The economic impact of aspergillosis: analysis of hospital expenditures across patient subgroups.

OBJECTIVE: To measure the impact of invasive aspergillosis infection on US hospital costs and financial performance across different patient populations. METHODS: Hospital discharge data for patients with a primary or secondary diagnosis of aspergillosis were extracted from the 2003 Nationwide Inpatient Sample (NIS) and the fiscal year 2003 (FYO3) Medicare Provider Analysis and Review (MedPAR) file. The data on patient demographics, length of stay (LOS), hospital charges, estimated costs, and reimbursement levels were reported. After controlling for comorbidities, operative procedures, and diagnosis-related group (DRG) assignment, the clinical and economic outcomes were compared for patients with and without aspergillosis. RESULTS: The NIS contains a total of over 38 million projected hospital discharges. From these, 10400 aspergillosis cases were identified across 171 DRGs, resulting in a US incidence rate of 36 per million per year. The mean age of aspergillosis patients was 55.6 years, with 53.4% male and 67.9% Caucasian. The median (mean) LOS per aspergillosis patient was 10 (17.7) days, with a median (mean) total hospital charge (THC) of $44,845 ($96,731). Among the patient subgroups analyzed, the median (mean) THC per patient ranged from $47,252 ($82,946) for HIV to $413,200 ($442,233) for bone marrow transplant (BMT). When compared to the non-aspergillosis patient population, the data showed a significant increase in LOS, THC, and hospital costs. Furthermore, the higher hospital costs associated with aspergillosis patients were not matched by similar increases in reimbursements, resulting in a greater financial loss for hospitals. The mean reimbursement-to-cost ratio for aspergillosis cases across the DRGs analyzed was 0.80. CONCLUSIONS: Aspergillosis affects a wide range of patient groups and has a negative economic impact across many DRGs. Improved prevention, diagnosis, and patient management strategies can help mitigate these effects on hospital financial performance.

The impact of esophageal candidiasis on hospital charges and costs across patient subgroups.

OBJECTIVE: Assess the impact of esophageal candidiasis on US hospital inpatient charges, length of stay (LOS), and costs across clinically relevant subgroups. METHODS: Total hospital charge (THC) and LOS data extracted from the 2005 National Inpatient Sample (NIS) were compared for patients with and without esophageal candidiasis within the top 20 most commonly assigned Diagnosis Related Groups (DRGs) for the disease. Total hospital costs were estimated using hospital charges in the 2005 Medicare Provider Analysis and Review (MEDPAR) file and hospital cost-to-charge ratios published in the Center for Medicare and Medicaid Service's (CMS) 2005 Inpatient Prospective Payment System Standardization File. RESULTS: Across 274 DRGs, 45 727 esophageal candidiasis patients were identified. Mean age was 50.8 years; 52.5% were female, 59.3% Caucasian. Median LOS was 7 days; median THC was $25 649. Of all esophageal candidiasis cases identified, 65% fell into the top 20 most commonly assigned DRGs. Within this subset, HIV-related DRGs accounted for 22% of the esophageal candidiasis cases. The difference in mean THC and LOS for esophageal candidiasis patients in HIV-related DRGs was not significant. However, total hospital costs were higher for esophageal candidiasis patients in this subset ($11 886 vs. $10 534, p < 0.01). The remaining 78% of esophageal candidiasis cases were assigned to 19 non-HIV-related DRGs. Mean LOS, THC, and total hospital costs were significantly higher for esophageal candidiasis patients within these 19 non-HIV-related DRGs, (8.4 vs. 6.1; $35 704 vs. $23 874, and $10 917 vs. $7474, p < 0.01 in all cases). CONCLUSIONS: Esophageal candidiasis affects a wide range of patient groups; it increases LOS and total charges within non-HIV-related hospitalizations. Although the costs presented in this study are estimates, they do suggest a significant increase in cost among esophageal candidiasis cases. Future studies on treatment and preventive care strategies for esophageal candidiasis should not be limited to HIV patients, but instead performed across a wider range of disease settings.

Health status disparities in ethnic minority patients with rheumatoid arthritis: a cross-sectional study.

OBJECTIVE: To examine disparities in disability, pain, and global health between Caucasian (n = 4294) and African American (n = 283) and Caucasian and Hispanic (n = 153) patients with rheumatoid arthritis (RA). METHODS: Patients were from 9 Arthritis, Rheumatism, and Aging Medical Information System databanks. Cross-sectional data were derived from the Health Assessment Questionnaire. Staged multivariate analysis of covariance was used to explore roles of possible contributing factors (age, sex, education, disease duration, number of comorbid conditions, and treatment) to ethnic minority disparities. RESULTS: The cohort was 91% Caucasian and 76% female. Caucasians were significantly older than African Americans and Hispanics (62 vs 56 and 55 yrs; both p < 0.0001 from Caucasians), better educated (13 vs 12 and 12 yrs; both p < 0.0001 from Caucasians), and had their RA longer (16 vs 13 and 15 yrs; p < 0.01 for African Americans). Unadjusted disability scores were statistically indistinguishable, but pain was worse in both ethnic groups (p < 0.01), and global health worse in Hispanics (p < 0.05). After adjustment for covariates, African Americans had the poorest outcomes in all 3 measures, although only pain in African Americans (p < 0.05) was statistically different from Caucasians. CONCLUSION: Results of this exploratory study suggest that in a relatively similar cohort of patients with RA, minority health disparities exist. Both ethnic groups had poorer outcomes for all 3 measures than Caucasians after adjustment. Additional study and longitudinal research with larger numbers of patients are needed to improve our understanding of these differences and to assess potential causal roles.

The rise and decline of nonsteroidal antiinflammatory drug-associated gastropathy in rheumatoid arthritis.

OBJECTIVE: Nonsteroidal antiinflammatory drug (NSAID)-associated gastropathy is a major cause of hospitalization and death. This study was undertaken to examine whether recent preventive approaches have been associated with a declining incidence of NSAID gastropathy, and, if so, what measures may have caused the decline. METHODS: We studied 5,598 patients with rheumatoid arthritis (RA) over 31,262 patient-years at 8 sites. We obtained standardized longitudinal information on the patients that had been previously used to establish the incidence of NSAID gastropathy, and also information on patient risk factors and differences in toxicity between NSAIDs. Consecutive patients were followed up with biannual Health Assessment Questionnaires and medical record audits between 1981 and 2000. The major outcome measure was the annual rate of hospitalization involving bleeding, obstruction, or perforation of the gastrointestinal (GI) tract and related conditions. RESULTS: Rates of GI-related hospitalizations rose from 0.6% in 1981 to 1.5% in 1992 (P < 0.001), and then declined to 0.5% in 2000 (P < 0.001). The fitted spline curve fit the data well (R2 = 0.70). The period of rise was mainly associated with increasing patient age and the GI risk propensity score. The period of decline was associated with lower doses of ibuprofen and aspirin, a decline in the use of "more toxic" NSAIDs from 52% to 42% of patients, a rise in the use of "safer" NSAIDs from 19% to 48% of patients, and increasing use of proton-pump inhibitors, but not with change in age, NSAID exposure, or GI risk propensity score. CONCLUSION: The risk of serious NSAID gastropathy has declined by 67% in these cohorts since 1992. We estimate that 24% of this decline was the result of lower doses of NSAIDs, while 18% was associated with the use of proton-pump inhibitors and 14% with the use of less toxic NSAIDs. These declines in the incidence of NSAID gastropathy are likely to continue.

Gender differences in physical disability among an elderly cohort.

OBJECTIVES: We analyzed the role of sociodemographic factors, chronic-disease risk factors, and health conditions in explaining gender differences in disability among senior citizens. METHODS: We compared 1348 men and women (mean age = 79 years) on overall disability and compared their specific activities of daily living, instrumental activities of daily living (IADL), and mobility limitations. Analysis of covariance adjusted for possible explanatory factors. RESULTS: Women were more likely to report limitations, use of assistance, and a greater degree of disability, particularly among IADL categories. However, these gender differences were largely explained by differences in disability-related health conditions. CONCLUSIONS: Greater prevalence of nonfatal disabling conditions, including fractures, osteoporosis, back problems, osteoarthritis and depression, contributes substantially to greater disability and diminished quality of life among aging women compared with men.

Attrition bias in rheumatoid arthritis databanks: a case study of 6346 patients in 11 databanks and 65,649 administrations of the Health Assessment Questionnaire.

OBJECTIVE: Patient dropout (attrition) can bias and threaten validity of databank-based studies. Although there are several databanks of rheumatoid arthritis (RA) in operation, this phenomenon has not been well studied. METHODS: We studied the attrition patterns of patients with RA in 11 long-running databanks where patients were followed using semiannual Health Assessment Questionnaires. Attrition rates were calculated as the proportion of living patients who were in active followup at the cutoff date. Mantel-Haenszel methods and Weibull regression were used to model the relationship between attrition and age, sex, race, education, disease duration, functional disability, and other characteristics. RESULTS: Overall, 6346 patients with RA were recruited into the study cohorts and followed for 32,823 person-years with 65,649 observations. The crude attrition rate was 3.8% per cycle. Rates were lowest in community-based databanks. Smaller size of the centers, inner-city location, and university clinic settings were associated with worse attrition. In multivariable analyses, younger age, lower levels of education, and non-Caucasian race predicted attrition. Level of disability and disease duration were not associated with attrition. Conclusion. In terms of person-years of followup and observation-points, this may be the largest study on attrition to date. While it is possible to have very high overall retention rates, certain types of databanks (smaller, inner-city-based, and university-based) are more likely to be biased due to selective retention of older, more educated Caucasian patients.