Disparities in timeliness of care for U.S. Medicare patients diagnosed with cancer.

BACKGROUND: Timeliness of care (rapid initiation of treatment after definitive diagnosis) is a key component of high-quality cancer treatment. The present study evaluated factors influencing timeliness of care for U.S. Medicare enrollees. METHODS: Data for Medicare enrollees diagnosed with breast, colorectal, lung, or prostate cancer while living in U.S. seer (Surveillance, Epidemiology and End Results) regions in 2000-2002 were analyzed. Patients were classified as experiencing delayed treatment if the interval between diagnosis and treatment was greater than the 95th percentile for each cancer site. The impacts of patient sociodemographic, clinical, and area-based factors on the likelihood of delayed treatment were analyzed using multivariate logistic regression. RESULTS: Black patients (compared with white patients) and patients initially treated with radiation therapy or chemotherapy (rather than surgery) had a greater likelihood of treatment delays across all four cancer sites. Hispanic status, dual Medicare-Medicaid status, location of initial treatment (inpatient vs. outpatient), and stage at diagnosis also affected timeliness of care for some cancer sites. Surprisingly, area-based factors reflecting availability of cancer care services were not significantly associated with timeliness of care or were associated with greater delays in areas with greater numbers of service providers. CONCLUSIONS: Multiple factors affected receipt of timely cancer care for members of the study population, all of whom had coverage of medical care services through Medicare. Because delays in treatment initiation can increase morbidity, decrease quality of life, shorten survival, and result in greater costs, prospective studies and tailored interventions are needed to address those factors among at-risk patient groups.

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

AIM This paper describes key factors that shaped implementation of prospective targeted injury-detection systems (TIDS) for adverse drug events (ADEs) and nosocomial pressure ulcers (PrU). METHODS Using case-study methodology, the authors conducted semistructured interviews with implementation champions and TIDS users at five hospitals. Interviews focused on implementation experiences, assessment of TIDS' effectiveness and utility, and plans for sustainability. The authors used content analysis techniques to compare implementation experiences within and across organisations and triangulated data for explanation and confirmation of common themes. FINDINGS Participating hospitals were more successful in implementing the low-complexity PrU-TIDS, as compared with high-complexity ADE-TIDS. This pattern reflected the greater complexity of ADE-TIDS, its higher costs and poorer alignment with existing workflows. Complexity affected the innovations' perceived usability, the time needed to learn and install the trigger systems, and their costs. Local factors affecting implementation and sustainability of both innovations included turnover affecting champions and other staff, shifting organisational priorities, changing information infrastructures, and institutional constraints on adapting existing IT to the electronic TIDS. CONCLUSIONS To facilitate implementation of complex healthcare innovations such as ADE-TIDS, staff in adopting organisations should give high priority to innovation implementation; allocate sufficient resources; effectively communicate with and involve local champions and users; and align innovations with workflows and information systems. In addition, they should monitor local factors, such as changes in organisational priorities and IT, availability of implementation staff and champions, and external regulations and constraints that may pose barriers to innovation implementation and sustainability.

Impact of adalimumab on work participation in rheumatoid arthritis: comparison of an open-label extension study and a registry-based control group.

BACKGROUND AND OBJECTIVES: Rheumatoid arthritis (RA) causes considerable disability and often results in loss of work capacity and productivity. This study evaluated the impact of adalimumab, a tumour necrosis factor antagonist with demonstrated efficacy in RA, on long-term employment. METHODS: Data from an open-label extension study (DE033) of 486 RA patients receiving adalimumab monotherapy who previously did not respond to at least one disease-modifying antirheumatic drug (DMARD) and had baseline work status information were compared with data from 747 RA patients receiving DMARD treatment in a Norway-based longitudinal registry. Primary outcomes included the time patients continued working at least part time and the likelihood of stopping work. Secondary outcomes included American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) responses and disease remission. Outcomes were compared 6, 12 and 24 months after enrolment. RESULTS: During a 24-month period, the 158 patients who received adalimumab and were working at baseline worked 7.32 months longer (95% CI 4.8 to 9.1) than did the 180 patients treated with DMARDs, controlling for differences in baseline characteristics. Regardless of baseline work status, patients receiving adalimumab worked 2.0 months longer (95% CI 1.3 to 2.6) and were significantly less likely to stop working than those receiving DMARDs (HR 0.36 (95% CI -0.30 to 0.42) for all patients and 0.36 (95% CI 0.15 to 0.85) for patients working at baseline, respectively). The patients who received adalimumab were also considerably more likely to achieve ACR responses and disease remission than DMARD-treated patients. Patients who achieved EULAR good response and remission were less likely to stop working, but this relationship was only seen in patients receiving DMARDs. CONCLUSIONS: Patients with RA who received adalimumab experienced considerably longer periods of work and continuous employment, and greater rates of clinical responses, than patients receiving DMARDs. The mechanism by which adalimumab decreases likelihood of stopping work seems to be different from that of DMARD treatment and independent of clinical responses.

Economic burden of revision hip and knee arthroplasty in Medicare enrollees.

UNLABELLED: The economic burden to Medicare due to revision arthroplasty procedures has not yet been studied systematically. The economic burden of revisions was calculated as annual reimbursements for revision arthroplasties relative to the sum total reimbursements of primary and revision arthroplasties. We evaluated this revision burden for total hip and knee arthroplasties through investigation of trends in charges and reimbursements in the Medicare population (Parts A and B claims from 1997-2003), while taking into account age and gender effects. Mean annual economic revision burdens were 18.8% (range, 17.4-20.2%) and 8.2% (range, 7.5-9.2%) for total hip arthroplasties and total knee arthroplasties, respectively. Procedural charges increased while reimbursements decreased over the study period, with higher charges observed for revisions than primary arthroplasties. Reimbursements per procedure were 62% to 68% less than associated charges for primary and revision total hip and knee arthroplasties. The effect of age and gender on reimbursements varied by procedure type. Unless some limiting mechanism is implemented to reduce the incidence of revision surgeries, the diverging trends in reimbursements and charges for total hip and knee arthroplasties indicate that the economic impact to the Medicare population and healthcare system will continue to increase. LEVEL OF EVIDENCE: Prognostic study, level II-1 (retrospective study). See Guidelines for Authors for a complete description of levels of evidence.

Economic analysis of the Confronting COPD survey: methodology.

Chronic obstructive pulmonary disease (COPD) is a condition characterized by progressive airflow limitation, which causes considerable morbidity and mortality worldwide. Yet the burden of COPD is poorly recognized, and the disease remains an inadequately managed health problem. Few studies have attempted to quantify the impact of the disease on patient health, the healthcare system and society as a whole. This provided the rationale for Confronting COPD in North America and Europe, the first large-scale international survey of the burden of COPD. This paper describes how quantitative measures of healthcare resource utilization and workplace productivity loss were derived from patient responses to the Confronting COPD survey, to investigate the country-specific impact of COPD on the healthcare system and society. The aim of this analysis is to inform countries of the economic impact of the condition, and demonstrate the need for better COPD treatment to improve health and reduce the sizeable burden of this disease.

The burden of COPD in the U.S.A.: results from the Confronting COPD survey.

Chronic obstructive pulmonary disease (COPD) is a progressive disorder of airflow limitation that is not fully reversible, with disabling symptoms including chronic cough and dyspnoea. Although a number of studies in the U.S.A. have assessed the impact of COPD on the healthcare system and society, data on healthcare resource utilization (particularly outpatient services and medication use) in patients with mild to moderate COPD, or patients who meet symptom criteria for COPD but have not received this diagnosis, are limited or unavailable. To fill gaps in current knowledge about the impact of this disease, an economic analysis was conducted on the data collected from patients enrolled in the U.S.A. sample of Confronting COPD in North America and Europe, the first large-scale international survey of the burden of the disease. The annual cost of healthcare resource utilization was estimated at US dollar 4119 per patient with COPD, with indirect (non-medical care) costs amounting to US dollar 1527 per patient. The annual estimated societal cost was therefore US dollar 5646 per patient. The majority of disease costs in the survey were associated with inpatient hospitalizations (US dollar 2891). The results of the survey suggest that interventions that improve COPD outcomes by decreasing symptoms and preventing acute exacerbations could substantially decrease the costs associated with this disease.

Impact of smoking status on workplace absenteeism and productivity.

OBJECTIVES: To: evaluate the impact of smoking status on objective productivity and absenteeism measures; evaluate the impact of smoking status on subjective measures of productivity; and assess the correlation between subjective and objective productivity measures. DESIGN: Prospective cohort study in a workplace environment. SUBJECTS: Approximately 300 employees (100 each of former, current, and never smokers) at a reservation office of a large US airline. MAIN OUTCOME MEASURES: Objective productivity and absenteeism data were supplied by the employer. Subjective assessments of productivity were collected using a self report instrument, the Health and Work Questionnaire (HWQ). RESULTS: Current smokers had significantly greater absenteeism than did never smokers, with former smokers having intermediate values; among former smokers, absenteeism showed a significant decline with years following cessation. Former smokers showed an increase in seven of 10 objective productivity measures as compared to current smokers, with a mean increase of 4.5%. While objective productivity measures for former smokers decreased compared to measures for current smokers during the first year following cessation, values for former smokers were greater than those for current smokers by 1-4 years following cessation. Subjective assessments of "productivity evaluation by others" and "personal life satisfaction" showed significant trends with highest values for never smokers, lowest for current smokers, and intermediate for former smokers. CONCLUSIONS: Workplace productivity is increased and absenteeism is decreased among former smokers as compared to current smokers. Productivity among former smokers increases over time toward values seen among never smokers. Subjective measures of productivity provide indications of novel ways of productivity assessment that are sensitive to smoking status.

Impact of poorly controlled hypertension on healthcare resource utilization and cost.

OBJECTIVE: To examine the relation between blood pressure (BP) control and utilization and cost of healthcare resources. STUDY DESIGN: A retrospective database study of managed care patients in New Mexico from January 1, 1996, to December 31, 1997. PATIENTS AND METHODS: We stratified 1000 hypertensive patients into categories based on average and maximum BP. Antihypertensive medication use and cost, number of physician visits, and interval between hypertension-related physician visits were determined. RESULTS: Medication costs increased progressively across all BP categories from lowest to highest, and higher average systolic BP (SBP) was significantly correlated with increased cost (P < .001). There were significant correlations between higher maximum BP and greater number of hypertension-related physician visits (P < .001). Mean number of visits for BP groups was 5.5 for patients with a maximum diastolic BP (DBP) < 85 mm Hg and 10.0 for those with a maximum DBP > or = 100 mm Hg (P < .001). Patients with a maximum SBP > or = 180 mm Hg averaged 9.7 visits, whereas those with a maximum SBP < 120 mm Hg averaged 4.1 visits (P < .001). Both SBP and DBP were significantly correlated with time to next visit (P < .001). Mean visit intervals ranged from 44 days for patients with an SBP < 85 mm Hg to 25 days for those with an SBP > or = 180 mm Hg (P < .001). A similar association was found between DBP and visit interval. CONCLUSIONS: Poor control of hypertension is associated with higher drug costs and more physician visits. Aggressive treatment might help reduce managed care costs and resource utilization.

Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs.

The development and application of an economic model designed to assess the specific costs and benefits of health plan coverage of smoking-cessation programs involving sustained-release bupropion hydrochloride are described. A cohort of 100,000 employees or health plan members and 60,000 adult dependents was followed from the start of the model to either retirement at age 65 or death at age 85. The model was used to compare outcomes for coverage versus no coverage of sustained-release bupropion hydrochloride as a component of a smoking-cessation benefit under four managed care plan scenarios and four employer scenarios. For the managed care scenarios involving coverage of bupropion sustained-release the overall decrease in health care costs over a 20-year period ranged from $7.9 million to $8.8 million; for every dollar spent covering smoking cessation, $4.10-$4.69 in health care costs was saved. For the employer scenarios, health care costs over 20 years decreased by $8.3 million to $14.0 million, and smoking-related indirect costs decreased an additional $5.1 million to $7.7 million; for every dollar spent covering smoking cessation, $5.04-$6.48 was saved. A model developed to assess the specific costs and benefits of covering sustained release bupropion hydrochloride as a component of a smoking-cessation benefit indicated cost savings for health plans and employers.

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.

Cost-effectiveness of cesarean section delivery to prevent mother-to-child transmission of HIV-1.

OBJECTIVE: To evaluate costs and outcomes of cesarean section performed before onset of labor and before rupture of membranes (elective cesarean section) compared to vaginal delivery among HIV-infected women. DESIGN: Cost-effectiveness and cost-benefit analysis. PARTICIPANTS AND SETTING: Pregnant HIV-infected women in the US who refrain from breastfeeding. INTERVENTION: Elective cesarean section versus vaginal delivery by antiretroviral therapy regimen. MAIN OUTCOME MEASURES: Pediatric HIV cases avoided, years of life saved, and direct medical costs for maternal interventions and pediatric HIV treatment. RESULTS: Elective cesarean section (versus vaginal delivery) was cost-effective among women receiving zidovudine prophylaxis (US$1131 per case avoided, US$17 per year of life saved) and combination antiretroviral therapy (US$112693 per case avoided, US$1697 per year of life saved), and cost saving among women receiving no antiretroviral therapy during pregnancy (benefit-cost ratio of 2.23). Although elective cesarean section remained cost-effective, results were sensitive to variations in vertical transmission rates and to pediatric HIV treatment costs. Population-based analyses indicated that elective cesarean section could prevent 239 pediatric HIV cases annually with a savings of over US$4 million. CONCLUSIONS: Elective cesarean section is a cost-effective intervention to prevent vertical transmission of HIV among women receiving various antiretroviral therapy regimens, who refrain from breastfeeding.

Smoking cessation in hospitalized patients.

The components of readiness to change for smoking cessation that are found in the general population are also applicable to hospitalized smokers. Smoking cessation interventions must be specifically tailored to subgroups among hospitalized patients, with emphasis on smoking-related diagnosis when applicable. Interventions should include key components related to smoking cessation, such as knowledge, self-efficacy, exposure to smoking, and social support. Interventions that include relapse prevention and are conducted in the context of other risk reduction strategies should be developed.

Economic assessment of the community-acquired pneumonia intervention trial employing levofloxacin.

OBJECTIVE: The purpose of this study was to assess use of a critical pathway designed to manage community-acquired pneumonia more efficiently than its management with conventional therapy. METHODS: Economic outcomes were assessed in conjunction with a cluster-design, randomized, controlled trial. Nineteen participating Canadian hospitals were randomized to implement the critical pathway (n = 9) or conventional therapy (n = 10). The critical pathway included a clinical prediction rule to guide the admission decision, treatment with levofloxacin, and practice guidelines. Patient data on medical resource use, lost productivity, and quality of life were collected prospectively for > or =6 weeks after treatment. Costs were calculated from the government, health care system, and societal perspectives, with imputation of missing outpatient costs and the costs of lost productivity when necessary. Bootstrapping was used to identify 95% CIs for the total cost per patient. RESULTS: The analysis included all eligible patients in the critical pathway (n = 716) and conventional therapy (n = 1027) arms. There were fewer hospital admissions in the critical pathway arm than in the conventional therapy arm, both overall (46.5% vs 62.2%; P = 0.01) and in low-risk patients (33.2% vs 46.8%; P < 0.001). Compared with conventional therapy, hospitals in the critical pathway arm had 1.6 fewer bed days per patient managed (P = 0.05) and used fewer inpatient medical resources. The 2 study arms had similar outpatient, readmission, and lost-productivity costs, and similar quality-of-life outcomes. The critical pathway produced cost savings from all 3 perspectives that ranged from $457 to $994 per patient. CONCLUSIONS: The critical pathway employing levofloxacin resulted in cost savings compared with conventional therapy and did not compromise health outcomes.

The relation of patient satisfaction with treatment of otitis externa to clinical outcomes: development of an instrument.

This survey was undertaken to develop a short, comprehensive measure of patient satisfaction with pharmacologic treatment for otitis externa and to assess the relationships between satisfaction, disease symptoms, and medication side effects. Otitis externa was diagnosed in 41 patients recruited from 6 sites; 34 patients completed and returned the study instruments and were included in the study. Patients or their caregivers administered polymyxin/neomycin/hydrocortisone ear drops prescribed by a physician and completed a daily diary for 10 days and a satisfaction questionnaire at the end of the treatment period. The main outcome measures were the subscale scores for patient satisfaction and their relation to medication side effects, symptoms of ear infection, activity limitations, pain, and adherence to prescription regimens. The questionnaire and its subscales demonstrated good psychometric properties (ie, reliability coefficients >0.75, except for 1 subscale). Overall satisfaction was found to be significantly correlated with relief of symptoms, ability to return to normal activities, ease of administration, and medication side effects. Satisfaction subscale scores were correlated with patient-reported severity of medication side effects and disease symptoms. More than half the patients took drops for more than the prescribed number of days, and one third took more than the prescribed number of drops per administration (ie, overadherence). The relation between satisfaction and adherence was weak, perhaps due to the high rates of overadherence. Our results demonstrate that patient satisfaction with otic medication can be assessed across various aspects of satisfaction and that it is correlated with reported disease symptoms and medication side effects. This type of multifaceted assessment may help physicians select between medications with different side-effect profiles and administration schedules. Larger studies are needed to evaluate the relationship between satisfaction with an otic medication and adherence to a medication regimen.

Health-related quality of life evaluations of gastric and pancreatic cancer.

This review addresses the state of the literature on health-related quality of life (HRQL) assessment among patients with cancers of the pancreas and stomach. We first briefly review the epidemiology of these cancers. We examine the concept of HRQL and the degree to which it has been measured among these patient groups. The impact of gastric and pancreatic cancers on HRQL is described, including the domains which these conditions are most likely to impact. The effect of different treatments on HRQL is considered, including surgical procedures, pharmacological and non-pharmacological therapies, and procedures for symptom palliation. Based on our findings on the limited quantity and quality of the body of literature, we make suggestions for further research in the area. Results suggest three areas in which HRQL can play an important role in the study of gastric and pancreatic cancer. First, future investigations should consider both survival and HRQL in comparing surgical procedures. Second, studies of chemotherapy should include HRQL evaluation, with careful attention to conducting assessments at times appropriate to capture the effects of chemotherapy. Third, studies of the impact of palliative care should include assessments of HRQL.

Economic evaluations of gastric and pancreatic cancer.

The total cost of cancer care in the US is about $146 billion, of which pancreatic cancer comprises $2.6 billion (1.8% of the total) and gastric cancer comprises $1.8 billion (1.3%). We have reviewed published studies presenting economic analysis of treatment or follow-up for patients with pancreatic or gastric cancer. Relatively few studies report on economic evaluations of pancreatic cancer care. There are also few economic studies for gastric cancer, although we identified three cost-effectiveness analyses. In general, economic analyses in these areas are relatively unsophisticated, relying on charge data or simple multipliers (e.g., average cost per day in the hospital multiplied by days in the hospital), and are often limited to in-hospital costs (particularly studies for pancreatic cancer). A wide range of costs is included in these studies and a variety of methodologies for assigning costs are used, making comparisons between studies difficult. Future health economics research in this area should evaluate the costs and effectiveness of alternative practice patterns for gastric and pancreatic cancer; conduct additional cost-effectiveness analyses of chemotherapeutic interventions; consider quality of life, survival, stage at diagnosis, patient-borne costs, and complications of therapy; and, take advantage of administrative data from large populations.

Treatment patterns for otitis externa.

BACKGROUND: Although otitis externa is a common and painful infection of the outer ear canal, there is little specific information available regarding current treatment patterns in the United States. We wanted to examine treatment patterns for otitis externa. METHODS: Data were analyzed from the 1993 National Ambulatory Medical Care Survey (NAMCS) and the 1993 National Hospital Ambulatory Medical Care Survey (NHAMCS) for adults and children treated for otitis externa. Data analyses included the reasons for physician visits, concomitant diagnoses, types of physicians seen, sources of payment, medical procedures administered, drugs prescribed, and patient disposition following a physician visit. RESULTS: Study results suggested that treatment patterns differ substantially for adults and children, as well as by physician specialty. Although otitis externa is frequently painful, few cases are classified as severe, and the data indicated that less than 20 percent of patients have concomitant diagnoses treatable by medication. Nevertheless, 40 percent of patients received both topical and systemic medication, and many of the oral antibiotics prescribed are not active against Staphylococcus aureus or Pseudomonas aeruginosa, the most common bacterial pathogens in otitis externa. CONCLUSIONS: Appropriate treatment of localized otitis externa with topical antibiotics should eliminate the need for systemic medications. Addition of systemic medications can unnecessarily increase treatment costs and the likelihood of side effects, and could reduce the likelihood of patient compliance.

The impact of candidemia on length of hospital stay, outcome, and overall cost of illness.

Although numerous studies have examined trends in nosocomial fungal infections, few have specifically addressed the cost of care associated with candidemia. This study analyzes the direct medical costs associated with treating candidemia in the United States. The study design was a cost-of-illness analysis estimating the average cost of candidemia for a single episode of care. Data were obtained from three sources: the 1993 Healthcare Cost and Utilization Project of the Agency for Health Care Policy and Research, the relevant literature, and a clinical expert in systemic fungal infections. The estimated cost (1997 U.S.$) of an episode of care for candidemia is $34,123 per Medicare patient and $44,536 per private insurance patient. The major cost associated with candidemia is that of an increased hospital stay. The estimated cost of care for candidemia may change in the future because of the use of more expensive antifungal treatments with improved safety and efficacy profiles.

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy.

OBJECTIVE: To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients. BACKGROUND: Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs). METHODS: We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years. RESULTS AND CONCLUSIONS: The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.