Health Resource Utilization and Direct Costs Associated with Angina for Patients with Coronary Artery Disease in a US Managed Care Setting

Background

Angina is often a first symptom of coronary artery disease (CAD); however, the specific burden of illness for patients with CAD-associated angina in managed care has not been reported.

Objective

To determine the clinical and cost burden of illness for patients with CAD-associated angina in a managed care environment.

Study design

A retrospective database analysis in a nationwide commercial managed care plan.

Methods

This study included patients with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic or procedure codes for CAD between July 1, 2004, and June 30, 2006, who had data available for the period 6 months before and 12 months after the index date. The primary analyses for patients classified as having CAD with angina were based on a 3-algorithm patient-identification model (combined positive predictive value of 89%, 95% confidence interval, 0.79–0.95). Utilization measures for the 12-month postindex period, annual CAD-related direct costs, and total all-cause costs (ie, medical plus pharmacy) were determined. A generalized linear model was used to compare CAD-related costs and overall costs.

Results

Of the 246,227 patients with CAD, the 3-algorithm model assigned 230,919 patients (93.8%) to the CAD-without-angina cohort and 15,308 (6.2%) to the CAD-with-angina cohort. Patients with angina were more likely than patients without angina to be hospitalized (41% vs 11%, respectively; P <.001), to visit the emergency department (34% vs 12%, respectively; P <.001), to have office visits (94% vs 79%, respectively; P <.001), and to have more revascularization procedures (35% vs 8%, respectively; P <.001). Average CAD-related inpatient costs were $9536 versus $2169, and pharmacy costs were $1499 versus $891, for patients with and without angina, respectively. Total average CAD-related medical and pharmacy costs for patients with angina were $14,851 versus $4449 for patients with CAD without angina, and the average all-cause per-patient cost was $28,590 versus $14,334, respectively.

Conclusion

Based on these results, US patients with CAD plus angina in a managed care setting use significantly more healthcare services and incur higher costs than patients who have CAD without angina. Revascularization procedures are a major driver of these increased costs for those with CAD and angina.Chest pain, or angina pectoris, is the primary symptom of coronary artery disease (CAD), or chronic heart disease, a leading cause of morbidity and mortality in the United States. An estimated 17.5 million Americans have CAD, 9 million have angina pectoris, and approximately 500,000 new cases of angina are diagnosed annually.1,2 Current evidence-based treatment guidelines for patients with stable ischemic heart disease recommend lifestyle changes, drug therapy, and revascularization procedures.3,4 Current treatment strategies are to identify and treat underlying conditions that may contribute to angina symptoms, modify risk factors, improve a patient''s health and survival through pharmacologic and nonpharmacologic means, and utilize revascularization procedures through evidence-based practice.5

KEY POINTS

• ▸ Approximately 17.5 million Americans have coronary artery disease (CAD) and 9 million have angina, which is often the initial symptom of CAD.
• ▸ There are limited data on healthcare resource utilization and direct costs for patients with CAD plus angina, and CAD without angina.
• ▸ This study used real-world data to compare treatment patterns and costs for patients who have CAD with and without angina in a managed care setting.
• ▸ Average CAD-related inpatient costs were $9536 for those with angina versus $2169 without angina; total average CAD-related medical and pharmacy costs for patients with angina were $14,851 versus $4449 for those without angina.
• ▸ Overall, patients with CAD plus angina used considerably more healthcare resources than those without angina, including hospitalization, emergency department visits, outpatient visits, and cardiovascular drug regimens.
• ▸ In addition, patients with CAD and angina were significantly more likely to have a revascularization procedure—a major cost driver—than patients without angina.

To date, several studies have examined resource utilization in patients with angina pectoris. These studies have examined the direct costs of chronic angina using national health statistics, as well as information in 2 large clinical trials—the COURAGE and MERLIN-TIMI 36 trials.1,6,7 However, no data exist comparing the manifestation of CAD with or without documented angina.Few US studies have examined treatment patterns, resource utilization, and the cost of care for patients with CAD plus angina. Javitz and colleagues, who conducted the only database study to investigate the annual direct medical costs of chronic angina, reported annual costs ranging from $1.9 billion to $74.8 billion, depending on the way in which angina was defined.8 The study was conducted from a societal perspective, using the National Center for Health Statistics'' public-use databases. Given the considerable burden of stable ischemic heart disease and the paucity of information about its economic impact, with particular emphasis in the public healthcare sector, the objective of the current study was to compare real-world treatment patterns and costs of CAD with angina versus CAD without angina in a large, commercially insured, managed care population.     

Monitoring Health Care for Children with Chronic Conditions in a Managed Care Environment

Objective: Children with chronic health conditions face special issues in their interactions with managed care. These children often require additional and more varied services than do other children. Managed care plans increasingly include these children, especially with the growth of Medicaid managed care. This article examines the special issues facing children with chronic conditions and develops strategies for monitoring their care in managed care settings. Methods: The project staff conducted an extensive review of the research and policy literature related to managed care and the special needs of families with children with chronic conditions. The project also reviewed current and proposed plans of federal, state, and private groups for monitoring and, working with parents and other outside groups, identified key issues to consider in developing monitoring plans. Results: The relative rarity of many childhood conditions and the complex interactions among child, family, and community over time make assessment of their care difficult. We describe these child and family characteristics, outline essential features and domains for monitoring systems, and describe population-based and plan-based monitoring systems to assess managed care for these children and their families. Conclusions: Monitoring for children with chronic conditions in managed care arrangements will require public health agencies and health providers to define populations systematically, assess across a variety of conditions, and monitor several domains central to the health of these families.     

Prevalence and Management of Anemia Among Patients with Chronic Kidney Disease in a Health Maintenance Organization

Background: Anemia often develops among patients with chronic kidney disease (CKD) and is an important cause of cardiovascular disease among patients with end-stage renal disease (ESRD). Objective: To evaluate the epidemiology and treatment of anemia among patients with CKD by undertaking an analysis of data from one Health Maintenance Organization. Methods: The CKD cohort was comprised of 1658 patients followed between 1 January 1994 and 1 December 1997 who had serum creatinine (SCr) levels above gender-specific norms. The prevalence of anemia and epoetin-α (recombinant human erythropoietin) use was determined, and the association with anemia and kidney function was assessed with multinomial logistic regression analysis. Results: 36% of patients with CKD had anemia, with at least two hematocrit (HCT) values (separated by ≥30 days) lower than the gender-specific norm (<42% for males, <36% for females). Eleven per cent of patients had a lowest HCT value less than the gender-specific norm but ≥33%, 6% had a lowest HCT value 30 to 32.9%, and 19% had a lowest HCT value <30%. The prevalence of anemia was positively correlated with the severity of kidney dysfunction.In the multivariate analysis, the independent relative risk of an HCT value <30% versus no anemia was 84.5, 9.8 and 2.0 for patients with SCr level ≥4.0, 3.0 to 3.9 and 2.0 to 2.9 mg/dl, respectively, compared with patients with SCr level <2.0 mg/dl. Epoetin-α was prescribed for only 7.4% of patients and, more significantly, for only 23% of patients with an HCT value <30%. Even among patients with an HCT value <30% who had received care from a nephrologist, only 66% received epoetin-α. Conclusions: This study demonstrates that the prevalence of anemia among patients with CKD is high and the management of anemia is suboptimal. Suboptimal treatment of anemia during CKD may lead to increased cardiovascular morbidity and cost of care among patients with CKD and ESRD.     

Rehabilitation Nutrition in Patients with Chronic Kidney Disease and Cachexia

Rehabilitation nutrition is a proposed intervention strategy to improve nutritional status and physical function. However, rehabilitation nutrition in patients with cachexia and protein-energy wasting (PEW), which are the main nutrition-related problems in patients with chronic kidney disease (CKD), has not been fully clarified. Therefore, this review aimed to summarize the current evidence and interventions related to rehabilitation nutrition for cachexia and PEW in patients with CKD. CKD is a serious condition worldwide, with a significant impact on patient prognosis. In addition, CKD is easily complicated by nutrition-related problems such as cachexia and PEW owing to disease background- and treatment-related factors, which can further worsen the prognosis. Although nutritional management and exercise therapy are reportedly effective for cachexia and PEW, the effectiveness of combined nutrition and exercise interventions is less clear. In the future, rehabilitation nutrition addressing the nutritional problems associated with CKD will become more widespread as more scientific evidence accumulates. In clinical practice, early intervention in patients with CKD involving both nutrition and exercise after appropriate assessment may be necessary to improve patient outcomes.     

PEER REVIEWED: Chronic Kidney Disease: A Public Health Problem That Needs a Public Health Action Plan

For a health problem or condition to be considered a public health issue, four criteria must be met: 1) the health condition must place a large burden on society, a burden that is getting larger despite existing control efforts; 2) the burden must be distributed unfairly (i.e., certain segments of the population are unequally affected); 3) there must be evidence that upstream preventive strategies could substantially reduce the burden of the condition; and 4) such preventive strategies are not yet in place. Chronic kidney disease meets these criteria for a public health issue. Therefore, as a complement to clinical approaches to controlling it, a broad and coordinated public health approach will be necessary to meet the burgeoning health, economic, and societal challenges of chronic kidney disease.     

慢性病自我管理计划用于慢性肾脏病患者护理中的效果

目的 探讨慢性病自我管理计划应用于慢性肾脏病患者护理中的效果.方法 68例慢性肾脏病患者随机分为两组各34例,对照组采用常规护理,观察组在常规护理基础上采用慢性病自我管理计划,比较两组护理前后的自我管理能力评分及肾功能.结果 护理后6个月,观察组的自我管理能力评分显著高于对照组,Scr、BUN、PRO水平均显著低于对照...     

初诊2型糖尿病患者微血管病变与相关危险因素分析

目的:分析初诊2型糖尿病患者微血管病变(周围神经病变、视网膜病变、糖尿病肾病)与其相关危险因素关系.方法:对120例新诊断的2型糖尿病患者进行神经传导速度、眼底荧光造影和尿微量白蛋白及相关指标测定,计算微血管病变的患病率,并对相关因素分析.结果:(1)初诊患者中糖尿病周围神经病变的患病率为34.6%,糖尿病视网膜病变的患病率为15.4%,糖尿病肾病的患病率为13.4%.(2)年龄、空腹血糖、餐后2 h血糖、收缩压、舒张压、糖化血红蛋白、总胆固醇均为糖尿病周围神经病变的独立危险因素.(3)糖化血红蛋白、尿微量白蛋白、收缩压为糖尿病视网膜病变独立危险因素.结论:初诊2型糖尿病患者有一定微血管病变患病率,应强化对血压、血糖、血脂相关危险因素的干预以控制和延缓糖尿病微血管病变的发生、发展.     

Analysis of Health Care Costs in Elderly Patients with Multiple Chronic Conditions Using a Finite Mixture of Generalized Linear Models

In this paper we analysed healthcare costs in a sample of elderly patients suffering from multimorbidity. On the one hand, multimorbid individuals consume a disproportionally large share of healthcare resources. On the other hand, the patient specific number and combination of co‐occurring single diseases result in inhomogeneous data leading to biased estimates when using traditional regression techniques. Therefore, we applied a mixture of regressions in order to control for unobserved heterogeneity focussing on the identification of multimorbidity patterns. We used a subsample of N = 1050 patients from a multicentre prospective cohort study of randomly selected multimorbid primary care patients aged 65 to 85 years in Germany (ISRCTN 89818205) who completed a detailed questionnaire on healthcare utilization during the 6‐month period preceding the interview. Disease combinations of 1047 were included. We detected four different groups of patients with regard to total costs. These groups corresponded largely to findings from the epidemiological literature. The effect of the presence of an additional disease on costs differed between groups. Moreover, two diametrically opposed cost trends were detected with respect to the number of co‐occurring diseases. While in one group costs increased with the number of co‐occurring diseases, in a second group cost tended to decrease. Copyright © 2016 John Wiley & Sons, Ltd.     

Vitamin and Mineral Deficiencies Are Highly Prevalent in Newly Diagnosed Celiac Disease Patients

Malabsorption, weight loss and vitamin/mineral-deficiencies characterize classical celiac disease (CD). This study aimed to assess the nutritional and vitamin/mineral status of current “early diagnosed” untreated adult CD-patients in the Netherlands. Newly diagnosed adult CD-patients were included (n = 80, 42.8 ± 15.1 years) and a comparable sample of 24 healthy Dutch subjects was added to compare vitamin concentrations. Nutritional status and serum concentrations of folic acid, vitamin A, B₆, B₁₂, and (25-hydroxy) D, zinc, haemoglobin (Hb) and ferritin were determined (before prescribing gluten free diet). Almost all CD-patients (87%) had at least one value below the lower limit of reference. Specifically, for vitamin A, 7.5% of patients showed deficient levels, for vitamin B₆ 14.5%, folic acid 20%, and vitamin B₁₂ 19%. Likewise, zinc deficiency was observed in 67% of the CD-patients, 46% had decreased iron storage, and 32% had anaemia. Overall, 17% were malnourished (>10% undesired weight loss), 22% of the women were underweight (Body Mass Index (BMI) < 18.5), and 29% of the patients were overweight (BMI > 25). Vitamin deficiencies were barely seen in healthy controls, with the exception of vitamin B₁₂. Vitamin/mineral deficiencies were counter-intuitively not associated with a (higher) grade of histological intestinal damage or (impaired) nutritional status. In conclusion, vitamin/mineral deficiencies are still common in newly “early diagnosed” CD-patients, even though the prevalence of obesity at initial diagnosis is rising. Extensive nutritional assessments seem warranted to guide nutritional advices and follow-up in CD treatment.     

慢性肾脏疾病非透析患者医院感染调查分析

目的 了解慢性肾脏疾病非透析患者医院感染的特点及相关因素。方法 对2003年6月1日-2006年6月1日间，996例慢性肾脏疾病非透析患者的临床资料进行回顾分析，其中112例发生医院感染，对感染部位、病原菌、肾功能、血清白蛋白、血红蛋白等进行比较分析。结果 112例医院感染患者共发生了124例次感染，感染率为11．2％，比同期总医院感染率6．8％显著增高（P〈0．05），病死率为20．5％，较未发生医院感染的慢性肾脏疾病非透析患者明显升高（P〈O．01）；感染部位主要为泌尿道（46．4％）和肺部（36．9％），病原菌检出革兰阳性菌28例次、革兰阴性菌21例次、真菌8例次，混合感染22例次，肾功能、血清白蛋白、血红蛋白与医院感染有相关性。结论 慢性肾脏疾病非透析患者医院感染病原菌主要是革兰阳性菌，以泌尿道感染发生率较高，肾功能不全、低白蛋白血症、低血红蛋白、广谱抗菌药物应用、侵袭性操作等均是医院感染的危险因素。     

慢性肾脏病不同分期血红蛋白水平的变化及其影响因素分析

目的探讨慢性肾脏病（CKD）患者血红蛋白水平的基础状况。方法对中山大学附属第三医院。肾内科门诊就诊的CKD患者进行为期9个月的前瞻性横断面调查。结果共有655例CKD病例入选。前四位慢性肾脏病的病因分别为原发性肾小球疾病、狼疮肾炎、高血压肾病和糖尿病肾病。CKD3期以后,患者血红蛋白水平逐级降低,贫血发生率逐级上升,差异均有显著性（P〈0．01）。多元回归分析结果显示,血红蛋白水平与肾小球滤过率、体质指数、血白蛋白水平、原发性肾小球疾病呈显著性正相关（P〈0．01）,与收缩压、年龄呈显著性负相关（P〈0．05）。结论血红蛋白水平是慢性肾脏病患者CKD3期以后肾脏病情动态变化的重要指标。