Analysis of Episodes of Care in Medicare Beneficiaries Newly Diagnosed with Alzheimer's Disease.

OBJECTIVES: To study transitions between healthcare settings and quantify the cost burdens associated with different combinations of transitions during a 6-month period before initial Alzheimer's disease (AD) diagnosis so as to investigate how using an episode-of-care approach to payment for specific disease states might apply in AD. DESIGN: A retrospective observational cohort study. SETTING: United States. PARTICIPANTS: A random sample of 8,995 individuals aged 65 to 100 with a diagnosis of AD (International Classification of Diseases, Ninth Revision, Clinical Modification code 331.0) were identified from the Medicare database between January 1, 2011, and June 30, 2014. This analysis identified individuals with AD diagnosed in inpatient (18%), skilled nursing facility (SNF) (1%), hospice (4%), and home and outpatient (77%) settings and analyzed episodes that began in the index setting (defined as the care setting in which the individual was first diagnosed with AD). MEASUREMENTS: Study outcomes included number of transitions between settings, primary discharge diagnoses, and total all-cause healthcare costs during the 6 months after the AD diagnosis. RESULTS: The average numbers of transitions between care settings were 2.8 originating from an inpatient setting, 2.4 from a SNF, 0.3 from a hospice setting and 0.7 from a home or outpatient setting during 6 months post-AD diagnosis. The overall cost burden during the 6 months after AD diagnosis (including costs incurred at the index setting) was high for individuals diagnosed in a nonambulatory setting (mean $41,468). Individuals diagnosed in an ambulatory setting incurred only $12,597 in costs during the same period. CONCLUSION: Episodes of care can be defined and studied in individuals with AD. An episode-of-care approach to payment could encourage providers to use the continuum of care needed for quality medical management in AD more efficiently.

Economic Burden, Mortality, and Institutionalization in Patients Newly Diagnosed with Alzheimer's Disease.

BACKGROUND: Current information is scarce regarding comorbid conditions, treatment, survival, institutionalization, and health care utilization for Alzheimer's disease (AD) patients. OBJECTIVES: Compare all-cause mortality, rate of institutionalization, and economic burden between treated and untreated newly-diagnosed AD patients. METHODS: Patients aged 65-100 years with ≥1 primary or ≥2 secondary AD diagnoses (ICD-9-CM:331.0] with continuous medical and pharmacy benefits for ≥12 months pre-index and ≥6 months post-index date (first AD diagnosis date) were identified from Medicare fee-for-service claims 01JAN2011-30JUN2014. Patients with AD treatment claims or AD/AD-related dementia diagnosis during the pre-index period were excluded. Patients were assigned to treated and untreated cohorts based on AD treatment received post-index date. Total 8,995 newly-diagnosed AD patients were identified; 4,037 (44.8%) were assigned to the treated cohort. Time-to-death and institutionalization were assessed using Cox regression. To compare health care costs and utilizations, 1 : 1 propensity score matching (PSM) was used. RESULTS: Untreated patients were older (83.85 versus 81.44 years; p < 0.0001), with more severe comorbidities (mean Charlson comorbidity index: 3.54 versus 3.22; p < 0.0001). After covariate adjustment, treated patients were less likely to die (hazard ratio[HR] = 0.69; p < 0.0001) and were associated with 20% lower risk of institutionalization (HR = 0.801; p = 0.0003). After PSM, treated AD patients were less likely to have hospice visits (3.25% versus 9.45%; p < 0.0001), and incurred lower annual all-cause costs ($25,828 versus $30,110; p = 0.0162). CONCLUSION: After controlling for comorbidities, treated AD patients have better survival, lower institutionalization, and sometimes fewer resource utilizations, suggesting that treatment and improved care management could be beneficial for newly-diagnosed AD patients from economic and clinical perspectives.

Predicting Pre-emptive Discussions of Biologic Treatment: Results from an Openness and Preference Survey of Inflammatory Bowel Disease Patients and Their Prescribers.

INTRODUCTION: It is important to compare patient and provider discrepancies on stated openness to and preference for biologics as well as predictors associated with initial discussions on biologic use. METHODS: Patients (N = 263) and physicians (N = 100) completed a self-administered Web-based survey assessing demographics, health characteristics, and behaviors related to inflammatory bowel disease (IBD) treatment. Bootstrap methods were used to check discrepancies between providers' and patients' stated openness to and preference for biologics. Classification and regression tree (CART) analysis identified patient-specific predictors associated with initial biologics discussions. RESULTS: A total of 170 patients responded consistently to preference questions, and 169 patients responded consistently to openness questions. Physicians significantly overestimated patients' openness to biologics in general (85.46% vs. 74.61%, p < 0.0001), but underestimated patients' openness to the intravenous (IV) mode of administration (MOA; 55.97% vs. 63.96%, p < 0.0001). Overall, physicians significantly underestimated patient preference for IV MOA (22.07% vs. 42.35%, p < 0.0001) and, to a lesser extent, subcutaneous MOA (48.84% vs. 54.69%, p < 0.0001). Among Crohn's disease (CD) patients (N = 123), CART threshold analysis identified an inpatient visit in the last 6 months, CD diagnosis for more than 3 years, and non-adherence to prior IBD treatment as most positively predictive of having an initial biologics discussion. CONCLUSION: Physicians appear to underestimate patient preferences in favor of biologics, especially IV formulations. Since it is unclear if physicians were aware of the patients' preferences beforehand, this study supports the need for validated, shared decision-making tools when initiating IBD treatment. Additional studies are necessary to measure physicians' influences on patient preference/treatment-related decisions and the impact on patient outcomes.

Economic Impact and Complications of Treated and Untreated Hepatitis C Virus Patients in Turkey.

BACKGROUND: According to the Turkish Ministry of Health's guidelines, standard double therapy, a combination of pegylated interferon-alpha and ribavirin, was the only treatment option for patients with hepatitis C virus (HCV) infection until the end of 2011. OBJECTIVE: The primary objective was to compare risk-adjusted clinical and economic outcomes between treated and untreated patients with HCV infection. METHODS: Patients with HCV infection were identified from the Turkish National Health Insurance Database (2009-2011) using International Classification of Diseases, 10th Revision, Clinical Modification codes. The first prescription date was designated as the index date. Mortality and hepatocellular carcinoma (HCC) rates and health care costs of treated and untreated patients were compared using propensity score matching. Baseline demographic and clinical factors were controlled in the models. Subgroup analysis was conducted for patient groups with and without a cirrhosis diagnosis. RESULTS: Out of 12,990 patients included in the study, 1,583 were treated for HCV infection. Out of 2,467 patients who had a cirrhosis diagnosis, 231 were treated, whereas out of 10,523 patients without cirrhosis, 1,352 patients were treated. Treated patients were younger, less likely to be diagnosed with comorbid conditions, and less likely to reside in Central or Eastern Anatolia. After adjusting for baseline demographic and clinical factors, mortality (2.27% vs. 5.31%; P < 0.001) and HCC rates (0.69% vs. 1.96%; P < 0.001) were found to be lower for treated patients. Differences were more significant among patients diagnosed with cirrhosis. Treated patients incurred higher risk-adjusted annual costs (€6172 vs. €1680; P < 0.001), mainly because of pharmaceutical costs (€4918 vs. €583; P < 0.001). CONCLUSIONS: HCV infection treatment, although costly, significantly reduces mortality and HCC rates in Turkey.

Assessing the Economic Burden and Health Care Utilizations of U.S. Veteran Patients with Schizophrenia.

Objective: To examine the economic burden and health care utilizations of schizophrenia in the U.S. veteran population. Methods: A retrospective database analysis was performed using the Veterans Health Administration (VHA) Medical SAS® datasets from October 1, 2008 through September 30, 2012. Patients diagnosed with schizophrenia were identified, and the initial diagnosis date was designated as the index date. A group of patients without schizophrenia of the same age, region, gender and index year were identified and matched by baseline Charlson Comorbidity Index (CCI) score, as the comparison group. Patients in both groups were required to be at least age 18 years and have continuous medical and pharmacy benefits 1 year pre- and 1 year post-index date. One-to-one propensity score matching was used to compare health care costs and utilizations during the follow-up period between the schizophrenia and comparison group patients, adjusted for baseline demographic and clinical characteristics. Results: A total of 171,086 eligible patients were identified for the schizophrenia and control cohorts. After 1:1 matching, a total of 70,045 patients were matched from each cohort with well-balanced baseline characteristics. Patients diagnosed with schizophrenia had significantly higher health care utilization in inpatient (18.12% vs. 2.30%, p<0.01), emergency room (19.67% vs. 6.46%, p<0.01), office (98.32% vs. 53.26%, p<0.01), and outpatient visits (98.53% vs. 54.16%, p<0.01). Higher health care utilizations translated into higher costs for schizophrenic patients including inpatient ($7,228 vs. $613, p<0.01), pharmacy ($1,012 vs. $343, p<0.01), outpatient ($3,998 vs. $1,302, p<0.01), and total costs ($12,238 vs. $2,260, p<0.01) relative to patients in the comparison group. Conclusion: Patients diagnosed with schizophrenia in the U.S. VHA system were associated with a substantial economic burden, compared to their matched controls.