Sturz- und Frakturpr?vention auf der Grundlage des Nationalen Expertenstandards Sturzprophylaxe

Background

A National Expert Standard for Fall and Fracture Prevention (??Expertenstandard Sturzprophylaxe??) was established a few years ago in Germany. The purpose of this study was to determine for the first time the implementation and costs of fall and fracture prevention measures based on this National Expert Standard in German nursing homes in a real world setting.

Material and methods

This before/after study is based on an un-blinded, controlled translational study focussing on the primary prevention of fall-related hip fractures in nursing homes in Bavaria. 274 nursing homes were included in this study in 2008. The intervention aimed at implementing fall and fracture prevention measures based on the National Expert Standard. A random sample of 79 nursing homes was assessed via telephone at baseline and two follow ups. Costs were determined from a societal perspective, based on a questionnaire covering use and costs of fall and fracture prevention measures. Costs were analysed using paired t-tests and non-parametric bootstrapping techniques.

Results

The implementation of this program led to an increase in fall and fracture prevention activities and to additional mean costs of 6,248?EUR (±?SD 7,340?EUR; pricing year 2008) per nursing home over 18 months. Costs varied widely between nursing homes. The majority of additional costs occurred for the implementation of strength and balance training. Depending on type and costs of staff conducting the training, total costs varied between 4,347?EUR (±?SD 7,167?EUR) and 7,024?EUR (±?SD 7,439?EUR).

Conclusion

The implementation of fall and fracture prevention measures based on the National Expert Standard led to additional costs. Cost figures can be used by decision-makers with respect to decisions on resource allocation for different prevention programs (e.g., different National Expert Standards), to determine the main cost components, and finally for model-based cost-effectiveness analyses of fall-prevention programs in nursing homes.     

The Effect of Quitting Smoking on Costs and Healthcare Utilization in Patients with Chronic Obstructive Pulmonary Disease: A Comparison of Current Smokers Versus Ex-Smokers in Routine Clinical Practice

Purpose

Chronic obstructive pulmonary disease (COPD) is a prevalent condition mainly related to smoking, which is associated with a substantial economic burden. The purpose was to compare healthcare resource utilization and costs according to smoking status in patients with COPD in routine clinical practice.

Methods

A retrospective cohort nested case–control study was designed. The cohort was composed of male and female COPD outpatients, 40 years or older, covered by the Badalona Serveis Assistencials (a health provider) health plan. Cases were current smokers with COPD and controls (two per case) were former smokers with COPD (at least 12 months without smoking), matched for age, sex, duration of COPD, and burden of comorbidity. The index date was the last visit recorded in the database, and the analysis was performed retrospectively on healthcare resource utilization data for the 12 months before the index date.

Results

A total of 930 COPD records were analyzed: 310 current and 620 former smokers [mean age 69.4 years (84.6 % male)]. Cases had more exacerbations, physician visits of any type, and drug therapies related to COPD were more common. As a consequence, current smokers had higher average annual healthcare costs: €3,784 (1,888) versus €2,302 (2,451), p < 0.001. This difference persisted after adjusting for severity of COPD.

Conclusions

Current smokers with COPD had significantly higher use of healthcare resources, mainly COPD drugs and physician visits, compared with former smokers who had abstained for at least 12 months. As a consequence, current smokers had higher healthcare costs to the National Health System in Spain than ex-smokers.     

Effects of Massachusetts Health Reform on the Use of Clinical Preventive Services

BACKGROUND

Expansion of health insurance coverage, and hence clinical preventive services (CPS), provides an opportunity for improvements in the health of adults. The degree to which expansion of health insurance coverage affects the use of CPS is unknown.

OBJECTIVE

To assess whether Massachusetts health reform was associated with changes in healthcare access and use of CPS.

DESIGN

We used a difference-in-differences framework to examine change in healthcare access and use of CPS among working-aged adults pre-reform (2002–2005) and post-reform (2007–2010) in Massachusetts compared with change in other New England states (ONES).

SETTING

Population-based, cross-sectional Behavioral Risk Factor Surveillance System surveys.

PARTICIPANTS

A total of 208,831 survey participants aged 18 to 64 years.

INTERVENTION

Massachusetts health reform enacted in 2006.

MEASUREMENTS

Four healthcare access measures outcomes and five CPS.

KEY RESULTS

The proportions of adults who had health insurance coverage, a healthcare provider, no cost barrier to healthcare, an annual routine checkup, and a colorectal cancer screening increased significantly more in Massachusetts than those in the ONES. In Massachusetts, the prevalence of cervical cancer screening in pre-reform and post-reform periods was about the same; however, the ONES had a decrease of ?1.6 percentage points (95 % confidence interval [CI] ?2.5, ?0.7; p <0.001). As a result, the prevalence of cervical cancer screening in Massachusetts was increased relative to the ONES (1.7, 95 % CI 0.2, 3.2; p?=?0.02). Cholesterol screening, influenza immunization, and breast cancer screening did not improve more in Massachusetts than in the ONES.

LIMITATIONS

Data are self-reported.

CONCLUSIONS

Health reform may increase healthcare access and improve use of CPS. However, the effects of health reform on CPS use may vary by type of service and by state.     

Geriatrietypische Multimorbidit?t im Spiegel von Routinedaten – Teil?1

Background

In Germany, typical geriatric multimorbidity is—next to age itself—of special significance for the identification of target groups for specific geriatric care offers. The present article primarily focuses on typical geriatric multimorbidity in the claims data of statutory health insurance and long-term care insurance in Germany. Using the definition of “the geriatric patient” that is agreed on by providers of services as well as by cost bearers, geriatric multimorbidity is defined as the coexistence of at least 2?of 15?typical geriatric conditions. A suggestion made by the German Geriatric Association was to assign ICD-10-GM codes to each of these 15?conditions. Thus, it becomes possible to identify the corresponding geriatric conditions in claims data.

Methods

The article investigates the frequency of geriatric conditions and, thus, of geriatric multimorbidity of patients aged ≥?60?years admitted to a hospital with a geriatric ward. Patients treated in a geriatric ward were compared with those who did not receive geriatric care. In anticipation of a high correlation between typical geriatric conditions and specific features that are preconditions for receiving long-term care insurance benefits (such as care levels and status of a nursing home resident), claims data of the long-term care insurance were included for external validation.

Results

The analyses showed a distinctly higher proportion of insured people with typical geriatric multimorbidity or rather a certain care level among the geriatrically treated cases than among those patients not receiving geriatric treatment (68.5%/67.9% versus 24.2%/33.4%). The different proportions of typical geriatric multimorbidity coded among the patients with features of a certain care level in the two given groups give rise to the suspicion that typical geriatric multimorbidity is not always statistically recorded—especially in cases of treatment without provision of geriatric care.

Conclusion

The frequency of cases of typical geriatric multimorbidity and a certain care level shows that—even when a specific geriatric offer exists—a considerable proportion of cases with typical geriatric conditions are treated in other medical departments.     

Wirksamkeit und Kostenwirksamkeit eines Case-Management-Programms bei Patienten mit Demenz

Background

The aim of the project was to evaluate case management for patients suffering from dementia in order to improve the quality of care and offer patients a chance to stay at home for a longer time.

Methods

The evaluation was prospective with a follow-up of 12?months. Data regarding efficacy and costs were taken from one local and three supraregional health insurance funds. Primary outcome was time remaining at home.

Results

Time remaining at home was 16.1?months with a mean of 12.2?months (p=0.02) in the control group. Regarding cost effectiveness, an additional month remaining at home costs between 41 and 53?EUR.

Conclusion

Regarding time remaining at home, institutionalization and all-cause death, data indicate that case management seems to be an effective intervention in patients with dementia; however, further evaluations with a major number of observed patients and longer follow-up are necessary.     

Increased Hospital and Emergency Department Utilization by Individuals with Recent Criminal Justice Involvement: Results of a National Survey

BACKGROUND

Individuals involved with the criminal justice system have increased health needs and poor access to primary care.

OBJECTIVE

To examine hospital and emergency department (ED) utilization and related costs by individuals with recent criminal justice involvement.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Non-institutionalized, civilian U.S. adult participants (n?=?154,356) of the National Survey on Drug Use and Health (2008–2011).

MAIN MEASURES

Estimated proportion of adults who reported past year 1) hospitalization or 2) ED utilization according to past year criminal justice involvement, defined as 1) parole or probation, 2) arrest without subsequent correctional supervision, or 3) no criminal justice involvement; estimated annual expenditures using unlinked data from the Medical Expenditure Panel Survey.

KEY RESULTS

An estimated 5.7 million adults reported parole or probation and an additional 3.9 million adults reported an arrest in the past year. Adults with recent parole or probation and those with a recent arrest, compared with the general population, had higher rates of hospitalization (12.3 %, 14.3 %, 10.5 %; P?P?CONCLUSIONS Recent criminal justice involvement is associated with increased hospital and ED utilization and costs. The criminal justice system may offer an important point of contact for efforts to improve the healthcare utilization patterns of a large and vulnerable population.     

Patienten mit Vorhofflimmern in Deutschland

Introduction

Atrial fibrillation (Afib) is considered to be the most frequent form of cardiac dysrhythmia and is well known as a key risk factor for arterial thromboembolism. The incidence of Afib will increase in the future due to demographic changes as well as improved treatment options for acute and chronic heart diseases.

Objective

The primary objectives of this analysis were to describe patient characteristics, to assess the resource consumption associated with Afib and to measure costs of direct treatment as well as consequential costs. A secondary objective was to identify factors that influence the costs or the type of Afib.

Methods

The analysis is based on the representative ATRIUM register (Ambulantes Register zur Morbidit?t des Vorhofflimmerns, Ambulatory register on morbidity of atrial fibrillation), a prospective, multicenter cohort study in which general practitioners and family doctors documented the characteristics and resource utilization of consecutively enrolled patients. The documented resource consumption use was subsequently valued with unit costs. The presented results are focused on the baseline documentation and refer to the period 12?months before enrollment.

Results

A total of 3,667?patients (mean age 72.1±9.2?years, 58% men) fulfilled all inclusion criteria and were included by a total of 730 doctors. The patients had an average of 2.4±1.0?risk factors and the most common was hypertension (84% of patients). The most commonly observed comorbidities were heart failure (43%) and coronary heart disease (CHD, 35%). Medicines for oral anticoagulation (86%) and beta blockers (75%) were the most frequently prescribed drugs. A total of 1/3 of all patients received a specific kind of Afib therapy (e.?g. drug conversion, cardioversion) during the past 12?months. The disease-specific mean costs of the patients were 3,274±5,134?Euro, while the acute (inpatient) treatment represented the largest proportion of these total costs (1,639±3,623?Euro). Patients with high treatment costs were significantly younger and suffered from more concomitant diseases.

Conclusion

Atrial fibrillation is associated with significant patient-related attributable costs that are caused particularly by expenditures of inpatient stay. New, innovative treatment strategies seem to offer particular potential savings if they are able to reduce the number of hospitalizations due to Afib itself or subsequent cardiac events.     

The Burden of Untreated Hepatitis C Virus Infection: A US Patients’ Perspective

Background

Hepatitis C virus (HCV) infection is widespread and associated with high economic costs and reduced quality of life, but the impact of untreated HCV infection on patient outcome is not well understood.

Aims

To estimate the impact of untreated HCV infection on work productivity, daily activity, healthcare use, economic costs, and health-related quality of life (HRQoL).

Methods

Respondents to the 2010 US National Health and Wellness Survey (n = 75,000) reporting physician diagnosis of HCV infection but not current or previous treatment (patients) were matched to respondents without HCV infection (controls) by use of propensity scores. Those reporting infection with hepatitis B virus (HBV) or human immunodeficiency virus (HIV) were excluded. Self-reported work impairment, activity impairment, healthcare resource use, and HRQoL were compared between patients and controls. Indirect and direct costs were estimated.

Results

A total of 306 patients met inclusion criteria. Patients were more impaired at work than controls, with overall work impairment of 26 % versus 15 %, respectively (P < 0.001), mostly because of presenteeism in both groups. Annual productivity losses were estimated at $10,316 per employed patient compared with $5,469 per control (P < 0.001). Patients used more healthcare, with all-cause healthcare costs estimated at $22,818 per patient annually, compared with $15,362 per control (P < 0.001). HRQoL and activity impairment were also worse among patients than controls.

Conclusions

Untreated HCV infection is associated with substantial economic costs to society, through loss of productivity and increased use of healthcare resources, and with impaired well-being of the patient.     

The Challenges of Multimorbidity from the Patient Perspective

Background

Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.

Objective

The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.

Design

This research is designed as a cross-sectional survey.

Participants

Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.

Measurements

Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.

Results

Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.

Conclusions

Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.

     

Geriatrietypische Multimorbidität im Spiegel von Routinedaten

Background

In various contexts, the identification of insurants with geriatric conditions (GC) can offer new approaches for specific medical services. GC can be determined from diagnoses data of insurants retrieved from different care sectors, and supplemented with other relevant claims data, e.g., long-term care levels and pharmaceutical data.

Methods

Part 3 of this study is based on a systematic sample of 957,447 AOK insurants (age ≥?60 years). Prevalence of 15 GC was investigated using anonymous claims data of diagnoses from physicians in the ambulant care setting and diagnoses from hospital settings in 2008. In addition the potential relationships of GC with mortality, nursing home admission, need for long-term care and hospital utilization in the following year were examined. All results were standardized by gender and age based on the general population aged ≥?60 years in Germany.

Results

Pain and impairment of vision or hearing was the most common GC (>?25%) followed by high risk of complications, fall risk/dizziness, and cognitive deficit (8–14%). Delayed convalescence, frailty, medication problems, immobility and malnutrition occurred in <?1% of the insurants. Almost all GC occurred more often with increasing age. Only 37% insurants in the sample showed no GC, while for 31% exactly one, for 17% two, and for 15% three or more GC were observed. With the exception of pain and impairment of vision or hearing all of the GC had a significant positive association with mortality, nursing home admission, increasing need of care, and hospital utilization in the following year.

Conclusions

The applied operational approach proved to be generally practicable and successful with few adaptations. The GC pain and impairment of vision or hearing, however, do not contribute sufficiently to the identification of geriatric multimorbidity based on claims data. These GC should be therefore disregarded from such identification processes. To enhance the reliability of an identified geriatric multimorbidity, the requirements on the specificity and number of individual GC (two, three, or more) can be adapted.     

Two-year Trends in Cancer Screening Among Low Socioeconomic Status Women in an HMO-based High-deductible Health Plan

BACKGROUND

Cancer screening is often fully covered under high-deductible health plans (HDHP), but low socioeconomic status (SES) women still might forego testing.

OBJECTIVE

To determine the impact of switching to a HDHP on breast and cervical cancer screening among women of low SES.

DESIGN

Pre-post with comparison group.

PARTICIPANTS

Four thousand one hundred and eighty-eight health plan members enrolled for one year before and up to two years after an employer-mandated switch from a traditional HMO to an HMO-based HDHP, compared with 9418 propensity score matched controls who remained in HMOs by employer choice. Both groups had low outpatient copayments. High-deductible members had full coverage of mammography and Pap smears, but $500 to $2000 individual deductibles for most other services. HMO members had full coverage of cancer screening and low copayments for other services without any deductible. We stratified analyses by SES.

INTERVENTION

Transition to a HDHP.

MAIN MEASURES

Annual breast and cervical cancer screening rates; rates of annual preventive outpatient visits.

KEY RESULTS

In follow-up years 1 and 2, low SES HDHP members experienced no statistically detectable changes in rates of breast cancer screening (ratio of change, 1.14, 95?% CI, [0.93,1.40] and 1.05, [0.80,1.37], respectively) or preventive visits (difference-in-differences, +1.9?%, [?11.9?%,+17.7?%] and +10.1?%, [?9.4?%,+33.7?%], respectively) relative to HMO counterparts. Similarly, among low SES HDHP members eligible for cervical cancer screening, no significant changes occurred in either screening rates (1.01, [0.86,1.20] and 1.08, [0.86,1.35]) or preventive visits (+0.2?%, [?11.4?%,+13.3?%] and ?1.4?%, [?18.1,+18.6]). Patterns were statistically similar for high SES members.

CONCLUSION

During two follow-up years, transition to an HMO-based HDHP with coverage of primary care visits and cancer screening did not lead to differentially lower rates of breast and cervical cancer screening or preventive visits for low SES women. Generalizability is limited to commercially insured women transitioning to HDHPs with low cost-sharing for cancer screening and primary care visits, a common design.     

Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge?

BACKGROUND

Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.

OBJECTIVE

To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).

DESIGN

A quasi-experimental cohort study using consecutive convenience sampling.

PATIENTS

Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.

INTERVENTION

The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.

MAIN MEASURES

We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.

KEY RESULTS

Compared to matched internal controls (N?=?321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P?=?0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.

CONCLUSIONS

This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.     

Effect of screening for type 2 diabetes on healthcare costs: a register-based study among 139,075 individuals diagnosed with diabetes in Denmark between 2001 and 2009

Aims/hypothesis

Trials have not demonstrated benefits to the population of screening for type 2 diabetes. However, there may be cost savings for those found to have diabetes. We therefore aimed to compare healthcare costs among individuals with incident type 2 diabetes in a screened group with those in an unscreened group.

Methods

In this register-based, non-randomised controlled trial, eligible individuals were men and women aged 40–69 years without known diabetes who were registered with a general practice in Denmark (n?=?1,912,392). Between 2001 and 2006, 153,107 individuals registered with 181 practices participating in the Anglo–Danish–Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care (ADDITION)-Denmark study were sent a diabetes risk-score questionnaire. Individuals with a moderate-to-high risk were invited to visit their family doctor for assessment of diabetes status and cardiovascular risk (screening group). The 1,759,285 individuals registered with all other practices in Denmark constituted the retrospectively constructed no-screening (control) group. In this post hoc analysis, we identified individuals from the screening and no-screening groups who were diagnosed with diabetes between 2001 and 2009 (n?=?139,075). Using national registry data, we quantified the cost of healthcare services in these two groups between 2001 and 2012. From a healthcare sector perspective, we estimated the potential healthcare cost savings for individuals with diabetes that were attributable to the screening programme.

Results

In the screening group, 27,177 of 153,107 individuals (18% of those sent a risk-score questionnaire) attended for screening, 1533 of whom were diagnosed with diabetes. Between 2001 and 2009, 13,992 people were newly diagnosed with diabetes in the screening group (including those diagnosed by screening) and 125,083 in the no-screening group. Healthcare costs were significantly lower in the screening group compared with the no-screening group (difference in mean total annual healthcare costs ?€889 per individual with incident diabetes; 95% CI ?€1196, ?€581). The screening programme was associated with a cost saving per person with incident diabetes over a 5-year period of €2688 (95% CI €1421, €3995).

Conclusions/interpretation

Healthcare costs were lower among individuals with incident type 2 diabetes in the screened group compared with the unscreened group. The relatively modest cost of screening per person discovered to have developed diabetes was offset within 2 years by savings in the healthcare system.

     

Die Epidemiologie von chronischen Krankheiten und Pflegebedürftigkeit

Background

It is generally assumed that chronic diseases and multimorbidity increase the risk of long-term care. Nevertheless, a systematic study on the nature and the prevalence of those diseases associated with long-term care has not been yet undertaken in Germany.

Materials and methods

The study was perfomed using claims data of one nationwide operating statutory health insurance company in 2006. Inclusion criteria were age ≥?65 years, minimum of 1 out of 46 diagnoses in a minimum of three quarters of the year (n?=?8,678). A comparison group was formed with n?=?114,962. We calculated prevalences and relative risks —using nominal regression— to determine influential factors on long-term care.

Results

A small number of diseases (e.g. dementia, urinary incontinence, chronic stroke and cardiac insufficiency) show high prevalences (>?20?%) among long-term care users and at the same time great prevalence differences between users and non-users

Conclusion

These data are important for improving medical and nursing care of long-term care users. Further research is needed with regard to the question by which mechanisms those diseases produce disability and frailty, thus leading to long-term care requirements.     

A Systematic Review of Communication Quality Improvement Interventions for Patients with Advanced and Serious Illness

Background

Effective communication is an interaction between two or more people that produces a desired effect and is a key element of quality of care for patients with advanced and serious illness and their family members. Suboptimal provider-patient/family communication is common, with negative effects on patient/family-centered outcomes.

Objectives

To systematically review the evidence for effectiveness of communication-related quality improvement interventions for patients with advanced and serious illness and to explore the effectiveness of consultative and integrative interventions.

Data Sources

MEDLINE, CINAHL, PsycINFO, Cochrane, and DARE from 2000 through December 2011 and reference list of eligible articles and reviews.

Study Eligibility Criteria, Participants And Interventions

Prospective, controlled quality improvement studies in populations with life-limiting or severe life-threatening illness with a primary intervention focus of improving communication with patients and/or families.

Study Appraisal and Synthesis Methods

Two investigators independently screened and abstracted data on patient/family-centered outcomes.

Results

We included 20 studies; 13 (65 %) were in intensive care. We found four intervention types: (1) family meetings with the usual team (11 studies, 77 % found improvement in healthcare utilization), (2) palliative care teams (5 studies, 50 % found improvement in healthcare utilization), (3) ethics consultation (2 studies, 100 % found improvement in healthcare utilization), and (4) physician-patient communication (2 studies, no significant improvement in healthcare utilization). Among studies addressing the outcomes of patient/family satisfaction, 22 % found improvement; among studies addressing healthcare utilization (e.g., length of stay), 73 % found improvement. Results suggest that consultative interventions, as opposed to integrative ones, may be more effective, but more research is needed.

Limitations

Study heterogeneity did not allow quantitative synthesis.

Conclusions and Implications of Key Findings

Communication in the care of patients with advanced and serious illness can be improved using quality improvement interventions, particularly for healthcare utilization as an outcome. Interventions may be more effective using a consultative approach.     

Association of Sustained Blood Pressure Control with Lower Risk for High-Cost Multimorbidities Among Medicare Beneficiaries in ALLHAT

BackgroundClustering of chronic conditions is associated with high healthcare costs. Sustaining blood pressure (BP) control could be a strategy to prevent high-cost multimorbidity clusters.ObjectiveTo determine the association between sustained systolic BP (SBP) control and incident multimorbidity cluster dyads and triads.DesignCohort study of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims.ParticipantsALLHAT included adults with hypertension and ≥1 coronary heart disease risk factor. This analysis was restricted to 5234 participants with ≥ 8 SBP measurements during a 48-month BP assessment period.Main MeasuresSBP control was defined as <140 mm Hg at <50%, 50 to <75%, 75 to <100%, and 100% of study visits during the BP assessment period. High-cost multimorbidity clusters included dyads (stroke/chronic kidney disease [CKD], stroke/chronic obstructive pulmonary disease [COPD], stroke/heart failure [HF], stroke/asthma, COPD/CKD) and triads (stroke/CKD/asthma, stroke/CKD/COPD, stroke/CKD/depression, stroke/CKD/HF, stroke/HF/asthma) identified during follow-up.Key ResultsIncident dyads occurred in 1334 (26%) participants and triads occurred in 481 (9%) participants over a median follow-up of 9.2 years. Among participants with SBP control at <50%, 50 to <75%, 75 to <100%, and 100% of visits, 32%, 23%, 23%, and 19% of participants developed high-cost dyads, respectively, and 13%, 9%, 8%, and 5% of participants developed high-cost triads, respectively. Compared to those with sustained BP control at <50% of visits, adjusted HRs (95% CI) for incident dyads were 0.66 (0.57, 0.75), 0.67 (0.59, 0.77), and 0.51 (0.42, 0.62) for SBP control at 50 to <75%, 75 to <100%, and 100% of visits, respectively. The corresponding HRs (95% CI) for incident triads were 0.69 (0.55, 0.85), 0.56 (0.44, 0.71), and 0.32 (0.22, 0.47).ConclusionsAmong Medicare beneficiaries in ALLHAT, sustained SBP was associated with a lower risk of developing high-cost multimorbidity dyads and triads.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06623-w.KEY WORDS: hypertension, systolic blood pressure, multimorbidity, aging, blood pressure control

Older adults with multimorbidity, defined as ≥ 2 chronic conditions, require more healthcare services and have higher healthcare costs compared to those without multimorbidity.^1,2 While the total number of chronic conditions a person has is associated with healthcare utilization, clustering of certain conditions may also affect outcomes and costs.^3,4 For example, annual spending for a beneficiary with the dyad cluster of stroke and chronic kidney disease (CKD) is more than fivefold higher compared to the average Medicare beneficiary.^5,6 A triad cluster that includes stroke, CKD, and asthma is associated with sevenfold higher spending.In addition to healthcare costs, multimorbidity is also associated with outcomes that are important to older adults including functional decline and reduced quality of life.^7,8 Therefore, identifying treatment approaches to prevent high-cost multimorbidity clusters is an important patient-centered goal. Among Medicare beneficiaries, the five costliest dyad and triad clusters all include one or more chronic conditions that can result from end-organ damage related to high blood pressure (BP) including stroke, heart failure (HF), and chronic kidney disease (CKD).^5,6 Antihypertensive medication has been shown to lower BP and prevent stroke and HF, and slow the progression of CKD.^9,10 By preventing one or more of these hypertension-related chronic conditions, controlling BP has the potential to reduce the incidence of costly dyad and triad clusters.Sustaining BP control at a greater percentage of visits over time has been shown to be associated with a slower progression of multimorbidity, delaying the age of onset of six or more chronic conditions by 8 years.¹¹ The percentage of visits at which patients achieve BP control can easily be calculated, could be used to guide discussions with patients about treatment goals, and could be used as a performance measure for quality improvement. The purpose of the current analysis was to determine the association between the percentage of visits with sustained BP control and incident high-cost multimorbidity cluster dyads and triads in an observational analysis of a large hypertension clinical trial.     

Diagnostic Stringency and Healthcare Needs in Patients with Biliary Dyskinesia

Aim

We have recently shown an increase in cholecystectomies for biliary dyskinesia. Based on these results, we hypothesized that diagnostic criteria are less stringently applied which may contribute to ongoing resource utilization.

Methods

Using billing codes, patients seen for biliary dyskinesia were identified and data were extracted from the electronic medical record to confirm the diagnosis, obtain demographic and clinical data and assess resource utilization 1 year prior to and after cholecystectomy.

Results

A total of 972 patients were identified, with 894 undergoing cholecystectomy. In 259 patients, symptoms had started <3 months prior to evaluation. Functional gallbladder imaging revealed a mean gallbladder ejection fraction of 23.1 ± 0.7 %; of the patients undergoing surgery, 116 had a normal gallbladder ejection fraction. Sufficient up data for pre- and post-operative assessment of resource utilization was available for 368 patients. Emergency room (ER) visits decreased from 0.86 ± 0.07 to 0.69 ± 0.03 (P < 0.05), while hospitalization rates remained unchanged after surgery. Patients not meeting consensus criteria for the diagnosis of biliary dyskinesia were more likely to use opioids and have ER visits prior to and after cholecystectomy. Using multiple logistic regression benzodiazepine use, migraine history and prior ER visits independently predicted postoperative resource utilization.

Conclusions

Our data demonstrate that a significant number of patients undergo cholecystectomy for biliary dyskinesia, even though they do not meet currently accepted diagnostic criteria. While healthcare resource utilization drops within the first year after surgery, ER visits and hospitalizations remain common, suggesting a more limited benefit of surgical approaches in these patients.     

Cost of Illness in Inflammatory Bowel Disease

Background

Frequent relapses sometimes necessitating hospitalization and the absence of pharmacological cure contribute to substantial healthcare costs in inflammatory bowel diseases (IBDs). The costs of health care in Indian patients with IBD are unknown.

Aim

To evaluate the annual costs for treating Crohn’s disease and ulcerative colitis.

Methods

A prevalence-based, micro-costing method was used to assess the components of annual costs in a prospective, observational study conducted in a tertiary healthcare center enrolled over a 24-month period beginning of July 2014.

Results

At enrollment, 43/59 (72.88%) patients with UC and 18/25 (72%) with CD were in remission. The annual median (IQR) cost per UC and CD patient in remission was INR 43,140 (34,357–51,031) [USD $707 (563–836)] and INR 43,763.5 (32,202–57,372) [USD $717 (527–940)], respectively, and in active disease was INR 52,436.5 (49,229–67,567.75) [$859 (807–1107)] and INR 72,145 (49,447–92,212) [USD $1182 (811–1512)], respectively. Compared with remission, active disease had a 1.4-fold higher cost for CD as compared to UC. In both groups, the greatest component of direct costs was drugs. Thirteen (22%) and 7 (28%) patients with UC and CD needed hospitalization accounting for 23.1 and 20.4% of the total costs, respectively. At one year, direct costs surmounted indirect costs in UC and CD (p < 0.001). Productivity losses contributed to 18.5 and 16% of the overall costs for UC and CD, respectively.

Conclusion

This first, panoptic, health economic study for IBD from India shows that the costs are driven by medication, productivity losses, and not merely hospitalization alone.

     

Inpatient costs for people with type 1 and type 2 diabetes in Scotland: a study from the Scottish Diabetes Research Network Epidemiology Group

Aims/hypothesis

The rising prevalence of diabetes worldwide has increased interest in the cost of diabetes. Inpatient costs for all people with diabetes in Scotland were investigated.

Methods

The Scottish Care Information??Diabetes Collaboration (SCI-DC), a real-time clinical information system of almost all diagnosed cases of diabetes in Scotland, UK, was linked to data on all hospital admissions for people with diabetes. Inpatient stay costs were estimated using the 2007?C2008 Scottish National Tariff. The probability of hospital admission and total annual cost of admissions were estimated in relation to age, sex, type of diabetes, history of vascular admission, HbA_1c, creatinine, body mass index and diabetes duration.

Results

In Scotland during 2005?C2007, 24,750 people with type 1 and 195,433 people with type 2 diabetes were identified, accounting for approximately 4.3% of the total Scottish population (5.1 million). The estimated total annual cost of admissions for all people diagnosed with type 1 and type 2 diabetes was ??26 million and ??275 million, respectively, approximately 12% of the total Scottish inpatient expenditure (??2.4 billion). Sex, increasing age, serum creatinine, previous vascular history and HbA_1c (the latter differentially in type 1 and type 2) were all associated with likelihood and total annual cost of admission.

Conclusions/interpretation

Diabetes inpatient expenditure accounted for 12% of the total Scottish inpatient expenditure, whilst people with diabetes account for 4.3% of the population. Of the modifiable risk factors, HbA_1c was the most important driver of cost in type 1 diabetes.