in hospitalized patients with end-stage renal disease. We also examined the association between end-stage renal disease treatment modality and risk of hospitalization with a diagnosis of a mental disorder, and compared rates of hospitalization with a diagnosis of psychiatric illness in renal failure patients to patients with other chronic medical illnesses. SUBJECTS AND METHODS: We performed a cohort study of all Medicare-enrolled dialysis patients in 1993. Risk of hospitalization with a diagnosis of a mental disorder among renal failure patients was compared with Medicare patients with diabetes mellitus, ischemic heart disease, cerebrovascular disease, and peptic ulcer disease. RESULTS: Almost 9% of all dialysis patients were hospitalized with a mental disorder. Men, African-Americans, and younger patients were more likely to be hospitalized with a mental disorder. The adjusted risk of hospitalization for peritoneal dialysis patients was lower compared with hemodialysis patients for any mental disorder, depression, and alcohol and drug use. Hospitalization with mental disorders was 1.5 to 3.0 times higher for renal failure patients compared with other chronically ill patients. CONCLUSIONS: Hospitalization with a psychiatric illness is common among the US end-stage renal disease population. Depression, dementia and drug-related disorders were especially common. The coexistence of psychiatric illness in patients with renal failure who require specialized medical regimens represents a challenge to nephrologists in diagnosis and treatment. Disparities between hospitalization rates of psychiatric illnesses among end-stage renal disease patients compared with other chronically ill populations warrant further research.

Influence of the NIH Consensus Conference on Helicobacter pylori on physician prescribing among a Medicaid population.

OBJECTIVES: In February 1994, an National Institutes of Health (NIH) Consensus Development Conference panel unequivocally recommended antimicrobial therapy to eradicate Helicobacter pylori in the treatment of peptic ulcer disease. The goal of this study was to determine if these recommendations resulted in a change in physician prescribing among an underserved population. METHODS: Computerized Pennsylvania Medicaid data from January 1993 through February 1996 were used to evaluate prescribing patterns in the year before and 2 years after the NIH conference. An interrupted time series model, based on 12,737 outpatient peptic ulcer disease encounters, assessed the impact of the conference in influencing physician prescribing. RESULTS: The prescription of antimicrobial agents for the treatment of peptic ulcer disease significantly increased across the study period, from 6.5% in January 1993 to 10.2% in February 1996. Similarly, the prescription rate for the proton pump inhibitor, omeprazole, significantly increased from 9.4% in January 1993 to 25.6% in February 1996. Neither trend, however, could be attributed to the NIH Consensus Development Conference. Stratification by physician specialty, ulcer type, nonsteroidal anti-inflammatory drug use, and patient demographics did not affect these results. The traditional treatment approach, using H2-receptor antagonists, remained the preferred pharmacotherapy (72% of all prescriptions). CONCLUSIONS: Two years after the highly publicized NIH conference on the eradication of Helicobacter pylori, antimicrobial agents were not widely prescribed among the Pennsylvania Medicaid population. In treating this underserved population, physicians do not appear to be using recommendations developed by an NIH expert panel based on recent scientific advances.

Race, income, urbanicity, and asthma hospitalization in California: a small area analysis.

STUDY OBJECTIVES: To explicate the interrelationship between asthma hospitalization and race/ethnicity and income. DESIGN: Small area ecologic analysis using census and administrative data. SETTING AND PARTICIPANTS: All asthma hospitalizations in California were identified using the 1993 California Hospital Discharge file. Small area analyses of Los Angeles (LA) were compared with published rates in New York City (NYC). RESULTS: In 1993, the age-adjusted asthma hospitalization rate in California for nonelderly blacks was 42.5/10,000-approximately four times higher than other populations. Black rates remained fourfold higher after stratification by age, income, and urbanicity. Multivariate analyses suggest that the association between black race and asthma hospitalization is independent of income. Regardless of race, children and persons living in poverty were at increased risk for asthma hospitalization. Urbanicity was not a predictor for asthma hospitalization. Overall, asthma hospitalization rates in NYC were 2.8 times higher compared with rates in LA; while rates were similar among blacks (60 vs 40/10,000, respectively), Puerto Rican Hispanics in NYC had dramatically higher rates compared with Mexican Hispanics in LA (63 vs 14/10,000, respectively). CONCLUSIONS: After controlling for socioeconomic status, notable differences in asthma hospitalization by race and ethnicity persist. The reasons for the significantly elevated risk of asthma morbidity among blacks remain unclear.

Drug use concomitant with cyclosporine immunosuppressive therapy for 3 years after renal transplantation.

Little is known about outpatient drug use concomitant with cyclosporine immunosuppressive therapy following renal transplantation. In part, this stems from the difficulty in monitoring drugs not covered by Medicare. Using several linked state and federal program data bases, a cohort of dually eligible Medicare/Medicaid California residents aged > or = 18 years with a first cadaver transplant in 1988 was followed for 3 years to examine drug use and medical expenditures: 99, 122, and 90 patients met these inclusion criteria in each study year, respectively. More than one third of the study population received one or more drugs that inhibit metabolism and increase cyclosporine circulating blood levels (class I) in each year posttransplant. The most commonly prescribed were diltiazem, verapamil, metoclopramide, and ketoconazole. Patients receiving class I drugs had a lower mean cyclosporine dose compared with those not receiving such drugs in all three study years, suggesting that overall cost savings were obtained among patients using class I drugs. Less than one tenth of the study population in any given year received a drug that induces metabolism and decreases cyclosporine blood levels (class II), the most common of which was phenytoin. Use of nephrotoxic drugs (eg, trimethoprim-sulfamethoxazole, gentamicin, and tobramycin) that exhibit nephrotoxic synergy when used with cyclosporine was common. Almost half of all posttransplant patients were prescribed a nephrotoxic drug during the study period. Pharmaceuticals (primarily cyclosporine) accounted for 35% to 43% of the approximately $17,000 to $19,500 per patient annual health care expenditures incurred in the first 3 years following kidney transplantation.

Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994.

BACKGROUND: Adhesion formation represents a major complication after lower abdominal operations. It is postulated that a shift in surgical practice in recent years toward the use of less invasive techniques, such as laparoscopy, may be associated with a reduction in the incidence of intraperitoneal adhesions and in the rate of adhesiolysis procedures. Using an attributable-risk methodology, this cost-of-illness study was designed to estimate the hospitalization rate and expenditures for adhesiolysis in the United States in 1994 and to examine changes in attributable expenditures since 1988. STUDY DESIGN: A national hospital discharge data base was used to identify all abdominal adhesion procedures performed in the United States in 1994. Total hospitalization expenditures were based on Medicare payment rates for adhesiolysis hospitalizations and physician services, which were applied to the total number of inpatient days attributed to adhesiolysis. The results were compared with published rates and expenditures attributed to adhesiolysis in 1988. RESULTS: Adhesiolysis was responsible for 303,836 hospitalizations during 1994, primarily for procedures on the digestive and female reproductive systems. These procedures accounted for 846,415 days of inpatient care and $1.3 billion in hospitalization and surgeon expenditures. CONCLUSIONS: Although the adhesiolysis hospitalization rate has remained constant since 1988, inpatient expenditures have decreased by nearly 10% because of a 15% decrease in the average length of stay. The increased use of laparoscopy during this 6-year period does not appear to be associated with a concomitant reduction in the adhesiolysis hospitalization rate, suggesting that the causes of adhesion formation warrant further research.

Fractures attributable to osteoporosis: report from the National Osteoporosis Foundation.

To assess the cost-effectiveness of interventions to prevent osteoporosis, it is necessary to estimate total health care expenditures for the treatment of osteoporotic fractures. Resources utilized for the treatment of many diseases can be estimated from secondary databases using relevant diagnosis codes, but such codes do not indicate which fractures are osteoporotic in nature. Therefore, a panel of experts was convened to make judgments about the probabilities that fractures of different types might be related to osteoporosis according to patient age, gender, and race. A three-round Delphi process was applied to estimate the proportion of fractures related to osteoporosis (i.e., the osteoporosis attribution probabilities) in 72 categories comprised of four specific fracture types (hip, spine, forearm, all other sites combined) stratified by three age groups (45-64 years, 65-84 years, 85 years and older), three racial groups (white, black, all others), and both genders (female, male). It was estimated that at least 90% of all hip and spine fractures among elderly white women should be attributed to osteoporosis. Much smaller proportions of the other fractures were attributed to osteoporosis. Regardless of fracture type, attribution probabilities were less for men than women and generally less for non-whites than whites. These probabilities will be used to estimate the total direct medical costs associated with osteoporosis-related fractures in the United States.

Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation.

Osteoporotic fractures are a significant public health problem, resulting in substantial morbidity and mortality. Previous estimates of the economic burden of osteoporosis, however, have not fully accounted for the costs associated with treatment of nonhip fractures, minority populations, or men. Accordingly, the 1995 total direct medical expenditures for the treatment of osteoporotic fractures were estimated for all persons aged 45 years or older in the United States by age group, sex, race, type of fracture, and site of service (inpatient hospital, nursing home, and outpatient). Osteoporosis attribution probabilities were used to estimate the proportion of health service utilization and expenditures for fractures that resulted from osteoporosis. Health care expenditures attributable to osteoporotic fractures in 1995 were estimated at $13.8 billion, of which $10.3 billion (75.1%) was for the treatment of white women, $2.5 billion (18.4%) for white men, $0.7 billion (5.3%) for nonwhite women, and $0.2 billion (1.3%) for nonwhite men. Although the majority of U.S. health care expenditures for the treatment of osteoporotic fractures were for white women, one-fourth of the total was borne by other population subgroups. By site-of-service, $8.6 billion (62.4%) was spent for inpatient care, $3.9 billion (28.2%) for nursing home care, and $1.3 billion (9.4%) for outpatient services. Importantly, fractures at skeletal sites other than the hip accounted for 36.9% of the total attributed health care expenditures nationally. The contribution of nonhip fractures to the substantial morbidity and expenditures associated with osteoporosis has been underestimated by previous researchers.

Health insurance coverage among foreign-born US residents: the impact of race, ethnicity, and length of residence.

OBJECTIVES: This study examined the health insurance status of the US foreign-born population and the influence of race, ethnicity, and length of residence on health insurance status. METHODS: Data were obtained from the 1989 and 1990 National Health Interview Surveys, including the Insurance and Family Resource Supplements. RESULTS: In 1989 and 1990, the foreign-born population was twice as likely as the US-born population to be uninsured (26.2% vs 13.0%). The highest rate of uninsured status, 40.8%, was found among foreign-born Hispanics. Persons who had lived in the United States for less than 15 years were 1.5 to 4.7 times more likely to be uninsured than were US-born Whites. CONCLUSIONS: Foreign-born US residents-especially Hispanics and persons residing in the United States for less than 15 years-are vulnerable to not having health insurance, which may limit their access to medical services. The administrative criteria for public programs may explain the high rates of uninsured status among recent immigrants. Recently enacted federal legislation could substantially increase the number of uninsured among the US foreign-born population, with profound public health implications.

Hospitalization and expenditures for the treatment of general medical conditions among the U.S. diabetic population in 1991.

Although the medical expenditures for the treatment of acute glycemic and chronic complications of diabetes are well documented, little is known about the costs of treating general medical conditions among persons with diabetes. Accordingly, data from the 1991 National Hospital Discharge Survey and the 1987 National Medical Expenditure Survey were used to estimate the risk of hospitalization for general medical conditions among middle-aged (45-64 yr) and elderly (> or = 65 yr) persons with diabetes and the associated in-patient expenditures attributable to diabetes in the United States. In 1991, there were 371,814 hospitalizations of middle-aged persons with diabetes and 712,725 hospitalizations of elderly persons with diabetes for treatment of general medical conditions. Both middle-aged and elderly persons with diabetes remained hospitalized longer than their nondiabetic peers (8.1 vs. 6.3 days and 10.1 vs. 8.9 days, respectively). Compared to their nondiabetic peers, middle-aged persons with diabetes were at greatest risk of hospitalization for peritonitis/intestinal abscess [relative risk, 13.1; 95% confidence interval (CI), 12.5-13.8] and respiratory failure (relative risk, 5.0; 95% CI, 4.9-5.1) and elderly persons with diabetes were at greatest risk of hospitalization for liver diseases (relative risk, 3.0; 95% CI, 2.9-3.0) and septicemia (relative risk, 2.8; 95% CI, 2.8-2.9). In-patient expenditures for the treatment of general medical conditions attributable to diabetes were estimated at +4.12 billion, nearly twice the in-patient expenditures incurred for the treatment of chronic complications of diabetes. These results demonstrate the disproportionate resources devoted to treating patients with diabetes for conditions that are neither acute glycemic nor chronic complications of diabetes.

The effect of insurance status on use of recombinant erythropoietin therapy among end-stage renal disease patients in three states.

Recombinant human erythropoietin (rHuEPO) has been demonstrated to be effective in ameliorating anemia among persons with chronic renal failure, and is associated with improved functional status and quality of life. Access to rHuEPO has been examined by a variety of clinical, demographic, geographic, and facility characteristics. However, rHuEPO utilization based on insurance status has not been previously examined. All Medicare and Medicaid prevalent end-stage renal disease (ESRD) patients receiving dialysis services in California, Georgia, and Michigan in December 1991 were identified using state and federal administrative program data. The population in each state was stratified by insurance status as follows: Medicare-entitled, Medicare/Medicaid dually entitled, and Medicaid-only entitled. Insurance coverage of the ESRD population by Medicaid, as either a primary or secondary payer, differed greatly by state. In December 1991, the proportion of Medicaid-only and Medicaid/Medicare dually eligible dialysis patients ranged, respectively, from 8% and 43% in California, to 3% and 26% in Michigan, and to 3% and 18% in Georgia. Compared with the Medicare-entitled population, the Medicaid/Medicare dually eligible and Medicaid-only populations disproportionately comprised women, black patients, and individuals younger than 20 years. Using Lee's two-stage binary logit model, dual-eligibility was found to be associated with an increased access to rHuEPO. Compared with their state-specific, dually eligible counterparts, the odds of receiving rHuEPO was lower for Medicare-entitled patients in California (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76,0.93) and Georgia (OR, 0.65; 95% CI, 0.53,0.80), and lower for Medicaid-only patients in Georgia (OR, 0.02; 95% CI, 0.01,0.05) and Michigan (OR, 0.34; 95% CI, 0.23,0.52). We hypothesize that the absence of substantial copayments associated with rHuEPO, approximately $1,000 per year for a portion of Medicare-entitled patients, resulted in increased access among the dually eligible ESRD population. Dosing of rHuEPO was associated primarily with patient hematocrit level (P < 0.0001) and was unrelated to insurance status. Regardless of insurance status, an unexpectedly large number of Medicare prevalent dialysis patients receiving rHuEPO in each state (31%, 42%, and 41% in California, Georgia, and Michigan, respectively) had hematocrit values lower than 0.28, indicating inadequate treatment of anemia. Eleven percent of all patients receiving rHuEPO in California and nearly 20% in Georgia and Michigan were deemed to be severely anemic (hematocrit < 0.25). The wide variability in access to rHuEPO among the Medicaid-only populations may be indicative of state-specific differences in Medicaid prior approval, copayments, and other drug restrictions. We conclude that the Medicaid-only ESRD population excluded from Medicare coverage is particularly vulnerable to cost-containment measures that focus on expensive technologies such as rHuEPO.

Relative risk and economic consequences of inpatient care among patients with renal failure.

During the final phases of chronic renal disease, inpatient care comprises an enormous share of morbidity and direct medical costs. Using an attributable risk methodology, this study calculated inpatient resource utilization and associated costs for chronic renal failure (CRF) and ESRD. A national hospital survey was used to identify the 348,962 hospitalizations for patients with renal failure in 1991. Among persons under the age of 65, pre-ESRD CRF patients had the same number of hospitalizations (nearly 75,000) as ESRD patients. Age-adjusted relative risk calculations indicate that patients with renal failure experience greater inpatient morbidity compared with other populations with chronic, progressive diseases. For example, compared with persons with diabetes, ischemic heart disease, hypertension, and emphysema, renal patients were at significantly higher risk of hospitalization for congestive heart failure, pneumonia, sepsis, electrolyte disorders, and gastrointestinal hemorrhage. Overall, renal failure patients were ten times more likely to be hospitalized (relative risk, 10.0; 95% confidence interval, 10.00 to 10.04) and, on average, were hospitalized nearly 1 day longer (P < 0.01) compared with the non-renal failure population in 1991. As a result, the economic consequences of inpatient care for the treatment of renal failure were enormous. In 1991, 222,827 hospitalizations, 1.5 million days of inpatient care, and $2.2 billion were attributable to renal failure. Further studies that examine other components of direct medical costs (e.g., long-term care, outpatient care, and pharmaceuticals) as well as indirect costs associated with the treatment and care of renal failure patients are warranted.

Excluded from universal coverage: ESRD patients not covered by Medicare.

Medicaid is believed to serve as the major insurer for end stage renal disease (ESRD) patients who are ineligible for Medicare coverage. Demographics, receipt of dialysis services, and costs of Medicaid-only populations were compared with Medicare ESRD populations in California, Georgia, and Michigan. Notable differences in patient demographics, dialysis practice patterns, and inpatient health resource utilization between the Medicaid and Medicare ESRD populations were observed. Medicaid expenditures for Medicare-ineligible ESRD patients were considerable: in 1991, California spent $46.4 million for 1,239 ESRD patients; Georgia and Michigan each spent nearly $5 million for approximately 140 ESRD patients.