MGA5 Health Utilities Index: Further Evidence of Responsiveness

Quality adjusted life years (QALYs) are well recognized as a valid measure for outcomes in cost-effectiveness analyses. However, it is difficult to obtain a summary utility score from health status measure such as the SF-36.
OBJECTIVE: To predict a summary utility score (represented by HUI) from the scores on the SF-36.
METHODS: A structural equation framework was applied to data collected from 1992 to 1995 on the Southern California Kaiser Permanente population (n = 5,794). An instrumental variable (IV) method mitigated the endogeneity in estimating the HUI(MarkII). Socioeconomic and disease variables were used as covariates. A split-sample analysis provided cross-validation.
RESULT: This model predicted 33.68% of the observed variance in HUI index scores with an adjusted R²of 0.3335. Observed HUI index scores were distributed with a mean of 0.7963 and std. deviation of 0.1796. Parameter estimates of most of the SF-36 components (except General Health & Social Functioning) showed statistical significance at α= 0.05 level. People with high chronic disease scores were found to have low SF-36 scores, and parameter estimates of this covariate were also found statistically significant at α= 0.05 level in all structural equations. However, all the socioeconomic variables showed statistical insignificance. Comparison of "Forecasting" and "Estimation" sub-samples showed satisfactory results during cross-validation.
CONCLUSION: Result of this study provides a quantitative link between two important measures of health status. The present model can be used to estimate overall health utility summary scores from previous studies using the SF-36.     

PHB1 Efficient Strategies for Osteoporosis Testing

There are multiple screening and testing tools for osteoporosis. We need to understand the most cost-efficient way to utilize these tools to identify postmenopausal women with osteoporosis. The objective of this study was to identify efficient strategies for detecting low bone mass in postmenopausal women and estimate the incremental cost per case found.
METHODS: The study sample consists of 392 women age >50. Each participant completed the Simple Calculated Osteoporosis Risk Estimation (SCORE ^* ) (a prescreening questionnaire), and bone mineral density (BMD) levels were collected at different skeletal sites. Assumed costs were: $5 for SCORE, $35 for peripheral site (pDXA) testing at the forearm, $120 for single central (DXA) site testing at hip or spine, and $200 for multiple site DXA. An osteoporotic woman was defined as a woman with BMD < −2 SD below peak adult mean at any site.
RESULTS: The cost, efficient frontier consisted of 7 strategies ranging in cost from $33 to $189 per patient, with corresponding sensitivity of 53% to 100%. The incremental cost per case found ranged from $62.30 to $1,100. Most importantly, the current gold standard (testing all women at the hip and spine) is not on the efficient frontier.
CONCLUSION: The efficiency of osteoporosis testing can be greatly increased through the appropriate use of sequential instruments to identify postmenopausal women with osteoporosis.     

Community Care of Older Women Living Alone

This paper compares the formal and informal care used by women living alone and women living with others using data from a household survey of women over 65. In contrast to those living with others, who use few formal services and receive most of their care from the children they live with, those living alone rely on a diverse group of informal caregivers and formal services, many of which are provided in their homes. Women living alone also report using mechanical devices more often, and are less confident that assistance will be available in the event of illness. Results are discussed from psychological and organizational perspectives.     

Postponement of Health Care by Unmarried Older Women

This longitudinal research examined postponement of needed health care by unmarried older women. This research is timely since the unmarried are projected to be an increasing proportion of the aged population. Relationships between being unmarried (widowed, separatedtdivorced. never married) and postponement of treatment, reasons for postponement of care, and changes in health care behavior were examined. Data were analyzed from 1,159 widowed, 264 never married, and 251 separatedldivorced women age 58 to 63 years at the time of the initial interview. Marital status was associated with postponing care and reasons for delaying care. The proportion of women who failed to obtain care and their reasons for doing so were fairly stable over a decade. Distress over finances tended to be more salient in determining postponement of care than health status. Formerly married and never-married women had somewhat different reasons for delaying care suggesting the need for targeted interventions by professionals.     

Older Jail Inmates and Community Acute Care Use

Objectives. We examined older jail inmates’ predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release.Methods. We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use.Results. We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89).Conclusions. The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.Jail has become a critical site for linking medically vulnerable older adults to community health care. Approximately 12 million Americans pass through jails each year and nearly all return to the community within 6 months where many struggle to access nonemergency medical care. Between 1996 and 2008 the number of “older” or “geriatric” inmates (aged 55 years or older) increased 278% compared with a 53% growth in the overall jail population.1,2 Now, approximately 550 000 older adults spend time in jail each year, comprising 10% of all inmates. Yet little is known about their health care and social service needs.Reducing acute care use (hospitalizations and emergency department [ED] use) and improving insurance access for former inmates is a priority in the Affordable Care Act (ACA).3 Although most inmates are without health insurance,4 those with insurance demonstrate reduced recidivism and better access to mental health and substance abuse treatment when released.5–7 The ACA expands Medicaid eligibility for low-income adults and allows eligible inmates to apply for coverage while in jail.3,8 As most persons passing through jails will be eligible for Medicaid in states participating in the expansion, an estimated 4 to 6 million jail inmates will gain new coverage by the end of 2014 through outreach and patient navigator assistance.9For community-dwelling older adults, health and social factors beyond insurance drive community acute care use, such as functional impairment, uncontrolled symptoms, and housing instability.10–12 This may also be true for older former inmates, many of whom experience “accelerated aging” because of high rates of disability and chronic disease at relatively young ages.13 Therefore, we conducted a study of older jail inmates to describe predetainment acute care use and anticipated plans for using acute care after release, and to assess the factors associated with use.     

Cost-Effectiveness of Chemotherapy for Breast Cancer and Age Effect in Older Women

BackgroundPrevious economic evaluations compared specific chemotherapy agents using input parameters from clinical trials and resource utilization costs. Cost-effectiveness of treatment groups (drug classes) using community-level effectiveness and cost data, however, has not been assessed for elderly patients with breast cancer.ObjectiveTo assess the cost-effectiveness of chemotherapy regimens by age and disease stage under “real-world” conditions for patients with breast cancer.MethodsThe Surveillance Epidemiology and End Results-Medicare data were used to identify patients with breast cancer with American Joint Committee on Cancer stage I/II/IIIa, hormone receptor–negative (estrogen receptor–negative and progesterone receptor–negative) patients from 1992 to 2009. Patients were categorized into three adjuvant treatment groups: 1) no chemotherapy, 2) anthracycline, and 3) non–anthracycline-based chemotherapy. Median life-years and quality-adjusted life-years (QALYs) were measured using Kaplan-Meier analysis and were evaluated against average total health care costs (2013 US dollars).ResultsA total of 4575 patients (propensity score–matched) were included for the primary analysis. The anthracycline group experienced 12.05 QALYs and mean total health care costs of $119,055, resulting in an incremental cost-effectiveness ratio of $7,688 per QALY gained as compared with the no chemotherapy group (QALYs 7.81; average health care cost $86,383). The non–anthracycline-based group was dominated by the anthracycline group with lower QALYs (9.56) and higher health care costs ($122,791). Base-case results were found to be consistent with the best-case and worst-case scenarios for utility assignments. Incremental cost-effectiveness ratios varied by age group (range $3,790–$90,405 per QALY gained).ConclusionsAnthracycline-based chemotherapy was found cost-effective for elderly patients with early stage (stage I, II, IIIa) breast cancer considering the US threshold of $100,000 per QALY. Further research may be needed to characterize differential effects across age groups.     

Concurrent Alcohol Use or Heavier Use of Alcohol and Cigarette Smoking Among Women of Childbearing Age with Accessible Health Care

This study was conducted to provide nationally representative findings on the prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age with accessible health care. For the years 2003–2005, a total of 20,912 women 18–44 years of age who participated in the National Health Interview Survey (NHIS) reported that during the study period, there was a place where they would usually go for health care when sick or in need of advice about their health. The prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking reported by such women was calculated. Logistic regression analysis was used to evaluate the “most often visited health care place” among concurrent users who reported having seen or talked to a health care provider during the previous 12 months. Among surveyed women with accessible health care, 12.3% reported concurrent alcohol use and cigarette smoking, and 1.9% reported concurrent heavier use of alcohol and cigarette smoking during the study period. Of women who reported either type of concurrent use, at least 84.4% also indicated having seen or talked to one or more health care providers during the previous 12 months. Such women were more likely than non-concurrent users to indicate that the “most often visited health care place” was a “hospital emergency room or outpatient department or some other place” or a “clinic or health center,” as opposed to an “HMO or doctor’s office.” Concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age is an important public health concern in the United States. The findings of this study highlight the importance of screening and behavioral counseling interventions for excessive drinking and cigarette smoking by health care providers in both primary care and emergency department settings.     

MM3 Development of Drug Use Performance Models as Measures of Patient Care

Results from economic analyses of the effectiveness of new therapeutic innovations determine whether a new product will be reimbursed by a managed care organization or government agency. Often, the results of these economic analyses are presented as formal empirical analyses in scientific journal articles. With the pace of medical innovations submitted for approval on a payers fee schedule or formulary list ever increasing, it is important to convey the results of analysis as effectively and efficiently as possible. In response, interactive computer models have been developed to present the key findings of an economic analysis. Ideally, these models allow a potential buyer to customize a scientific analysis to determine their own reservation price for a new product. The quality and costs of these software applications vary-geatly. Given the resources expended to develop these models and time to produce them, it useful to examine the features of cost-effective "laptop model" design. This workshop will review an inventory of the features of laptop models. Participants will gain an understanding of the development process and costs for developing these models from the conceptual development phase to production of a stand-alone software application. A checklist of critical ingredients for software development will be reviewed with a special focus on role of a multidisciplinary development team and the capital resources required. A review of the discordance between scientists, biomedical manufactrures, software applications developers and potential clients and methods to gain consensus to build the application will be discussed. Examples from Project HOPE's and other firms' software development initiatives will be demonstrated as successful applications currently in use. Participants with a basic knowledge of computer applications, cost-effectiveness methods, and systems analysis will likely gain the most from this workshop.     

CM6 The use of Patient Self-Reports to Collect Health Care Resource Utilization Data

The conversion of hospital bill charges using Uniform Bill (UB)-92s and Medicare Ratios of Cost of Charges (RCCs) to costs in economic analyses is one of the most efficient, accurate and accessible ways of measuring resource consumption for US hospitalizations.
OBJECTIVES: We used the hospital bill charges to cost conversion method in our analysis of over 3,000 patients with 4,700 hospital bills in the recently completed PURSUIT pharmacoeconomic substudy. Using the PURSUIT trial experience as a model, this workshop will provide a detailed explanation of the cost to charge conversion methodolgy. We will begin with a detailed procedure for incorporating this method of cost collection into a clinical trial's overall protocol and case repot form. We will explain how to ensure collection of bills for all patient hospitalizations and procedures; how to interpret the UB-92; how to extract charges from the UB-92 and convert those charges into costs using each hospital's Medicare Ratio of Cost to Charges. This workshop will also explore mechanisms for ensuring successful compliance across sites in large, randomized clinical trails including inservice training for coordinators and common obstacles to successful and complete collection. In addition, the workshop will explore the limitations and strengths of this method compared with other cost collection methods. This workshop will be particularly useful to project leaders, clinical trial coordinators, and database managers interested in performing economic analyses as part of larger clinical trials or as stand-alone endeavors.     

PHB9 Use of Centralized Pharmacy Records in a Managed Care Organization to Determine Effect of Educational Material on Hormone Replacement Therapy Patient Compliance

OBJECTIVES: To study differences among two regimens of estrogen/progestin replacement therapy in post-menopausal women with respect to quality of life, pharmacoeconomics, bleeding pattern, compliance, and safety profile.
METHODS: A 12-center, randomized, comparative dose study was conducted in 183 women (mean age: 53.9 years) randomized to one of two treatment arms: Prometrium™ 200 mg (n = 90) or Provera® 5 mg (n = 93) administered in a single daily dose for 14 days in a 30-day cycle. All patients received 0.625 mg Premarin® for 25 of the 30 days. Quality of life was measured by the Nottingham Health Profile (NHP), Woman's Health Questionnaire (WHQ), and Short Form 36 (SF-36).
RESULTS: Improvements in climacteric symptoms were observed between baseline and month 9 within both groups. All domains within the NHP and WHQ improved significantly for both patient groups (p < 0.008), and greater improvements were observed for Prometrium patients in the Menstrual Problems and Cognitive Difficulties domains of the WHQ. While Prometrium patients reported an improvement in the Menstrual Problems domain, Provera patients reported a worsening. The number of cycles with bleeding was significantly higher for the Provera patients (p = 0.001). Average nine-month societal menopausal costs/patient were $367 ±$120 (Cdn) for Prometrium patients and $360 ±$369 (Cdn) for Provera patients (not statistically significant). Although costs were variable, offsetting savings for Prometrium patients were observed in out-of-pocket expenses and missed time from work.
CONCLUSIONS: This study highlights important quality of life and cost aspects of Prometrium and Provera use that may impact longer term compliance when patients use Prometrium + Premarin regimens.     

Impact of Cognitive Impairment on Screening Mammography Use in Older US Women

Objectives. We evaluated mammography rates for cognitively impaired women in the context of their life expectancies, given that guidelines do not recommend screening mammography in women with limited life expectancies because harms outweigh benefits.Methods. We evaluated Medicare claims for women aged 70 years or older from the 2002 wave of the Health and Retirement Study to determine which women had screening mammography. We calculated population-based estimates of 2-year screening mammography prevalence and 4-year survival by cognitive status and age.Results. Women with severe cognitive impairment had lower rates of mammography (18%) compared with women with normal cognition (45%). Nationally, an estimated 120 000 screening mammograms were performed among women with severe cognitive impairment despite this group''s median survival of 3.3 years (95% confidence interval = 2.8, 3.7). Cognitively impaired women who had high net worth and were married had screening rates approaching 50%.Conclusions. Although severe cognitive impairment is associated with lower screening mammography rates, certain subgroups with cognitive impairment are often screened despite lack of probable benefit. Given the limited life expectancy of women with severe cognitive impairment, guidelines should explicitly recommend against screening these women.Screening mammography guidelines suggest that women with a life expectancy less than 4 to 5 years at the time of screening are unlikely to benefit from breast cancer screening and, thus, should not be screened.^1–3 Although some cancer screening guidelines specify upper-age cutoffs for stopping screening as a surrogate for life expectancy (e.g., prostate-specific antigen screening guidelines suggest stopping at age 75 years),⁴ we do not know of any guidelines that specify the types of comorbidity that would preclude screening. This is despite the fact that certain comorbid conditions, such as dementia, are stronger predictors of life expectancy than age.⁵ Specifically, patients with dementia generally live less than 5 years^6–12 and therefore are unlikely to benefit from screening mammography.In addition, having dementia or severe cognitive impairment increases the likelihood that elderly women will experience harm from screening mammography (e.g., more psychological distress from false-positive results because of the inability to understand screening procedures, and more complications from the treatment of clinically insignificant disease).^13,14 Moreover, screening mammography can distract care away from more pressing medical problems arising from either the cognitive impairment itself or from other comorbid conditions. However, it is unknown how often these women with severe cognitive impairment in the United States are undergoing screening mammography.A few prior studies have examined screening mammography rates in women with cognitive impairment; however, they relied on self-report of screening mammography, which is likely to be inaccurate among women with cognitive impairment^15–17 or older studies limited to a local geographic area.^17,18 To our knowledge, there have not been any recent national studies that have used objective measures, such as Medicare claims, to document the actual mammography rates in older women with severe cognitive impairment. Such data are needed to determine current practice patterns and to identify whether cognitive status appropriately factors into screening mammography decisions.Therefore, we conducted a study to document the actual rates of screening mammography in a US-representative sample of older women stratified according to their cognitive status. We used Medicare claims data linked to the Health and Retirement Study (HRS) to define rates of screening mammography (based on claims data) for women with differing levels of cognitive impairment. We also calculated survival according to level of cognitive impairment to validate that women with severe cognitive impairment defined by a standardized instrument have a median survival less than 5 years and are therefore unlikely to benefit from screening mammography.     

PHB8 Cost-Effectiveness of Hormone Therapy Versus Calcium Therapy: An Osteoporosis Markov Model

Osteoporosis is a chronic degenerative disease with concentrated prevalence in the most rapidly growing segment of the population, the elderly. Its clinical and economic consequences are substantial. This study assesses the cost-effectiveness of two gold standard therapeutic approaches to reducing the impact of related fractures.
OBJECTIVES: To determine the cost-effectiveness ratios of the two therapeutic approaches. To model the cohort progression through the Markov states.
METHODS: Using published literature values, a Markov model was constructed. The model depicts a cohort of 1,000 women progressing from age 50 to 90 years or death, whichever comes first. The hormone therapy alternative includes calcium supplementation as part of the regimen. The model accounts for the following confounders: age dependent rate of death, predisposition to subsequent fracture, and the cardioprotective effect of hormone therapy. Sensitivity analysis was conducted on all relevant variables to assess the robustness of the findings. The primary outcome of interest was cost per fracture avoided. Additionally, Markov analysis of the model reports the distribution of women across each Markov state.
RESULTS: The study revealed that hormone therapy is more cost-effective than calcium therapy. Cost-effectiveness ratios for the two alternatives were $43,729.82 and $87,003.53 per fracture avoided for hormone therapy and calcium therapy, respectively. The incremental cost-effectiveness ratio was $32,828.60, indicating the cost of avoiding each additional fracture using the less desirable calcium therapy. The cardioprotective effect of hormone therapy accounted for nearly 3 additional years of life for each woman on therapy.
CONCLUSIONS: Hormone replacement therapy in conjunction with calcium supplementation is far more cost-effective than calcium supplementation alone.     

MM1 Monte Carlo Simulation in Health Care Models

In this workshop we will focus on Monte Carlo disease simulations and how they can be used to perform economic evaluations of health care interventions. Monce Carlo disease simulation is a modeling technique that operates on a patient level basis, explicitly estimating the effect of variability among patients in both underlying disease progression patterns and in individual responsiveness to treatments. Typical outputs from these simulations are patient functional status, life years, quality-adjusted life years, and associated costs, all of which can be appropriately discounted. The output information is presented in the form of distributions which can be used to estimate mean or median values and confidence intervals for the outcomes of interest. These results can be used to compute cost-effectiveness ratios and other drug value measures. Monte Carlo disease simulation also allows decision makers to address the question of risk associated with smaller populations that may not tend to the "average" results generated by Markov models or simulations of large populations. In this workshop, we describe how to create a Monte Carlo simulation model and how different types of uncertainly can be incorporated into the model. We will briefly compare and contrast Monte Carlo and Markov simulation techniques. Discussion topics will be illustrated and motivated by an HIV/AIDS model of the effect of combination antiretroviral therapy on viral load and CD4 progression. This workshop should be beneficial to outcomes researchers and health care decision makers who need to incorporate uncertainty about the natural history of a disease and the impact of alternative disease management strategies for individual patients into their drug value analyses.     

PMD6 Chronic Care Costs of New Medicare HMO Enrollees: Implications for Disease Management

Cost-effective care for chronic conditions is a growing concern of health plans enrolling increasing numbers of the elderly and disabled under Medicare risk contracts. This study provides evidence of the prevalence, patterns of care, and costs of chronic illnesses among new Medicare HMO enrollees. The results provide a foundation for estimates of the cost-effectiveness of drug therapy and care management programs that serve this group.
METHODS: We used national Medicare claims data to examine chronic care services and associated costs for a sample of 19,084 beneficiaries who enrolled in an HMO in 1995. We constructed three measures of cost: the total Medicare-covered cost, the cost of medical claims with the chronic condition coded as a diagnosis, and the regression-estimated effect of the chronic condition on cost.
RESULTS: 58% of the new Medicare HMO enrollees in our sample were treated for at least one of the selected chronic conditions in the six months before enrollment. One-third of the new enrollees had multiple conditions represented by diagnoses in more than one of eighteen chronic-condition groups. Persons with chronic conditions accounted for 93% of pre-enrollment Medicare costs among new HMO enrollees. Per 1,000 enrollees, pre-enrollment Medicare costs were greatest for those with hypertensive disease, coronary heart disease, heart failure, and diabetes.
CONCLUSIONS: The concentration of utilization and costs in those with chronic conditions suggests that appropriate drug therapy and care management for those with chronic conditions should be a top priority for HMOs with Medicare risk contracts. These estimates of prevalence suggest a need for HMOs to screen new Medicare HMO enrollees for chronic conditions immediately upon enrollment to ensure continuity of care.