Anemia in chronic obstructive pulmonary disease: epidemiology and economic implications

ABSTRACT

Background: Anemia in chronic illness is associated with increased healthcare resource utilization (HRU) and costs. In COPD, it occurs frequently and influences both clinical and economic outcomes. Because no data studies have been performed either in a single center or a subpopula­tion of COPD patients, anemia's influence on the outcomes is not fully understood.

Research design and methods: We conducted a retrospective cohort study in a large healthcare database to quantify prevalence, HRU and costs of anemia in COPD. From 1997 to 2005, patients ≥?45 years of age with an ICD-9 diagnosis code for COPD and >?3.5 years of follow-up were included. Anemia was defined by the WHO criteria. Other disease states for which anemia is a known complication were excluded. We calculated the prevalence of anemia and compared annual HRU and costs between COPD patients with and without anemia. Multiple regression analysis adjusted for the effects of age, gender, race, length of enrollment, diagnosing physician specialty, co-morbidity burden, anemia and COPD severity.

Results: Of the 2404 patients with COPD, 33% (n = 788) had a diagnosis of anemia. Anemic patients were older, more likely to be male and non-Caucasian, and had a greater co-morbidity burden than non-anemic individuals. Annual costs for COPD patients with anemia were more than twice those for patients without anemia ($17?240 vs. 6492, p < 0.001, unadjusted). HRU was also significantly greater among anemic than non-anemic COPD patients (?p < 0.0001). In a multiple regression analysis, anemia accounted for $7929 per patient (95% CI: $5572–10?599) of the total costs of care.

Limitations: This is a retrospective cohort study and thus subject to multiple forms of bias. Although spirometric evidence of COPD was available only for a subgroup of patients, our case identification methods have been previously validated and found to be accurate in recognizing COPD.

Conclusions: Anemia is a common co-morbidity in COPD. It is significantly associated with an increase in HRU and costs of care for COPD, independent of demographic and clinical patient characteristics.     

Healthcare costs among adults with type 2 diabetes initiating saxagliptin or linagliptin: a US-based claims analysis

Objective: To compare healthcare costs of adults with type 2 diabetes (T2D) after initiation of saxagliptin or linagliptin, two antidiabetic medications in the dipeptidyl peptidase-4 inhibitor medication class.

Methods: Patients with T2D who were at least 18 years old and initiated saxagliptin or linagliptin (index date) between 1 June 2011 and 30 June 2014 were identified in the MarketScan Commercial and Medicare Supplemental Databases. All-cause healthcare costs and diabetes-related costs (T2D diagnosis on a medical claim and/or an antidiabetic medication claim) were measured in the 1 year follow-up period. Saxagliptin and linagliptin initiators were matched using propensity score methods. Cost ratios (CRs) and predicted costs were estimated from generalized linear models and recycled predictions.

Results: There were 34,560 saxagliptin initiators and 18,175 linagliptin initiators identified (mean ages 57 and 59; 55% and 56% male, respectively). Before matching, saxagliptin initiators had significantly lower all-cause total healthcare costs than linagliptin initiators (mean?=?$15,335 [SD $28,923] vs. mean =?$20,069 [SD $48,541], p?p?n?=?16,069 per cohort), saxagliptin initiators had lower all-cause follow-up costs than linagliptin initiators (CR?=?0.953, 95% CI?=?0.932–0.974, p?p?=?0.017; predicted costs?=?$3989 vs. $4159).

Conclusions: Adult patients with T2D initiating treatment with saxagliptin had lower total all-cause healthcare costs and diabetes-related medical costs over 1 year compared with patients initiating treatment with linagliptin.     

Resource use and costs in patients with poorly controlled type 2 diabetes mellitus and obesity in routine clinical practice in Spain

Abstract

Objective

To compare healthcare resource use (HRU) and annual costs in type 2 diabetes mellitus (T2DM) patients with poor glycaemic control and obesity versus good glycaemic control without obesity.     

Transitioning from oral risperidone or paliperidone to once-monthly paliperidone palmitate: a real-world analysis among Veterans Health Administration patients with schizophrenia who have had at least one prior hospitalization

Abstract

Objective: To address gaps in the literature on healthcare resource utilization (HRU) and costs among patients with schizophrenia and prior hospitalization who transition from oral risperidone or paliperidone (oral ris/pali) to once-monthly paliperidone palmitate (PP1M) in a real-world setting by comparing treatment patterns, HRU, and costs 12-months pre- and post-transition to PP1M among Veterans Health Administration (VHA) patients affected by schizophrenia who have had ≥1 hospitalization.

Methods: VHA patients with schizophrenia (aged ≥18?years) who initiated oral ris/pali, had ≥1 all-cause inpatient stay, and transitioned to PP1M from January 2015–March 2017 were included from the VHA database. The first transition date to PP1M was identified as the index date. Patients were required to have continuous health plan eligibility for 12?months pre- and post-PP1M. Outcomes were compared using the Wilcoxon signed-rank and McNemar’s test, as appropriate.

Results: The study included 319 patients (mean [SD] age?=?51.6 [4.2] years) during 12 months of baseline and follow-up. During pre-PP1M transition, 7.2% of the patients were adherent (proportion of days covered [PDC]?≥?80%) to oral ris/pali. Post-PP1M transition, 27.6% of the patients were adherent to PP1M. Comparison of HRU outcomes from the pre- to post-PP1M transition revealed significantly lower all-cause inpatient stays (3.5 vs 1.4, p?<?.0001) and shorter inpatient length of stay (43.4 vs 18.3?days, p?<?.0001). Similar trends were seen for mental health and schizophrenia-related HRU. Cost outcome comparison indicated significantly lower all-cause inpatient costs ($64,702 vs $24,147, p?<?.0001), total medical costs ($87,917 vs $56,947, p?<?.0001), and total costs ($91,181 vs $69,106, p?<?.0001). A similar trend was observed for mental health and schizophrenia-related costs.

Conclusions: Transitioning from oral ris/pali to PP1M may significantly improve HRU and provide potential cost savings in VHA patients with schizophrenia and ≥1 prior hospitalization.     

The economic burden of fibromyalgia: comparative analysis with rheumatoid arthritis*

ABSTRACT

Objective: To quantify and compare direct costs, utilization, and the rate of comorbidities in a sample of patients with fibromyalgia (FM), a poorly understood illness associated with chronic widespread pain that is commonly treated by rheumatologists, to patients with rheumatoid arthritis (RA), a well studied rheumatologic illness associated with inflammatory joint pain. Patients with both illnesses were isolated and reported as a third group. A secondary analysis of work loss was performed for an employed subset of these patients.

Research design and methods: Retrospective cohort analysis of Thomson Reuters MarketScan administrative healthcare claims and employer-collected absence and disability data for adult patients with a diagnosis of FM (ICD-9-CM 729.1) and/or RA (ICD-9-CM 714.0x,–714.3x) on at least one inpatient or two outpatient claims during 2001–2004.

Main outcome measures: The 12-month healthcare utilization, expenditures, and rates of comorbidities were quantified for all study-eligible patients; absence and short-term disability days and costs were quantified for an employed subset.

Results: The sample included 14?034 FM, 7965 RA, and 331 FM?+?RA patients. Patients with FM had a higher prevalence of several comorbidities and greater emergency department (ED) utilization than those with RA. Mean annual expenditures for FM patients were $10?911 (SD?=?$16?075). RA patient annual expenditures were similar to FM: $10?716 (SD?= $16?860). Annual expenditures were almost double in patients with FM+RA ($19?395, SD?= $25?440). A greater proportion of patients with FM had any short-term disability days than those with RA (20 vs. 15%); and a greater proportion of patients with RA had any absence days (65 vs. 80%). Mean costs for absence from work and short-term disability in the FM and RA groups were substantial and similar. The FM+RA group was of insufficient sample size to report on work loss.

Limitations: The availability of newer and more expensive FDA-approved medications since 2004 is not reflected in our findings. This analysis was restricted to commercially insured patients and therefore may not be generalizable to the entire U.S. population.

Conclusions: The burden of illness in FM is substantial and comparable to RA. Patients with FM incurred direct costs approximately equal to RA patients. Patients with FM had more ED, physician, and physical therapy visits than RA patients. Patients in both groups had several comorbidities. Patients with FM+RA incurred direct costs almost double those of the patients with either diagnosis alone. FM and RA patients incurred similar overall absence and short-term disability costs.     

One-year costs of ischemic heart disease among patients with acute coronary syndromes: findings from a multi-employer claims database*

ABSTRACT

Objective: Acute coronary syndromes (ACS) are life-threatening disorders requiring intensive medical management or invasive cardiovascular procedures. Limited data exist on the costs and resource utilization associated with ACS.

Methods: This retrospective single-cohort study analyzed administrative claims data from employer-sponsored plans for patients with an ACS hospitalization in 2001–2002. A 1?year follow-up period was used, and patients who were under age 35 or had an ACS diagnosis in the 12 months before the hospitalization were excluded. Costs were reported in 2005 US dollars.

Results: We identified 16?321 patients hospitalized for ACS during the study period. Mean (±?SD) age was 55.6 (±?6.7) years, 66.7% were male, and 46.3% underwent a revascularization procedure during their initial hospital­ization. Mean length of stay for the initial hospitalization was 4.6 days (median: 3.0; IQR: 2.0–5.0), and per-patient expenditures averaged $22?921 (median: $13?960; IQR: $6839–28?588). During the follow-up period, 21% of patients were rehospitalized for ischemic heart disease (IHD), and the cost of rehospitalization averaged $28?637. Additionally, in the year following the inpatient admission, 50% of patients were prescribed antiplatelet or anti­coagulant medications, and 90% of patients were prescribed lipid-lowering, antihypertensive, or anti­arrhythmic medications. IHD-related expenditures after the initial inpatient stay averaged $9425 (median: $2800; IQR: $899–7577); 61% of these costs were due to rehospitalization. Total first-year costs averaged $32?345 (median: $21?653; IQR: $10?642–41?106).

Limitations: Diagnoses could not be verified through medical charts. Payments for Medicare patients were not assessed given our focus on the working-age population.

Conclusions: In this employer-sponsored health plan population, the costs of inpatient and outpatient IHD-related care were high. Future studies should evaluate the impact of improved patient management on post-discharge costs.     

The burden of illness associated with psoriasis: cost of treatment with systemic therapy and phototherapy in the US

SUMMARY

Objective: To evaluate utilization and direct healthcare expenditures among psoriasis patients treated with systemic therapy and phototherapy in the United States.

Design: Cohort study using retrospective administrative medical claims.

Patients: Psoriasis patients treated with systemic therapy and phototherapy, as well as a matched cohort of non-psoriasis patients. All patients were covered by employer-sponsored insurance between 1 April 1996 and 31 December 2000.

Main outcome measures: Estimated risk of hospitalization and total annual healthcare expenditures overall and by comorbidity status were compared for persons with psoriasis using systemic therapy or phototherapy and persons without psoriasis. Annualized utilization rates for hospitalizations, and use of emergency department, outpatient physician, outpatient laboratory, and outpatient pharmaceutical services were also compared across the two cohorts.

Results: Seventeen percent of psoriasis patients were treated with systemic therapy or phototherapy. Patients with comorbid anemia, carcinoma, diabetes, depression, GI disorders, hepatotoxicity, hypertension, and nephrotoxicity had significantly higher expenditures than non-psoriasis patients with the same comorbidities (?p ≤ 0.05). Elevated risk of hospitalization also contributed to higher expenditures in patients treated with systemic therapy or phototherapy. Limitations of this study include those inherent in using claims data such as dependence on diagnosis coding, the fact that psoriasis severity cannot be determined directly from claims data, confounding comorbidities, and the fact that only direct healthcare expenditures were considered in this analysis.

Conclusion: Psoriasis patients treated with systemic therapies/phototherapies have significantly more comorbidities and higher mean total healthcare expenditures compared to non-psoriasis patients. Psoriasis patients with selected comorbidities have significantly higher mean total healthcare expenditures compared to non-psoriasis persons with the same comorbidities.     

The impact of anemia on quality of life and healthcare resource utilization in patients with HIV/AIDS receiving antiretroviral therapy*

ABSTRACT

Objective: To understand the impact of anemia on health-related quality of life (HRQOL) and healthcare resource utilization (HRU) in patients with HIV/AIDS.

Methods: In 2003, adults with HIV/AIDS were recruited through 114 US STD/HIV clinics to complete self-administered questionnaires. Adults reporting anemia as a side-effect of antiretroviral therapy (ART) during the past month were considered anemic. HRU was evaluated by emergency room (ER) visits, days of hospitalization, and healthcare provider visits in the past 6 months. The SF?8 was used to measure HRQOL. Linear regression was used to evaluate independent effects of anemia on HRQOL and HRU controlling for demographics, years since HIV diagnosis, HIV viral load, CD4⁺ count, and ART use.

Results: 2044 patients were enrolled, with 498 (24%) experiencing anemia. Anemic patients had lower SF?8 summary scores (mental: 38.2 ± 11.6 vs. 42.9 ± 11.9, p < 0.001; physical: 40.1 ± 10.0 vs. 45.5 ± 10.4, p < 0.001) than nonanemic patients. HRU in the anemic group was significantly higher (?p < 0.05), with respect to percentage of patients visiting ER, mean number of ER visits, mean number of days hospitalized, and mean number of total visits to providers. In linear regression models, anemic patients had mental and physical HRQOL scores more than 4 points lower than nonanemic patients (?p < 0.001 for both). Additionally, anemic patients had 2.7 more visits to healthcare providers (?p < 0.001).

Limitations: Data were cross-sectional, self-reported by patients, and did not include clinical measures of anemia.

Conclusion: Based on this survey, self-reported anemia appears to be associated with worsened HRQOL and greater HRU among HIV/AIDS patients using ART.     

Healthcare expenditures and patient satisfaction: cost and quality from the consumer's perspective in the US*

ABSTRACT

Background: Both cost and quality of healthcare are major concerns in the United States. Using patient satisfaction as a quality indicator, we seek to identify the relationship between healthcare cost and quality from the perspective of the community-dwelling population in the United States.

Methods: We examined a nationally representative sample of 13?980 adults (age?≥?18 years) in the 2003 Medical Expenditure Panel Survey (MEPS). Given the idiosyncrasies of the cost data distribution, a recently developed extended estimating equation (EEE) model was employed to identify the relationship between patient satisfaction and healthcare expenditure, after controlling for individual demographic covariates, co-morbidity profile, and functional and activity limitations. A series of sensitivity analyses were conducted, in addition, to verify the identified relationship. All statistics were adjusted using the proper sampling weight from the MEPS data.

Results: Average annual healthcare expenditures for 2003 ranged between $3923 and $6073 when grouped by patient satisfaction ratings with a mean value $4779 for all individuals who rated perceived satisfaction of their healthcare. We found that there is no statistically signif­icant relationship between patient satisfaction and total healthcare expenditure (?p?=?0.60) and a non-monotonic relationship is not identified either. All sensitivity analyses results revealed a lack of relationship between patient satisfaction and healthcare expenditures.

Limitations: Patient satisfaction might not reflect the quality of healthcare from an objective clinical standpoint. The identified cost–satisfaction relationship may not be extrapolated to other quality indicators. Due to the cross-sectional study design, no causal relationship could be inferred between patient satisfaction and healthcare expenditure.

Conclusions: Our study adds to the literature on health­care cost and quality by suggesting that the improvement of patient satisfaction may not require additional health­care spending.     

Real-world costs of ischemic stroke by discharge status

Objective: The objective of this study was to estimate the acute healthcare costs of ischemic stroke during hospitalization and the quarterly all-cause healthcare costs for the first year after discharge by discharge status.

Methods: Adult patients with a hospitalization with a diagnosis of ischemic stroke (ICD-9-CM: 434.xx or 436.xx) between 1 January 2006 and 31 March 2015 were identified from a large US commercial claims database. Patients were classified into three cohorts based on their discharge status from the first stroke hospitalization, i.e. dead at discharge, discharged with disability, or discharged without disability. Third-party (medical and pharmacy) and out-of-pocket costs were adjusted to 2015 USD.

Results: A total of 7919 patients dead at discharge, 45,695 patients discharged with disability, and 153,778 patients discharged without disability were included in this analysis. The overall average age was 59.7 years and 52.3% were male. During hospitalization, mean total costs (third-party and out-of-pocket) were $68,370 for patients dead at discharge, $73,903 for patients discharged with disability, and $24,448 for patients discharged without disability (p?p?p?p?Conclusion: The results demonstrated the high economic burden of ischemic stroke, especially among patients discharged with disability with the highest costs incurred during the inpatient stays.     

Impact of comorbid depression or anxiety on patterns of treatment and economic outcomes among patients with diabetic peripheral neuropathic pain

ABSTRACT

Objective: The objective of this retrospective analysis was to assess the correlation of comorbid depression and/or anxiety to patterns of treatment, healthcare utilization, and associated costs among diabetic peripheral neuropathic pain (DPNP) patients, employing a large US administrative claims database.

Research design and methods: Patients under age 65 with commercial insurance and patients aged 65 and older with employer-sponsored Medicare supplemental insurance were selected for the study if they had at least one diagnosis of DPNP in 2005. The first observed DPNP claim was considered the ‘index date.’ All individuals had a 12-month pre-index and 12-month follow-up period. For both populations, two subgroups were constructed for individuals with depression and/or anxiety (DPNP-DA cohort) or without these disorders (DPNP-only cohort). Patients’ demographic characteristics, clinical characteristics, and medication use were compared over the pre-index period. Healthcare expenditures and resource utilization were measured for the post-index period. Two-part models were used to examine the impact of comorbid depression and/or anxiety on healthcare utilization and costs, controlling for demographic and clinical characteristics.

Results: The study identified 11?854 DPNP-only and 1512 DPNP-DA patients in the Medicare supplemental cohort, and 11?685 and 2728 in the commercially insured cohort. Compared to DPNP-only patients over the follow-up period, a significantly higher percentage of DPNP-DA patients were dispensed pain and DPNP-related medication. All components of healthcare utilization, except home healthcare visits and physician office visits, were more likely to be provided to DPNP-DA patients versus the DPNP-only cohort (all p?<?0.01). Controlling for differences in demographic and clinical characteristics, DPNP-DA patients had significantly higher total costs than those of DPNP-only patients for Medicare ($9134, p?<?0.01) and commercially insured patients ($11?085, p?<?0.01).

Limitations: Due to the use of a retrospective administrative claims database, limitations of this study include the potential for selection bias between study cohorts, mis-identification of DPNP and/or depression, and inability to assess indirect costs as well as use and cost of over-the-counter medications.

Conclusions: These findings indicate that the healthcare costs were significantly higher for DPNP patients comorbid with depression and/or anxiety relative to those without such disorders.     

An economic model of adverse events and costs for oral anticoagulants used for atrial fibrillation

ABSTRACT

Objective: To construct a semi-Markov model to compare health outcomes and medical costs associated with warfarin and a second anticoagulant over 1- and 5-year periods.

Design: We posited a hypothetical cohort of 10?000 identical 70-year-old patients with atrial fibrillation. We posited 20 scenarios for events that included four possibilities for ischemic strokes (mild, moderate, severe, death) and 16 possibilities for hemorrhages. The model allowed for four levels of International Normalized Ratio. Event rates were based on outcomes in clinical trials and observational studies. Costs were estimated from the perspective of the third-party payer.

Results: The greatest cost-generating events were virtually the same for the two drugs and included severe stroke ($1?758?548 for 1 year for both drugs), moderate stroke ($380?355 for 1 year for both drugs), and severe lower gastrointestinal (GI) hemorrhage ($193?804 for 1 year for warfarin and $193?474 for second drug). The least costly events for both drugs were mild intracranial or intracerebral hemorrhage ($7584 for warfarin and $4314 for second drug) and fatal upper GI hemorrhage ($16?781 and $16?752). Total costs for adverse events over 5 years were similar: $18?330?662 for warfarin and $17?102?847 for the second drug. Fatalities for 5 years were 123 for warfarin and 101 for the non-warfarin drug. Varying assumptions for nursing home care and numbers of ischemic strokes and hemorrhages generated the widest variation in costs.

Limitations: We did not account for out-of-pocket expenses, ‘pain and suffering’ costs, or variation across practice settings.

Conclusions: There was substantial variation in numbers and costs of adverse events across 20 scenarios, and for fatalities between the two drugs, but variation in costs between the two drugs was modest.     

Will insomnia treatments produce overall cost savings to commercial managed-care plans? A predictive analysis in the United States

ABSTRACT

Objective: Research indicates that insomnia may contribute significantly to healthcare costs; however, information on the effects of treatments on costs has not been thoroughly published. This study presents predictive models that forecast, from the perspective of commercial managed care, the effects of insomnia medications in reducing overall medical costs. The main objectives of this study were to predict the level of cost savings associated with insomnia treatments, illustrate the variation in outcomes given underlying model assumptions, and assist managed-care policy-makers with the evaluation of medications routinely administered for insomnia.

Methods: Data on four primary-efficacy measures: wake after sleep onset (WASO), sleep efficiency (SE), sleep onset latency (SOL) and total sleep time (TST) were abstracted from published clinical trial data for eszopiclone, indiplon, low-dose trazodone, ramelteon, zaleplon, zolpidem and zolpidem extended-release. Change in per-patient per-year (PPPY) healthcare costs in a single claims database was calculated for subjects taking zolpidem, zaleplon and low-dose trazodone using generalized linear model (GLM) techniques, controlling for baseline demographics and baseline costs. Change in costs for emerging insomnia medications was forecasted by imputing efficacy values for these drugs into the regressions.

Results: Using the accepted efficacy measure, WASO, zolpidem extended-release had the overall forecasted savings of –$1253 (CI: –$1404 to –$1404) PPPY compared to remaining treatments, whereas ramelteon cost an additional $348 (–$1280 to $584) PPPY. In three out of four cost-efficacy models, zolpidem extended-release had higher mean forecasted PPPY savings.

Conclusion: This study examined cost effects of existing and emerging insomnia medications using models integrating clinical literature and medical claims within a statistical framework. The use of a single database may limit generalizability and models only address a 1?year period. Results suggest treatments can offer health plans direct cost savings, with amounts sensitive to variable and efficacy measures, potentially limited by those variables available in the claims database. Compared to other evaluated treatments, zolpidem extended-release produced consistently higher predicted cost savings.