Racial variation in healthcare resource utilization and expenditures in knee/hip osteoarthritis patients: a retrospective analysis of a Medicaid population.

BACKGROUND: Osteoarthritis (OA) is a leading cause of chronic pain and disability. Prior studies have documented racial disparities in the clinical management of OA. The objective of this study was to assess the racial variations in the economic burden of osteoarthritis within the Medicaid population. METHODS: We conducted a retrospective observational study using the MarketScan Multi-State Medicaid database (2012-2019). Newly diagnosed, adult, knee and/or hip OA patients were identified and followed for 24 months. Demographic and clinical characteristics were collected at baseline; outcomes, including OA treatments and healthcare resource use (HCRU) and expenditures, were assessed during the 24-month follow-up. We compared baseline patient characteristics, use of OA treatments, and HCRU and costs in OA patients by race (White vs. Black; White vs. Other) and evaluated racial differences in healthcare costs while controlling for underlying differences. The multivariable models controlled for age, sex, population density, health plan type, presence of non-knee/hip OA, cardiovascular disease, low back pain, musculoskeletal pain, presence of moderate to severe OA, and any pre-diagnosis costs. RESULTS: The cohort was 56.7% White, 39.9% Black and 3.4% of Other race (American Indian/Alaska Native, Hispanic, Asian, Native Hawaiian/Other Pacific Islander, two or more races and other). Most patients (93.8%) had pharmacologic treatment for OA. Inpatient admission during the 24-month follow-up period was lowest among Black patients (25.8%, p < .001 White vs. Black). In multivariable-adjusted models, mean all-cause expenditures were significantly higher in Black patients ($25,974) compared to White patients ($22,913, p < .001). There were no significant differences between White patients and patients of Other race ($22,352). CONCLUSIONS: The higher expenditures among Black patients were despite a lower rate of inpatient admission in Black patients and comparable length and number of hospitalizations in Black and White patients, suggesting that other unmeasured factors may be driving the increased costs among Black OA patients.

Higher healthcare costs were observed in Black Medicaid patients with knee/hip osteoarthritis despite lower rates of inpatient admission. We observed these differences in this Medicaid population, where socioeconomic status is more homogeneous.Black patients had significantly higher healthcare costs compared to White patients and the difference persisted even after accounting for underlying differences in Black and White patients.Higher healthcare costs among Black patients were found in both the baseline and follow-up periods overall for all types of healthcare (hospitalizations, ER, office visit, other services).Higher hospitalization costs in Black patients were observed despite lower rates of hospitalizations in Black patients. These increased costs cannot be attributed to either longer or more frequent hospitalizations; no significant difference in either the length of stay or the number of hospitalizations was observed when comparing Black patients to White patients.

Efficacy and safety of tanezumab, NSAIDs, and placebo in patients with moderate to severe hip or knee osteoarthritis and a history of depression, anxiety, or insomnia: post-hoc analysis of phase 3 trials.

Objective: Treatment outcomes for chronic pain can be poor in patients with depression, anxiety, or insomnia. This analysis evaluated the efficacy and safety of subcutaneous tanezumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and placebo in patients with osteoarthritis (OA) and a history of these conditions using data from three phase 3 studies.Methods: A post-hoc analysis of data from two pooled placebo-controlled studies and one NSAID-controlled study of subcutaneous tanezumab. All patients had moderate to severe knee or hip OA that was inadequately controlled with standard-of-care analgesics. Efficacy outcomes were least-squares mean change from baseline to Week 16 in Western Ontario McMaster Universities OA Index (WOMAC) Pain, WOMAC Physical Function, Patient's global assessment of OA, and EQ-5D-5L scores. Results were summarized for patients with and without a history of depression, anxiety, or insomnia at baseline.Results: 1545 patients were treated in the pooled placebo-controlled studies (history of depression, 12%; anxiety, 8%; insomnia, 10%; any, 23%) and 2996 in the NSAID-controlled study (16%, 11%, 13%, 28%, respectively). In groups with positive histories, 38-80% took antidepressant or anxiolytic medications at baseline. Within treatments, largely similar improvements in efficacy outcomes were observed in patients with and without a history of depression, anxiety, or insomnia; the types of treatment-emergent adverse events were similar.Conclusions: Patients with OA and a history of depression, anxiety, or insomnia did not appear to experience reduced efficacy outcomes or an altered safety profile in response to tanezumab or NSAID treatment as compared with those without. NCT02697773; NCT02709486; NCT02528188.

Disparities across Diverse Populations in the Health and Treatment of Patients with Osteoarthritis.

The study of disparities across diverse populations regarding the health and treatment of patients with osteoarthritis (OA) is recognized as a priority for investigation and action by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the American Academy of Orthopedic Surgeons (AAOS). OA is a common condition that increases with age, but with prevalence generally similar across racial and ethnic groups. However, disparities in the treatment of OA among racial, ethnic, and socioeconomic groups are well-documented and continue to rise and persist. The reasons are complex, likely involving a combination of patient, provider, and healthcare system factors. Treatment disparities among these different populations have an impact on clinical outcomes, healthcare, and productivity, and are projected to increase significantly with the growing diversity of the United States population. The aim of this short review is to summarize studies of racial, ethnic, and socioeconomic disparities among patients with OA in the United States, with a focus on prevalence, treatment utilization, and clinical and economic outcomes.

Household members of persons with Alzheimer's disease: health conditions, healthcare resource use, and healthcare costs.

OBJECTIVES: To compare medical condition burden, healthcare resource use, and healthcare costs of household members (HHMs) of individuals diagnosed with Alzheimer's disease (AD) with those of HHMs of matched individuals without AD. DESIGN: Retrospective cohort study based on administrative claims data collected between January 1, 2007, and December 31, 2011. SETTING: Medicare Advantage Prescription Drug (MAPD) plan. PARTICIPANTS: MAPD plan members with a diagnosis of AD (International Classification of Disease Ninth Revision, Clinical Modification, code 331.0) were selected and linked to a HHM to form patient-HHM dyads. AD dyads were matched to non-AD dyads. MEASUREMENTS: Health-related endpoints, including medical condition burden, healthcare resource use, and direct healthcare costs, were measured during 36 months of continuous health plan enrollment. RESULTS: Individuals with AD (n = 1,861) were linked to HHMs (n = 1,861), and these AD dyads were matched to 1,861 non-AD patient-HHM dyads. AD HHMs had greater medical condition burden scores than non-AD HHMs, with mood disorders, anxiety disorders, insomnia, substance abuse or dependence, cardiovascular disease, and rheumatoid arthritis being more prevalent in AD HHMs. Emergency department and outpatient service use were more common in AD HHMs than in non-AD HHMs, and AD HHMs had greater healthcare costs. CONCLUSION: HHMs of individuals diagnosed with AD demonstrated greater medical condition burden, healthcare resource use, and direct healthcare costs than non-AD HHMs. These findings demonstrate the significant clinical and financial impact of AD on HHMs of individuals with AD.

The clinical and economic burden of newly diagnosed Alzheimer's disease in a medicare advantage population.

BACKGROUND/RATIONALE: Alzheimer's disease (AD) represents a serious public health issue affecting approximately 5.4 million individuals in the United States and is projected to affect up to 16 million by 2050. This study examined health care resource utilization (HCRU), costs, and comorbidity burden immediately preceding new diagnosis of AD and 2 years after diagnosis. METHODS: This study utilized a claims-based, retrospective cohort design. Medicare Advantage members newly diagnosed with AD (n = 3374) were compared to matched non-AD controls (n = 6748). All patients with AD were required to have 12 months of continuous enrollment prior to AD diagnosis (International Classification of Diseases, Clinical Modification [ICD-9] 331.0), during which time no diagnosis of AD, a related dementia, or an AD medication was observed. Non-AD controls demonstrated no diagnosis of AD, a related dementia, or a prescription claim for an AD medication treatment during their health plan enrollment. Medical and pharmacy claims data were used to measure HCRU, costs, and comorbidity burden over a period of 36 months (12 months pre-diagnosis and 24 months post-diagnosis). RESULTS: The HCRU and costs were greater for AD members during the year prior to diagnosis and during postdiagnosis years 1 and 2 compared to controls. The AD members also displayed greater comorbidity than their non-AD counterparts during postdiagnosis years 1 and 2, as measured by 2 different comorbidity indices. CONCLUSIONS: Members newly diagnosed with AD demonstrated greater HCRU, health care costs, and comorbidity burden compared to matched non-AD controls.

Variability in frontotemporal brain structure: the importance of recruitment of African Americans in neuroscience research.

BACKGROUND: Variation in brain structure is both genetically and environmentally influenced. The question about potential differences in brain anatomy across populations of differing race and ethnicity remains a controversial issue. There are few studies specifically examining racial or ethnic differences and also few studies that test for race-related differences in context of other neuropsychiatric research, possibly due to the underrepresentation of ethnic minorities in clinical research. It is within this context that we conducted a secondary data analysis examining volumetric MRI data from healthy participants and compared the volumes of the amygdala, hippocampus, lateral ventricles, caudate nucleus, orbitofrontal cortex (OFC) and total cerebral volume between Caucasian and African-American participants. We discuss the importance of this finding in context of neuroimaging methodology, but also the need for improved recruitment of African Americans in clinical research and its broader implications for a better understanding of the neural basis of neuropsychiatric disorders. METHODOLOGY/PRINCIPAL FINDINGS: This was a case control study in the setting of an academic medical center outpatient service. Participants consisted of 44 Caucasians and 33 ethnic minorities. The following volumetric data were obtained: amygdala, hippocampus, lateral ventricles, caudate nucleus, orbitofrontal cortex (OFC) and total cerebrum. Each participant completed a 1.5 T magnetic resonance imaging (MRI). Our primary finding in analyses of brain subregions was that when compared to Caucasians, African Americans exhibited larger left OFC volumes (F (1,68) = 7.50, p = 0.008). CONCLUSIONS: The biological implications of our findings are unclear as we do not know what factors may be contributing to these observed differences. However, this study raises several questions that have important implications for the future of neuropsychiatric research.

Public's view of mental health services for the elderly: responses to Dear Abby.

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.

Programs for developing the pipeline of early-career geriatric mental health researchers: outcomes and implications for other fields.

This report summarizes the findings and recommendations of an expert consensus workgroup that addressed the endangered pipeline of geriatric mental health (GMH) researchers. The workgroup was convened at the Summit on Challenges in Recruitment, Retention, and Career Development in Geriatric Mental Health Research in late 2007. Major identified challenges included attracting and developing early-career investigators into the field of GMH research; a shortfall of geriatric clinical providers and researchers; a disproportionate lack of minority researchers; inadequate mentoring and career development resources; and the loss of promising researchers during the vulnerable period of transition from research training to independent research funding. The field of GMH research has been at the forefront of developing successful programs that address these issues while spanning the spectrum of research career development. These programs serve as a model for other fields and disciplines. Core elements of these multicomponent programs include summer internships to foster early interest in GMH research (Summer Training on Aging Research Topics-Mental Health Program), research sponsorships aimed at recruitment into the field of geriatric psychiatry (Stepping Stones), research training institutes for early career development (Summer Research Institute in Geriatric Psychiatry), mentored intensive programs on developing and obtaining a first research grant (Advanced Research Institute in Geriatric Psychiatry), targeted development of minority researchers (Institute for Research Minority Training on Mental Health and Aging), and a Web-based clearinghouse of mentoring seminars and resources (MedEdMentoring.org). This report discusses implications of and principles for disseminating these programs, including examples of replications in fields besides GMH research.

Establishment of a predominantly African-American cohort for the study of Alzheimer's disease: the South Carolina Alzheimer's disease clinical core.

BACKGROUND/AIMS: The recruitment of culturally diverse subject populations into research studies, particularly African-Americans (AA), has been the focus of intense interest by many groups. METHODS: In this paper, we present the methodology utilized to create a predominantly AA cohort for the longitudinal study of risk factors in Alzheimer's disease (AD). The underlying strategy was that of identifying geographically diverse clinical venues within South Carolina (SC) where large numbers of AA patients already come to seek medical care. RESULTS: This strategy was successful, although recruitment rates for AA subjects (43.4%) still fell below those for white subjects (70.3%; p = 0.0025). Subject characteristics of AA subjects that chose to enroll were not substantially different from those that declined to participate. The demographic characteristics of this cohort were largely similar to those of the SC Alzheimer Disease Registry, a population-based database. The problems of standardization of subject recruitment and assessment across diverse clinical venues are also addressed. CONCLUSION: The utilization of geographically diverse sites for research recruitment where minorities already receive medical care is one practical solution to the problem of minority participation in research. Multi-site recruitment to improve minority recruitment can be accomplished with acceptable standardization and inter-rater reliability.

Potential ethnic modifiers in the assessment and treatment of Alzheimer's disease: challenges for the future.

OBJECTIVE: Despite numerous clinical trials, it is unknown whether ethnicity affects treatment response to cognitive enhancers in Alzheimer's disease (AD). There is convincing evidence of ethnic and genetic variability in drug metabolism. This article reviews the available data on ethnicity in clinical trials for AD to answer two questions: (1) what are the challenges to diagnose and treat AD across different ethnic groups, and (2) are there differences in response to pharmacologic interventions for AD across these different ethnic groups? METHOD: Available data from Alzheimer's Disease Cooperative Study (ADCS) randomized controlled clinical trials and from randomized controlled industry-sponsored trials for four cognitive enhancers (donepezil, galantamine, rivastigmine and sabeluzole) were pooled to assess the numbers of non-Caucasian participants. RESULTS: The participation of ethnic minority subjects in clinical trials for AD was dependent on the funding source, although Caucasian participants were over-represented and non-Caucasian participants were under-represented in the clinical trials. Because of the low participation rate of ethnic minorities, there were insufficient data to assess any differences in treatment outcome among different ethnic groups. Strategies to improve diversity in clinical trials are discussed. CONCLUSION: Greater participation of ethnically diverse participants in clinical trials for AD would generate additional information on possible differences in metabolism, treatment response, adverse events to therapeutic agents, and could foster the investigation of genetic variability among ethnic groups.

Formulating a clinical practice care plan for the diagnosis and assessment of Alzheimer's disease.

Alzheimer's disease is a devastating neurological disorder characterized by cognitive deficits, functional impairment, and often troublesome behavioral symptoms. Unfortunately, Alzheimer's disease can be difficult to diagnose at early and even moderate stages of the disease. This article outlines simple, efficient strategies for identifying patients with potential dementia. The discussion focuses on the key components of a comprehensive assessment plan, which typically involves taking the patient's history, as well as conducting cognitive testing, laboratory testing, neurologic examination, and neuroimaging to evaluate patients for Alzheimer's disease. Finally, opportunities for the improvement of care are discussed, with an emphasis on overcoming barriers to diagnosis such as time limitations and reimbursement issues.

Cultural aspects of psychosis in the elderly.

The elderly population is rapidly growing and increasing in diversity. Furthermore, mental disorders are common in this population. Elderly patients are at increased risk for developing psychotic symptoms. Consequently, clinicians must increase their awareness of culture and its effect on psychosis in the elderly. This article briefly reviews the components of cultural assessments, cultural issues pertaining to diagnosis and treatment, and culture-bound syndromes. Some studies have demonstrated ethnic differences in the presention, assessment, diagnosis, and treatment of psychotic disorders in the elderly. These differences may be explained by factors including clinicians' bias, cultural distance between patients and clinicians, culturally biased diagnostic instruments, stereotypes of psychopathology, and biological and other environmental factors. However, some studies have not documented ethnic differences in diagnosing and treating psychotic disorders. Appropriate assessments and diagnoses include patients' and clinicians' ethnic and cultural contexts. Rigorous methodological research is needed to further evaluate the prevalence and treatment of psychotic disorders in ethnic minority elders.

Combination pharmacotherapy in Alzheimer's disease.

Alzheimer's disease is a progressive, debilitating form of dementia affecting more than 18 million people worldwide. Without a cure, many patients and their families must turn to long-term care institutions during the later stages of the disease. Our current treatments only delay progression and help control behavioral symptoms. In recent years, research within this field has expanded to include many clinical trials on potential drug therapies. However, despite the numerous studies, the enigma of this disease remains. It is difficult yet necessary, to stay abreast of emerging information that may warrant changes in current therapy. Rationale for combination therapy becomes evident as we review the multiple neurochemical pathways common to the disease. This paper will review available information on Alzheimer's disease pharmacotherapy, and evaluate data on the use of combination drug therapy. Individual efficacy, possible synergistic effects, and the safety of combination therapy will also be addressed.