Readmission among hospitalized patients with nonvalvular atrial fibrillation.

PURPOSE: Hospital readmission rates for patients with nonvalvular atrial fibrillation (NVAF), as well as reasons and risk factors for rehospitalization, were investigated. METHODS: Demographic, clinical, and prescription claims data on patients hospitalized for atrial fibrillation (AF) over a five-year period were extracted from insurance claims databases; from that data set, a subset of adults with NVAF on whom continuous data were available before and after the index admission (n = 6439) was identified, and their 30-day readmission rate was examined. RESULTS: The overall 30-day readmission rate was 18.0%. The five most common readmission diagnoses (grouped per International Classification of Diseases codes) were general and other nonspecific symptoms (12.8% of readmitted patients), AF (10.2%), ischemic heart disease (7.2%), heart failure (7.1%) and cerebrovascular disease (6.0%). Controlling for demographic and clinical variables,index admission factors associated with an increased risk of readmission included a longer hospital length of stay, higher Charlson Comorbidity Index scores, and admission through the emergency room (p ≤ 0.01 for all). For the subset of patients discharged from the index admission to home self-care (n = 1161), no individual follow-up care measure evaluated (a physician or other medical office visit, International Normalized Ratio testing, filling an anticoagulant prescription) taken within 7 days of discharge correlated with reduced readmission risk during postdischarge days 8-30. CONCLUSION: The 30-day readmission rate for patients hospitalized with NVAF was comparable to rates previously documented among patients with other cardiac conditions. Symptoms, AF, ischemic heart disease, heart failure, and cerebrovascular disease were the most common reasons for readmission.

Cost of illness and comorbidities in adults diagnosed with attention-deficit/hyperactivity disorder: a retrospective analysis.

OBJECTIVE: This retrospective study assessed the cost of illness and medical and psychiatric comorbidities in adults with attention-deficit/hyperactivity disorder (ADHD) compared with adults without ADHD (matched 1:3) and adults with depression (1:1). Individuals with depression were included as a benchmark against which the burden of ADHD could be measured. METHOD: Measures of health care and employment-related costs were compared to generate estimates of medical expenditures, workplace absences, and comorbidities in adults with ADHD (using ICD-9-CM codes) who were enrolled in employer-sponsored health plans throughout 2006. Individuals with ADHD (31,752) were matched with 95,256 non-ADHD controls. The majority of individuals with ADHD (n = 29,965) were also matched with an equal number of individuals with a depression diagnosis (using ICD-9-CM codes). RESULTS: In this adult population with ADHD enrolled in an employer-sponsored health plan, medical and psychiatric comorbidities were the primary drivers of health care utilization and cost. Of note, depression was significantly prevalent among those with ADHD compared to matched non-ADHD controls (14% vs 3.2%; P ≤ .0001). Subgroup analysis demonstrated that ADHD patients with depression had a significantly higher number of medical and other psychiatric comorbid illnesses including diabetes, hypertension, asthma, irritable bowel syndrome, bipolar disorder, anxiety, alcohol abuse, and substance abuse compared to those with ADHD alone (P ≤ .0001). Patients with ADHD incurred higher total annual health care expenditures than control subjects ($4,306 vs $2,418); approximately 15% of costs were paid by the patient. The total annual costs associated with productivity losses were also higher (driven by differences in short-term disability costs) in the ADHD group compared with controls ($4,403 vs $4,209). CONCLUSIONS: Medical and psychiatric comorbidities were primary drivers of the direct health care cost associated with ADHD in adult patients. The present study demonstrated that the total costs of ADHD among adults are doubled when indirect costs associated with workplace productivity losses are included.

Risk of injury associated with attention-deficit/hyperactivity disorder in adults enrolled in employer-sponsored health plans: a retrospective analysis.

OBJECTIVE: Attention-deficit/hyperactivity disorder (ADHD) is linked to an increased risk of injury in children. This retrospective analysis evaluated the risk and type of injury associated with ADHD in adults. METHOD: Data were taken from the MarketScan databases, which provide details of health care claims and productivity data for individuals and their dependents with access to employer-sponsored health plans. Adults (aged 18-64 years) with ≥ 2 ADHD-related diagnostic claims (using ICD-9-CM codes) between 2002 and 2007 and evidence of ADHD treatment in 2006 (n = 31,752) were matched to controls without ADHD (1:3; n = 95,256) or individuals with a depression diagnosis (using ICD-9-CM codes; 1:1; n = 29,965). Injury claims were compared between cohorts, and multivariate analyses controlled for differences that remained after matching. RESULTS: Injury claims were more common in individuals with ADHD than in non-ADHD controls (21.5% vs 15.7%; P< .0001) or individuals with depression (21.4% vs 20.5%; P= .008). Multivariate analyses indicated that the relative risk of injury claims was higher in individuals with ADHD than in the non-ADHD control (odds ratio [OR] = 1.32; 95% CI, 1.27-1.37; P< .01) and depression (OR = 1.13; 95% CI, 1.07-1.18; P< .01) groups. Injury claims increased total direct health care expenditure; total expenditures for ADHD patients with injuries were $6,482 compared with $3,722 for ADHD patients without injuries (P < .0001). Comparison of injury-related costs were similar between ADHD patients and non-ADHD controls ($1,109 vs $1,041, respectively), but higher for depression patients than for ADHD patients ($1,792 vs $1,084; P < .01). Injury claim was also associated with increased short-term disability expenditures, as ADHD patients with injury incurred higher mean cost than those without injury ($1,303 vs $620; P = .0001), but lower than those with injury in the depression cohort (vs $2,152; P = .0099) CONCLUSIONS: Adults with ADHD were more likely to incur injury claims than non-ADHD controls or adults with depression in this sample selected on the basis of claims data rather than clinical referrals. Most injuries were relatively minor; however, individuals with injuries incurred higher total direct health care costs than those without injuries. Furthermore, the ratio of indirect costs due to workplace absence to direct health care costs was higher for adults with ADHD than for adults with depression, demonstrating not only the impact of ADHD in the workplace, but also the importance of accounting for productivity data in calculating the true economic burden of ADHD in adults.

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

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 14034 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 $10911 (SD=$16075). RA patient annual expenditures were similar to FM: $10716 (SD= $16860). Annual expenditures were almost double in patients with FM+RA ($19395, SD= $25440). 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.

Economic costs of obesity to self-insured employers.

OBJECTIVE: To quantify the direct and indirect costs of obesity within a cohort of commercially insured employees in the United States. METHOD: Health plan claims, self-reported health risk assessment, and productivity data (Thomson MarketScan) from 2003 to 2005 were used to identify employees. Two-part regression models were used to compare body mass index (BMI) groups to estimate the incremental direct and indirect costs, conditional on expenditure, associated with elevated BMI. RESULTS: Regression-adjusted incremental direct medical costs associated with being overweight, obese, and severely obese were estimated to be $147.11, $712.34, and $1977.43, respectively. Adjusted incremental indirect costs due to paid absence associated with being overweight, obese, and severely obese were estimated at $1403.81, $1511.24, and $1414.09, respectively. CONCLUSIONS: Overall adjusted direct and indirect costs were higher for workers with elevated BMI relative to those of normal weight.

A framework to evaluate the economic impact of pharmacogenomics.

INTRODUCTION: Pharmacogenomics and personalized medicine promise to improve healthcare by increasing drug efficacy and minimizing side effects. There may also be substantial savings realized by eliminating costs associated with failed treatment. This paper describes a framework using health claims data for analyzing the potential value of pharmacogenomic testing in clinical practice. METHODS: We evaluated a model of alternate clinical strategies using asthma patients' data from a retrospective health claims database to determine a potential cost offset. We estimated the likely cost impact of using a hypothetical pharmacogenomic test to determine a preferred initial therapy. We compared the annualized per patient costs distributions under two clinical strategies: testing all patients for a nonresponse genotype prior to treating and testing none. RESULTS: In the Test All strategy, more patients fall into lower cost ranges of the distribution. In our base case (15% phenotype prevalence, 200 US dollars test, 74% overall first-line treatment efficacy and 60% second-line therapy efficacy) the cost savings per patient for a typical run of the testing strategy simulation ranged from 200 US dollars to 767 US dollars (5th and 95th percentile). Genetic variant prevalence, test cost and the cost of choosing the wrong treatment are key parameters in the economic viability of pharmacogenomics in clinical practice. CONCLUSIONS: A general tool for predicting the impact of pharmacogenomic-based diagnostic tests on healthcare costs in asthma patients suggests that upfront testing costs are likely offset by avoided nonresponse costs. We suggest that similar analyses for decision making could be undertaken using claims data in which a population can be stratified by response to a drug.

Matching documented training needs with practical capacity: lessons learned from Project Public Health Ready.

The Upper Midwest offers a distinct environment for identifying and addressing threat and preparedness scenarios. The population is often scattered, with residents using urban centers periodically. This has also led to the challenge of providing specific skills and cross-disciplinary awareness and coordination to the public health community. The Upper Midwest Center for Public Health Preparedness was established by a grant from the Centers for Disease Control and Prevention to assist in meeting the challenge of adding capacity to develop the preparedness workforce in the Upper Midwest. Project Public Health Ready (PPHR) provides an example of the role academic preparedness centers can play in partnering with local public health agencies to strengthen the public health workforce. The purpose of this article is to present the Iowa Systems Model for Workforce Development being utilized for workforce training and education, describe how the model has been applied in the example of PPHR, and discuss lessons learned from the PPHR experience.