Asthma exacerbation rates in adults are unchanged over a 5-year period despite high-intensity therapy.

BACKGROUND: Few data exist regarding the natural history of asthma exacerbations over time. OBJECTIVE: To evaluate the frequency and risk factors of asthma exacerbation occurrence over a 5-year period in a large cohort of adult patients with persistent asthma. METHODS: Health insurance claims from the Truven Health MarketScan database were analyzed for 2543 patients who had full medical and drug claims for years 2006 to 2011, did not have co-occurring chronic obstructive pulmonary disease in the index year (2006), and were treated with high-dose inhaled corticosteroids and long-acting ß2-agonists for at least 120 days ("high intensity" therapy) in the index year. A retrospective analysis was conducted to assess the pattern of severe exacerbations (encounter with health care system and steroid burst) over time and their associations with the other measures of health status. RESULTS: Despite the use of high-intensity asthma therapy, there was only a small decrease in total asthma exacerbations over time, but no significant time trend for asthma hospitalizations. An exacerbation in the prior year increased the risk for exacerbations almost 8-fold, (odds ratio 7.8 [95% CI, 7.1-8.6]). A 50% increase in exacerbation risk (odds ratio 1.5 [95% CI, 1.4-1.6]) was associated with continued high-intensity treatment for the duration of the study. Patients with encounters of chronic obstructive pulmonary disease after the index year were at 60% increased risk of an exacerbation. CONCLUSIONS: This study showed that exacerbation rates for patients with asthma in a real-world setting remained relatively constant over time, and continuous high treatment intensity was not associated with a substantially lower risk of exacerbations.

Clinical and economic outcomes after surgical aortic valve replacement in Medicare patients.

BACKGROUND: Aortic valve replacement (AVR) is the standard of care for patients with severe, symptomatic aortic stenosis who are suitable surgical candidates, benefiting both non-high-risk and high-risk patients. The purpose of this study was to report long-term medical resource use and costs for patients following AVR and validate our assumption that high-risk patients have worse outcomes and are more costly than non-high-risk patients in this population. METHODS: Patients with aortic stenosis who underwent AVR were identified in the 2003 Medicare 5% Standard Analytic Files and tracked over 5 years to measure clinical outcomes, medical resource use, and costs. An approximation to the logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) based on administrative data was used to assess surgical risk, with a computed logistic EuroSCORE > 20% considered high-risk. RESULTS: We identified 1474 patients with aortic stenosis who underwent AVR, of whom 1222 (82.9%) were non-high-risk and 252 (17.1%) were high-risk. Among those who were non-high-risk, the mean age was 73.3 years, 464 (38.2%) were women, and the mean logistic EuroSCORE was 7%, whereas in those who were high-risk, the mean age was 77.6 years, 134 (52.8%) were women, and the mean logistic EuroSCORE was 37%. All-cause mortality was 33.2% for non-high-risk and 66.7% for high-risk patients at 5 years. Over this time period, non-high-risk patients experienced an average of 3.9 inpatient hospitalizations and total costs of $106,277 per patient versus 4.7 hospitalizations and total costs of $144,183 for high-risk patients. CONCLUSION: Among elderly patients undergoing AVR, long-term mortality and costs are substantially greater for high-risk than for non-high-risk individuals. These findings indicate that further research is needed to understand whether newer approaches to aortic valve replacement such as transcatheter AVR may be a lower cost, clinically valuable alternative.

Five-year clinical and economic outcomes among patients with medically managed severe aortic stenosis: results from a Medicare claims analysis.

BACKGROUND: Patients with severe, symptomatic aortic stenosis, who do not undergo valve replacement surgery have a poor long-term prognosis. Limited data exist on the medical resource utilization and costs during the final stages of the disease. METHODS AND RESULTS: We used data from the 2003 Medicare 5% standard analytic files to identify patients with aortic stenosis and a recent hospitalization for heart failure, who did not undergo valve replacement surgery within the ensuing 2 calendar quarters. These patients (n=2150) were considered to have medically managed severe aortic stenosis and were tracked over 5 years to measure clinical outcomes, medical resource use, and costs (from the perspective of the Medicare Program). The mean age of the cohort was 82 years, 64% were female, and the estimated logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (a measure of predicted mortality with cardiac surgery) was 17%. During 5 years of follow-up, overall mortality was 88.4% with a mean survival duration of 1.8 years. During this time period, patients experienced an average of 4.4 hospital admissions, 52% were admitted to skilled nursing care, and 28% were admitted to hospice care. The total 5-year costs were $63 844 per patient, whereas mean annual follow-up costs (excluding the index quarter) per year alive were $29 278. CONCLUSIONS: Elderly patients with severe aortic stenosis undergoing medical management have limited long-term survival and incur substantial costs to the Medicare Program. These results have important implications for policy makers interested in better understanding the cost-effectiveness of emerging treatment options such as transcatheter aortic valve replacement.