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1.
BMC Neurol ; 19(1): 324, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842786

RESUMO

BACKGROUND: In this study, we aimed to understand the trends in total and itemized medical expenses, especially of disease-modifying therapy (DMT), for multiple sclerosis (MS) in Japan through an analysis of health insurance claims data. METHODS: We analyzed a database containing health insurance claims data from hospitals that have adopted the Diagnosis Procedure Combination/Per-Diem Payment System in Japan. According to an algorithm based on diagnosis codes, data for all patients diagnosed with MS from April 2008 to July 2016 were extracted. Medical costs, rate of each medical treatment, and rate of relapses were analyzed by calendar-year. Medical costs in the month of relapse were compared with average medical costs per month of all MS patients by a cross-sectional analysis. RESULTS: Four thousand three hundred seventy-four MS patients were identified in the database. Total medical cost per patient per month (PPPM) increased from ¥87,640 (US$787.7 or €723.0 as of May 2017) to ¥102,846 (US$924.4 or €848.4) during the study period. This increment was mainly attributed to the growth in cost of outpatient DMT prescriptions, which increased from ¥23,039 (US$207.1 or €190.1) to ¥51,351 (US$461.5 or €423.6). In contrast, the rate of hospitalizations and relapses PPPM decreased during the study period (from 0.053 to 0.030, and 0.032 to 0.019, respectively). Medical costs in the month of relapse (¥424,661, US$3816.8 or €3503.1) were 3.57 times higher than the average monthly costs for all MS patients (¥119,021, US$1069.8 or €981.8), with the majority comprising hospitalization cost. CONCLUSION: Concomitant with the increased usage of DMT, the total medical cost for treating MS is increasing in Japan. However, rates of relapse and hospitalization have shown a decreasing trend. Although this study does not show the direct causality between DMT and reduction of relapse rates/fewer hospitalizations among MS patients, a reduction in hospital costs has been revealed concomitantly with the increasing prevalence of DMT.


Assuntos
Imunossupressores/uso terapêutico , Esclerose Múltipla/tratamento farmacológico , Esclerose Múltipla/economia , Adulto , Doença Crônica/economia , Custos e Análise de Custo , Estudos Transversais , Bases de Dados Factuais , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Recidiva
3.
BMC Health Serv Res ; 19(1): 739, 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31640684

RESUMO

BACKGROUND: Because there is heterogeneity in disease types, competition among hospitals could be influenced in various ways by service provision for diseases with different characteristics. Limited studies have focused on this matter. This study aims to evaluate and compare the relationships between hospital competition and the expenses of prostatectomies (elective surgery, representing treatments of non-acute common diseases) and appendectomies (emergency surgery, representing treatments of acute common diseases). METHODS: Multivariable log-linear models were constructed to determine the association between hospital competition and the expenses of prostatectomies and appendectomies. The fixed-radius Herfindahl-Hirschman Index was employed to measure hospital competition. RESULTS: We collected data on 13,958 inpatients from the hospital discharge data of Sichuan Province in China from September to December 2016. The data included 3578 prostatectomy patients and 10,380 appendectomy patients. The results showed that greater competition was associated with a lower total hospital charge for prostatectomy (p = 0.006) but a higher charge for appendectomy (p <  0.001). The subcategory analysis showed that greater competition was consistently associated with lower out-of-pocket (OOP) and higher reimbursement for both surgeries. CONCLUSIONS: Greater competition was significantly associated with lower total hospital charges for prostatectomies, while the opposite was true for appendectomies. Furthermore, greater competition was consistently associated with lower OOP but higher reimbursement for both surgeries. This study provides new evidence concerning the heterogeneous roles of competition in service provision for non-acute and acute common diseases. The findings of this study indicate that the pro-competition policy is a viable option for the Chinese government to relieve patients' financial burden (OOP). Our findings also provide references and insights for other countries facing similar challenges.


Assuntos
Doença Aguda/terapia , Doença Crônica/terapia , Preços Hospitalares/estatística & dados numéricos , Hospitais , Doença Aguda/economia , Idoso , China , Doença Crônica/economia , Assistência à Saúde , Competição Econômica , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Marketing de Serviços de Saúde
4.
Acta Med Port ; 32(7-8): 488-498, 2019 Aug 01.
Artigo em Português | MEDLINE | ID: mdl-31445528

RESUMO

INTRODUCTION: Due to epidemiological change, interest in complex chronic conditions has been increasing within the pediatric health system. As such, we aim to evaluate hospital inpatient care in the National Health Service (mainland Portugal) by pediatric patients (0 - 17 years) with complex chronic conditions. MATERIAL AND METHODS: Observational longitudinal retrospective epidemiological study using anonymized administrative data. We selected hospitalizations within the pediatric age limit, 2011 - 2015; healthy newborns and radiotherapy outpatients were excluded. A descriptive analysis of the admissions with complex chronic conditions was analysed by number of complex chronic conditions categories and by complex chronic conditions categories. Non-parametric tests were applied to length of stay, expense, and mortality. RESULTS: Out of 419 927 admissions, 64 918 (15.5%) contained at least one complex chronic conditions code. These admissions due to complex chronic conditions represented 29.8% of hospital days, 39.4% of expense and 87.2% of deaths. Compared to those without complex chronic conditions, expense was double (median €1467 vs €745) and mortality 40 times higher (2.4% vs 0.06%). Of these, 46% were planned (no complex chronic conditions 23.2%); 64.8% occurred in group III - IV hospitals (no complex chronic conditions 27.1%). Malignant was the most frequent category (23.0%); neonatal had the highest median length of stay (12 days, 6 - 41), median expense (€3568,929 - 24 602), and number of deaths (43.5% of total). DISCUSSION: As in other developed countries where the number of pediatric admissions is decreasing, in mainland Portugal we found an increase in the proportion of complex chronic conditions admissions, which are longer, costlier and deadlier (trends intensified in the presence of two or more complex chronic conditions categories). CONCLUSION: Complex chronic conditions are relevant in the activity and costs regarding pediatric hospitalizations in mainland Portugal. Recognizing this and integrating pediatric palliative care from the moment of diagnosis are essential to promote appropriate hospital use, through the development of effective and sustainable alternatives that meet the needs of children, families, and healthcare professionals.


Assuntos
Doença Crônica/epidemiologia , Hospitalização/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Doença Crônica/classificação , Doença Crônica/economia , Doença Crônica/mortalidade , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitais/classificação , Humanos , Lactente , Recém-Nascido , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde , Cuidados Paliativos , Portugal/epidemiologia , Estudos Retrospectivos , Medicina Estatal/economia , Medicina Estatal/estatística & dados numéricos , Estatísticas não Paramétricas
6.
Aust N Z J Public Health ; 43(5): 484-495, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31390112

RESUMO

OBJECTIVE: The aim of this literature review was to establish the economic burden of preventable disease in Australia in terms of attributable health care costs, other costs to government and reduced productivity. METHODS: A systematic review was conducted to establish the economic cost of preventable disease in Australia and ascertain the methods used to derive these estimates. Nine databases and the grey literature were searched, limited to the past 10 years, and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed to identify, screen and report on eligible studies. RESULTS: Eighteen studies were included. There were at least three studies examining the attributable costs and economic impact for each risk factor. The greatest costs were related to the productivity impacts of preventable risk factors. Estimates of the annual productivity loss that could be attributed to individual risk factors were between $840 million and $14.9 billion for obesity; up to $10.5 billion due to tobacco; between $1.1 billion and $6.8 billion for excess alcohol consumption; up to $15.6 billion due to physical inactivity and $561 million for individual dietary risk factors. Productivity impacts were included in 15 studies and the human capital approach was the method most often employed (14 studies) to calculate this. CONCLUSIONS: Substantial economic burden is caused by lifestyle-related risk factors. Implications for public health: The significant economic burden associated with preventable disease provides an economic rationale for action to reduce the prevalence of lifestyle-related risk factors. New analysis of the economic burden of multiple risk factors concurrently is needed.


Assuntos
Alcoolismo/economia , Doença Crônica/economia , Doença Crônica/prevenção & controle , Assistência à Saúde/economia , Custos de Cuidados de Saúde , Doenças não Transmissíveis/economia , Obesidade/economia , Obesidade/prevenção & controle , Comportamento Sedentário , Fumar/economia , Alcoolismo/terapia , Austrália/epidemiologia , Doença Crônica/epidemiologia , Efeitos Psicossociais da Doença , Custos e Análise de Custo , Humanos , Estilo de Vida , Doenças não Transmissíveis/terapia , Obesidade/epidemiologia , Fumar/efeitos adversos
7.
Inquiry ; 56: 46958019871815, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31455121

RESUMO

This study examined income-based disparities in financial burdens from out-of-pocket (OOP) medical spending among individuals with multiple chronic physical and behavioral conditions, before and after the Affordable Care Act's (ACA) implementation in 2014. Using the 2012-2015 Medical Expenditure Panel Survey data, we studied changes in financial burdens experienced by nonelderly U.S. populations. Financial burdens were measured by (1) high financial burden, defined as total OOP medical spending exceeding 10% of annual household income; (2) health care cost-sharing ratio, defined as self-paid payments as a percent of total health care payments, excluding individual contributions to premiums; and (3) the total OOP costs spent on health care utilization. The findings indicated reductions in the proportion of those who experienced a high financial burden, as well as reductions in the OOP costs for some individuals. However, individuals with incomes below 138% federal poverty level (FPL) and those with incomes between 251% and 400% FPL who had multiple physical and/or behavioral chronic conditions experienced large increases in high financial burden after the ACA, relative to those with incomes greater than 400% FPL. While the ACA was associated with relieved medical financial burdens for some individuals, the worsening high financial burden for moderate-income individuals with chronic physical and behavioral conditions is a concern. Policymakers should revisit the cost subsidies for these individuals, with a particular focus on those with chronic conditions.


Assuntos
Doença Crônica/economia , Família , Gastos em Saúde/estatística & dados numéricos , Cobertura do Seguro/economia , Seguro Saúde/economia , Pobreza/estatística & dados numéricos , Fatores Socioeconômicos , Adulto , Custo Compartilhado de Seguro , Feminino , Humanos , Masculino , Transtornos Mentais/economia , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/economia , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
8.
Int J Health Plann Manage ; 34(3): 926-934, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31353750

RESUMO

In China, patients with chronic diseases have complete freedom to choose the medical institutions at which they are treated, which has resulted in wasted medical resources and increased medical expenses. The purpose of this study is to determine the effective mechanisms to incentivise patients with chronic diseases to obtain referrals from community health centres to tertiary hospitals and estimate the funds that could be saved using various mechanisms. Questionnaire research, expert consultations, and data simulation were applied. We surveyed 1824 outpatients at nine tertiary hospitals in Shanghai, and the results showed that the proportion of patients willing to obtain referrals was 48.4%. By increasing the registration fee, reducing the payment ratio of medical insurance, publicising, and rating the quality of community health centres, up to 51.3%, 50.6%, and 65.41% patients with chronic diseases indicated that they would obtain referrals, respectively. According to the 2015 Shanghai outpatient database, the funding that could be saved through these three mechanisms would be 361.67, 356.73, and 461.14 million yuan, respectively. We conclude that referral of patients with chronic diseases could reduce medical expenses and save medical insurance funds. Nevertheless, no single measure can effectively change patient habits. Comprehensive measures need to be applied to guide patient referral actively.


Assuntos
Doença Crônica/terapia , Preferência do Paciente/psicologia , Alocação de Recursos/métodos , China/epidemiologia , Doença Crônica/economia , Doença Crônica/epidemiologia , Redução de Custos/métodos , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Preferência do Paciente/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Inquéritos e Questionários
9.
Aten. prim. (Barc., Ed. impr.) ; 51(6): 359-366, jun.-jul. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-185716

RESUMO

Objetivo: Describir el uso de dispositivos sanitarios de las personas con cronicidad avanzada, cuantificando y caracterizando el coste de dicho consumo para sugerir mejoras en los modelos de atención. Diseño: Estudio observacional, analítico y prospectivo durante 3 años de una cohorte de personas con cronicidad avanzada. Emplazamiento: Tres equipos de atención primaria (EAP) de Osona, Cataluña. Participantes: Un total de 224 personas identificadas como enfermos avanzados mediante una estrategia poblacional sistemática. Mediciones principales: Edad, sexo, tipo de domicilio, trayectoria final de vida; uso, tipo y coste de los recursos en atención primaria, urgencias, por equipos de paliativos o de hospitalización (en agudos o atención intermedia). Resultados: Se realizaron una media de 1,1 ingresos al año (estancia media = 6 días), el 74% en hospitales de atención intermedia. El 93,4% del tiempo los pacientes vivieron en la comunidad, realizando un contacto semanal con el EAP (45,1% en domicilio). El coste medio diario fue 19,4euros, siendo los principales capítulos la hospitalización de atención intermedia (36,5%), la actividad EAP (29,4%) y los ingresos en agudos (28,6%). Los determinantes de menor coste serían la trayectoria fragilidad/demencia (p < 0,001), vivir en una residencia (p < 0,001) y el sobreenvejecimiento (p < 0,001). Hay ciertas diferencias en el comportamiento de los EAP en el coste global y en recursos comunitarios (p < 0,05). Conclusiones: Los consumos en hospitalización intermedia y atención primaria son más relevantes que las estancias en centros de agudos. Los contextos residencial y domiciliario son importantes para atender con efectividad y eficiencia, especialmente cuando los EAP se preparan para ello


Objective: To describe the use of health resources of people with advanced chronicity, quantifying and characterizing its cost to suggest improvements in health care models. Design: Observational, analytical and prospective study during 3 years of a cohort of people with advanced chronicity. Location: Three primary care teams (EAP) of Osona, Cataluña. Participants: 224 people identified as advanced patients through a systematic population strategy. Main measurements: Age, sex, type of home, end-of-life trajectory; use, type and cost of resources in primary care, emergencies, palliative teams or hospitalization (in acute or intermediate care). Results: Patients made an average of 1.1 admissions per year (average stay = 6 days), 74% in intermediate care hospitals. They lived in the community 93.4% of time, carrying out 1 weekly contact with the EAP (45.1% home care). The average daily cost was 19.4 euros, the main chapters were intermediate care hospitalizations (36.5%), EAP activity (29.4%) and admissions in acute hospitals (28.6%). Factors determining a potential lower cost are frailty/dementia as trajectory (p < 0.001), living in a nursing-home facility (p < 0.001) and over-aging (p < 0.001). There are certain differences in the behavior of the EAP related to the global cost and to community resources (p < 0.05). Conclusions: Consumption in intermediate hospitalization and primary care is more relevant than stays in acute care centers. Nursing-homes and home-care strategies are important to attend effectively and efficiently, especially when primary care teams get ready for it


Assuntos
Humanos , Doença Crônica/economia , Equipamentos e Provisões/economia , Estudos de Coortes , Modelos de Assistência à Saúde , Atenção Primária à Saúde/economia , Recursos em Saúde/economia , Estudos Prospectivos , Análise de Variância , Planejamento em Saúde/economia , Recursos em Saúde/estatística & dados numéricos
10.
BMJ ; 365: l2191, 2019 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-31208954

RESUMO

Much of the burden on healthcare systems is related to the management of chronic conditions such as cardiovascular disease and chronic obstructive pulmonary disease. Although conventional outpatient cardiopulmonary rehabilitation programs significantly decrease morbidity and mortality and improve function and health related quality of life for people with chronic diseases, rehabilitation programs are underused. Barriers to enrollment are multifactorial and include failure to recommend and refer patients to these services; poor communication with patients about potential benefits; and patient factors including logistical and financial barriers, comorbidities, and competing demands that make participation in facility based programs difficult. Recent advances in rehabilitation programs that involve remotely delivered technology could help deliver services to more people who might benefit. Problems with intensity, adherence, and safety of home based programs have been investigated in recent clinical trials, and larger dissemination and implementation trials are under way. This review summarizes the evidence for benefit of in-person cardiac and pulmonary rehabilitation programs. It also reviews the literature on newer developments, such as home based remotely mediated exercise programs developed to decrease cost and improve accessibility, high intensity interval training in cardiac rehabilitation, and alternative therapies such as tai chi and yoga for people with chronic obstructive pulmonary disease.


Assuntos
Reabilitação Cardíaca/economia , Doença Crônica/economia , Doença Crônica/reabilitação , Custos de Cuidados de Saúde , Doença Pulmonar Obstrutiva Crônica/reabilitação , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/terapia , Humanos , Doença Pulmonar Obstrutiva Crônica/economia , Melhoria de Qualidade , Estados Unidos
11.
J Manag Care Spec Pharm ; 25(5): 573-577, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31039057

RESUMO

BACKGROUND: Mismanaged polypharmacy among older adults costs the health care system approximately $2 billion each year. Medication therapy management (MTM), a service designed to optimize medication use, improve health outcomes, and reduce associated costs, is available to eligible Medicare beneficiaries. Yet, it remains unclear which beneficiaries benefit most from this service. OBJECTIVE: To assess associations between patient characteristics, chronic disease, polypharmacy, and medication-related problems (MRPs) in a sample population of Medicare beneficiaries. METHODS: This study was a retrospective cross-sectional analysis of 1 Medicare Part D plan provider for the year 2015. Medicare beneficiaries were included if they were eligible to receive MTM services and excluded if they were aged under 65 years or the dataset had no count of MRPs for the beneficiary. A negative binomial regression assessed the relationship between age, sex, and chronic health conditions with MRPs. Second and third negative binomial regressions assessed the relationship between age, sex, and polypharmacy with MRPs. RESULTS: A sample of 27,765 Medicare beneficiaries had a mean (SD) age of 76 (±7) years, were predominantly female (59%), and used a mean (SD) of 11 (±4) chronic medications. Beneficiaries with certain conditions were more likely to incur an MRP than those without, including depression (OR = 1.58; 95% CI = 1.51-1.64), congestive heart failure (OR = 1.26; 95% CI = 1.20-1.31), diabetes (OR = 1.24; 95% CI = 1.18-1.29), end-stage renal disease (OR = 1.38; 95% CI = 1.25-1.52), respiratory conditions (OR = 1.25; 95% CI = 1.19-1.31), and hypertension (OR = 1.09; 95% CI = 1.01-1.18). Medicare beneficiaries with polypharmacy (11 or more medications) were 1.86 (95% CI = 1.80-1.93) times more likely to experience an MRP than those taking fewer medications. For every additional medication, the odds of incurring an MRP increased by 10% (OR = 1.11; 95% CI = 1.10-1.1.11). CONCLUSIONS: The diagnosis of depression presented with the strongest association with MRPs. Diabetes, congestive heart failure, end-stage renal disease, respiratory conditions, and hypertension also presented with significant associations with MRPs. Beneficiaries with polypharmacy (11 or more medications) were almost 2 times more likely to experience an MRP than those taking fewer medications. Addition of a chronic medication resulted in a 10% increase in the odds of incurring an MRP. MTM programs may find a greater number of MRPs among those diagnosed with depression in their MTM-eligible patient populations. DISCLOSURES: No outside funding supported this research. Silva Almodóvar reports fees from SinfoniaRx, outside the submitted work. Nahata has nothing to disclose.


Assuntos
Doença Crônica/tratamento farmacológico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/economia , Medicare Part D/economia , Conduta do Tratamento Medicamentoso/organização & administração , Polimedicação , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/economia , Doença Crônica/epidemiologia , Estudos Transversais , Conjuntos de Dados como Assunto , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Medicare Part D/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/economia , Prevalência , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologia
12.
J Manag Care Spec Pharm ; 25(5): 612-620, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31039058

RESUMO

BACKGROUND: Chronic disease is associated with increased health care resource utilization and costs. Effective development and implementation of health care management and clinical intervention programs require an understanding of health plan member enrollment and disenrollment behavior. OBJECTIVE: To examine the health plan enrollment and disenrollment behavior of commercially insured and Medicare Advantage members with established chronic disease compared with matched members without the disease of interest, using data from a large national health insurer in the United States. METHODS: This retrospective matched cohort study used administrative claims data from the HealthCore Integrated Research Database from January 1, 2006, to November 30, 2015, to identify adults with chronic disease (type 2 diabetes mellitus [T2DM], cardiovascular disease [CVD], chronic obstructive pulmonary disease [COPD], rheumatoid arthritis [RA], and breast cancer [BC]). Members with no established chronic disease (controls) were directly matched to members with established chronic disease (cases) on demographic characteristics. The earliest date on which members met the criteria for a given disease was defined as the index date. Controls had the same index date as the matched cases. All members had ≥ 12 months of continuous health plan enrollment before the index date. Outcomes included health plan member disenrollment and enrollment duration. Incidence rates per 1,000 member-years for member disenrollment were evaluated along with incidence rate ratios (relative risk) using a Poisson model. Time to disenrollment was analyzed by Cox proportional hazard models and Kaplan-Meier survival curves. Sensitivity analyses were conducted where death was included as a disenrollment event. RESULTS: 70,907 health plan members with BC (99.7% female, mean age 60.5 years); 28,883 members with COPD (52.3% female, mean age 66.7); 835,358 members with CVD (50.5% female, mean age 62.7 years); 210,936 members with T2DM (45.2% female, mean age 53.6 years); and 31,954 members with RA (72.0% female, mean age 55.5 years) were matched to controls and met the study criteria. The incidence rates of health plan disenrollment ranged from 155 to 192 members per 1,000 members per year. Compared with controls, members with chronic disease were 30%-40% less likely to disenroll from a health plan (P < 0.001 for all comparisons). Among those who disenrolled, enrollment duration ranged from 2.3 to 2.7 years among cases and 1.5 to 1.8 years among matched controls (P ≤ 0.001 for all comparisons). CONCLUSIONS: This real-world study demonstrated that members with chronic disease had a significantly lower rate of disenrollment and a longer duration of enrollment compared with matched controls and were continuously enrolled for almost a year longer than members without a diagnosed chronic disease. Understanding health plan enrollment and disenrollment behavior may provide a valuable context for determining the time frame for the effect of health care programs and initiatives. DISCLOSURES: Funding for this study was provided by HealthCore, a wholly owned subsidiary of Anthem. Chung, Deshpande, Zolotarjova, Quimbo, and Willey are employees of HealthCore. Kern and Cochetti are former employees of HealthCore. Quimbo, Cochetti, and Willey are shareholders of Anthem. HealthCore receives funding from multiple pharmaceutical companies to perform various research studies outside of the submitted work. The preliminary results of this study were presented at AMCP Nexus 2015; March 26-29, 2015; Orlando, FL, and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2017 Conference; May 20-24, 2017; Boston, MA.


Assuntos
Artrite Reumatoide/economia , Comércio/estatística & dados numéricos , Diabetes Mellitus Tipo 2/economia , Medicare Part C/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/economia , Adulto , Idoso , Artrite Reumatoide/terapia , Doença Crônica/economia , Doença Crônica/terapia , Comércio/economia , Diabetes Mellitus Tipo 2/terapia , Feminino , Custos de Cuidados de Saúde , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/estatística & dados numéricos , Masculino , Medicare Part C/economia , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/terapia , Estudos Retrospectivos , Estados Unidos
13.
Pediatrics ; 143(6)2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31138667

RESUMO

BACKGROUND AND OBJECTIVES: Although potentially dangerous, little is known about outpatient opioid exposure (OE) in children and youth with special health care needs (CYSHCN). We assessed the prevalence and types of OE and the diagnoses and health care encounters proximal to OE in CYSHCN. METHODS: This is a retrospective cohort study of 2 597 987 CYSHCN aged 0-to-18 years from 11 states, continuously enrolled in Medicaid in 2016, with ≥1 chronic condition. OE included any filled prescription (single or multiple) for opioids. Health care encounters were assessed within 7 days before and 7 and 30 days after OE. RESULTS: Among CYSHCN, 7.4% had OE. CYSHCN with OE versus without OE were older (ages 10-18 years: 69.4% vs 47.7%), had more chronic conditions (≥3 conditions: 49.1% vs 30.6%), and had more polypharmacy (≥5 other medication classes: 54.7% vs 31.2%), P < .001 for all. Most (76.7%) OEs were single fills with a median duration of 4 days (interquartile range: 3-6). The most common OEs were acetaminophen-hydrocodone (47.5%), acetaminophen-codeine (21.5%), and oxycodone (9.5%). Emergency department visits preceded 28.8% of OEs, followed by outpatient surgery (28.8%) and outpatient specialty care (19.1%). Most OEs were preceded by a diagnosis of infection (25.9%) or injury (22.3%). Only 35.1% and 62.2% of OEs were associated with follow-up visits within 7 and 30 days, respectively. CONCLUSIONS: OE in CYSHCN is common, especially with multiple chronic conditions and polypharmacy. In subsequent studies, researchers should examine the appropriateness of opioid prescribing, particularly in emergency departments, as well as assess for drug interactions with chronic medications and reasons for insufficient follow-up.


Assuntos
Analgésicos Opioides/uso terapêutico , Doença Crônica/terapia , Necessidades e Demandas de Serviços de Saúde/tendências , Medicaid/tendências , Pacientes Ambulatoriais , Adolescente , Analgésicos Opioides/economia , Criança , Pré-Escolar , Doença Crônica/economia , Doença Crônica/epidemiologia , Estudos de Coortes , Feminino , Necessidades e Demandas de Serviços de Saúde/economia , Humanos , Lactente , Masculino , Medicaid/economia , Estudos Retrospectivos , Estados Unidos/epidemiologia
14.
Ann Intern Med ; 170(9_Suppl): S87-S92, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31060054

RESUMO

Background: The Centers for Disease Control and Prevention estimates that 10% of the U.S. population delays or avoids health care because of cost concerns. It is unknown whether and how cost-of-care conversations occur in primary encounters, especially settings that provide care to vulnerable patients. Objective: To describe cost-of-care conversations with financially vulnerable (<400% federal poverty level) adult patients during clinical encounters. Design: Five observers shadowed a convenience sample of patients during encounters and then interviewed patients and clinicians after the encounter. Setting: Federally Qualified Health Centers in Texas (n = 2) and Pennsylvania (n = 2). Participants: A convenience sample of 67 adult patients seeking chronic disease management or prenatal care from 9 clinicians (5 medical doctors, 2 physician assistants, and 2 nurse practitioners). Measurements: Self-reported characteristics of patients, and frequency and characteristics of interviewer-observed cost-of-care conversations. Results: Because of missing responses from patient and clinician interviews, data are reported for 67 consenting patients. During 46.3% of encounters, some discussion of costs of care was observed. Discussion of indirect costs (lost work time or transportation) was observed in only 2.9% of encounters. In only 11.9% of encounters did the physician discuss costs of care. When costs were discussed, the conversation was not organized and did not take place in conjunction with the discussion of the treatment plan. Limitations: This exploratory work involved a small convenience sample, and generalizability to other settings is uncertain. Missing data prohibited meaningful analysis of patient and clinician interview data. Conclusion: In the 4 federally funded health centers studied, cost-of-care conversations occurred in a minority of clinical visits, discussions were unorganized, and indirect costs of care were rarely addressed. Whether more frequent discussion of the costs of care improves patient adherence and outcomes requires further study. Primary Funding Source: Robert Wood Johnson Foundation.


Assuntos
Comunicação , Gastos em Saúde , Relações Médico-Paciente , Pobreza , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/organização & administração , Adulto , Doença Crônica/economia , Efeitos Psicossociais da Doença , Feminino , Humanos , Masculino , Pennsylvania , Cuidado Pré-Natal/economia , Texas , Estados Unidos
15.
J Gerontol Nurs ; 45(5): 5-10, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31026326

RESUMO

The objective of the current study was to investigate the perspectives of nursing home (NH) providers regarding the requirements to achieve reimbursement for nursing restorative care (NRC) services and propose recommendations to state agencies to assist NH providers to conduct NRC programs that are person-centered and able to achieve full reimbursement. Methods included a survey of NH providers in one state and a stakeholder focus group to discuss survey findings and develop recommendations. Key findings are that NH providers perceive value to residents from the provision of NRC; providers do not associate these benefits with the stringent reimbursement requirements; and NHs often provide NRC that is individualized, based on resident goals and activity tolerance, as well as realistic given competing demands on staff, even when doing so means giving up reimbursement for NRC services. Recommendations include basing reimbursement for NRC on outcomes rather than the process; reconsideration of the frequency and intensity requirements for NRC components; and increased availability of NRC training/education and resources for providers and case-mix reviewers. [Journal of Gerontological Nursing, 45(5), 5-10.].


Assuntos
Enfermagem Geriátrica/economia , Enfermagem Geriátrica/normas , Assistência de Longa Duração/economia , Assistência de Longa Duração/normas , Assistência Centrada no Paciente/economia , Assistência Centrada no Paciente/normas , Enfermagem em Reabilitação/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/economia , Doença Crônica/reabilitação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Casas de Saúde/economia , Casas de Saúde/normas , Guias de Prática Clínica como Assunto , Estados Unidos
16.
Pediatrics ; 143(5)2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30971431

RESUMO

BACKGROUND: Children with complex chronic conditions (CCCs) require a disproportionate share of health care services and have high mortality rates, but little is known about their end-of-life care. METHODS: We performed a retrospective population-based analysis using a California State administrative database of children aged 1 to 21 years with a CCC who died of disease-related causes between 2000 and 2013. Rates of and sociodemographic and clinical factors associated with previously defined inpatient end-of-life intensity indicators were determined. The intensity indicators included: (1) hospital death, (2) receipt of a medically intense intervention within 30 days of death (ICU admission, cardiopulmonary resuscitation, hemodialysis, and/or intubation), and (3) having ≥2 intensity markers (including hospital death). RESULTS: There were 8654 children in the study population with a mean death age of 11.8 years (SD 6.8). The 3 most common CCC categories were neuromuscular (47%), malignancy (43%), and cardiovascular (42%). Sixty-six percent of the children died in the hospital, 36% had a medically intense intervention in the last 30 days of life, and 35% had ≥2 intensity markers. Living in a low-income neighborhood was associated with increased odds of hospital death, a medically intense intervention, and ≥2 intensity markers. Hispanic and "other" race and/or ethnicity were associated with hospital death and ≥2 intensity markers. Age 15 to 21 years was associated with hospital death, a medically intense intervention, and ≥2 intensity markers. CONCLUSIONS: Sociodemographic disparities in the intensity of end-of-life care for children with CCCs raise concerns about whether all children are receiving high-quality and goal-concordant end-of-life care.


Assuntos
Doença Crônica/mortalidade , Doença Crônica/tendências , Disparidades em Assistência à Saúde/tendências , Mortalidade Hospitalar/tendências , Assistência Terminal/tendências , Adolescente , California/epidemiologia , Criança , Pré-Escolar , Doença Crônica/economia , Feminino , Disparidades em Assistência à Saúde/economia , Hospitalização/economia , Hospitalização/tendências , Humanos , Lactente , Masculino , Estudos Retrospectivos , Assistência Terminal/economia , Adulto Jovem
18.
Eur J Health Econ ; 20(6): 841-856, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30923986

RESUMO

Value-based health insurance designs (VBIDs) are one approach to increase adherence to highly effective medications and simultaneously contain rising health care costs. The objective of this systematic review was to identify VBID effects on adherence and incentive designs within these programs that were associated with higher effects. Eight economic and medical databases were searched for literature. Random effects meta-analyses and mixed effects meta-regressions were used to synthesize VBID effects on adherence. Thirteen references with evaluation studies, including 12 patient populations with 79 outcomes, were used for primary meta-analyses. For qualitative review and sensitivity analyses, up to 19 references including 20 populations with 119 outcomes were used. Evidence of synthesized effects was good, because references with high risk of bias were excluded. VBIDs significantly increased adherence in all indication areas. Highest effects were found in medications indicated in heart diseases (4.05%-points, p < 0.0001). Each additional year increased effects by 0.15%-points (p < 0.01). VBIDs with education were more effective than without education, but the difference was not significant. Effects of VBIDs with full coverage were more than twice as high as effects of VBID without that option (4.52 vs 1.81%-points, p < 0.05). These findings were robust in most sensitivity analyses. It is concluded that VBID implementation should be encouraged, especially for patients with heart diseases, and that full coverage was associated with higher effects. This review may provide insight for policy-makers into how to make VBIDs more effective.


Assuntos
Doença Crônica/tratamento farmacológico , Doença Crônica/economia , Cobertura do Seguro/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Seguro de Saúde Baseado em Valor/estatística & dados numéricos , Custo Compartilhado de Seguro , Custos de Cuidados de Saúde , Humanos
19.
JMIR Mhealth Uhealth ; 7(3): e11082, 2019 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-30892274

RESUMO

BACKGROUND: Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this support model unsustainably burdensome on health care systems globally. Mobile health technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being used to their full extent within US health care systems. OBJECTIVE: The purpose of this study was to examine the use of staff and costs of a remote monitoring care model in persons with and without a chronic condition. METHODS: At Dartmouth-Hitchcock Health, 2894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a mobile phone app that facilitated digital communication with nursing and health behavior change staff. Health data were collected and automatically analyzed, and behavioral support communications were generated based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per capita expenditures. RESULTS: Participants averaged 41 years of age; 72.70% (2104/2894) were female and 12.99% (376/2894) had at least one chronic condition. On average each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 39.74% (8587/21,607) of all staff conversations, with higher per capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 and 0.19 per capita conversations, respectively, P<.001). When compared to the same period in the prior year, per capita health care expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls. CONCLUSIONS: The technology-based chronic condition management care model was frequently used and demonstrated potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.


Assuntos
Doença Crônica/terapia , Aplicativos Móveis/normas , Assistência Centrada no Paciente/métodos , Adulto , Idoso , Doença Crônica/economia , Doença Crônica/psicologia , Estudos de Coortes , Gerenciamento Clínico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aplicativos Móveis/economia , Aplicativos Móveis/tendências , Assistência Centrada no Paciente/normas , Projetos Piloto , Autocuidado/métodos
20.
Eur J Health Econ ; 20(6): 801-817, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30877400

RESUMO

In 2010-2012, new outpatient service locations were established in poor Hungarian micro-regions. We exploit this quasi-experiment to estimate the extent of substitution between outpatient and inpatient care. Fixed-effects Poisson models on individual-level panel data for years 2008-2015 show that the number of outpatient visits increased by 19% and the number of inpatient stays decreased by 1.6% as a result, driven by a marked reduction of potentially avoidable hospitalization (PAH) (5%). In our dynamic specification, PAH effects occur in the year after the treatment, whereas non-PAH only decreases with a multi-year lag. The instrumental variable estimates suggest that a one euro increase in outpatient care expenditures produces a 0.6 euro decrease in inpatient care expenditures. Our results (1) strengthen the claim that bringing outpatient care closer to a previously underserved population yields considerable health benefits, and (2) suggest that there is a strong substitution element between outpatient and inpatient care.


Assuntos
Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitalização/tendências , Doença Crônica/economia , Custos e Análise de Custo , Custos de Cuidados de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Hungria
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