Emotional distress as a basis for claims.
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Family↗
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Partners for child passenger safety: a unique child-specific crash surveillance system.
Insurance claims data were combined with telephone survey and on-site crash investigation data to create the first large scale, child-focused motor vehicle crash surveillance system in the US. Novel data management and transfer techniques were used to create a nearly real-time data collection system. In the first year of this on-going project, known as Partners for Child Passenger Safety, over 1200 children < or = 15 years of age per week were identified in crashes reported to State Farm Insurance Co. from 15 states and Washington, D.C. Partners for Child Passenger Safety is similar in its design and overall objectives to National Automotive Sampling System (NASS), the only other population-based crash surveillance system currently operating in the US.
Accidents, Traffic↗
Effect of a home monitoring system on hospitalization and resource use for patients with heart failure.
BACKGROUND: Heart failure has a large medical and economic impact on the elderly. Past studies have shown that high-intensity multidisciplinary interventions at academic medical centers can reduce future hospitalizations. Our pilot study examined the effects of a low-intensity monitoring program on hospitalizations and cost of care for patients with heart failure treated by community physicians. METHODS: We enrolled 68 patients with heart failure (mean age 73 +/- 13 years, 53% male) monitored by 31 physicians in a multidisciplinary program of patient education, daily self-monitoring, and physician notification of abnormal weight gain, vital signs, and symptoms. Comparisons of medical claims were made between the patients who received the intervention and a control group of 86 patients matched to the intervention group on medical claims during the preceding year. RESULTS: Compared with the prior year, medical claims per year decreased in the intervention group ($8500 +/- $13,000 to $7400 +/- $11,400), whereas they increased in the control group ($9200 +/- $15,000 to $18,800 +/- $34,000, P <.05). Similar differences were observed for hospitalizations and total hospital days. The program's effectiveness was unrelated to age, sex, or type of left ventricular dysfunction. CONCLUSIONS: These findings suggest that a multidisciplinary program of patient education, monitoring, and physician notification can reduce resource use in patients with heart failure managed in a community setting.
Aged↗
The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope.
BACKGROUND: Patients with recurrent syncope frequently undergo extensive investigations that consume significant health care resources. Recent advances in long-term monitoring techniques have enhanced diagnostic yield in patients with infrequent symptoms. There is little information on the relative cost-effective profile of the investigative tools used in patients with syncope. METHODS: Two methods to determine health care costs in patients with syncope were used. In the first, health care resource utilization was determined in 24 patients with recurrent unexplained syncope and negative investigations who underwent insertion of the implantable loop recorder (ILR) during a pilot study of the feasibility of the device. The costs of investigations before, during, and after ILR implantation in each patient were calculated on the basis of median charges for an index investigation and a regression analysis of 1018 US Medicare hospital claims for syncope from 1993. Charges were converted to costs using a cost-to-charge ratio of 0.64. The second method was based on estimated costs per diagnosis and published diagnostic yields of 6 commonly applied tests in patients with syncope. A cohort simulation using theoretic models of 100 patients undergoing investigation for syncope was created to compare the diagnostic yield and cost per diagnosis of various diagnostic cascades. RESULTS: In the pilot study, the cost of investigation of syncope in the 2 years before ILR insertion was $7584 per patient. After the ILR was inserted, a diagnosis was obtained in 21 of 24 patients (diagnostic yield 88%). The cost of therapy was $2452, followed by a reduction in cost of care to $596 over 30 +/- 10 months of follow-up. In the second method, the diagnostic yield of individual tests ranged from 3% for echocardiography to 88% for the ILR. The cost per diagnosis obtained ranged from $529 for the external loop recorder to $73,260 for electrophysiologic testing in patients without structural heart disease. An approach to syncope similar to that of the ILR pilot study resulted in a cost per diagnosis of $3193 and a diagnostic yield of 98%. Performance of echocardiography in half of the patients and electrophysiologic testing only in the presence of structural heart disease reduced the cost to $2494 and retained a diagnostic yield of 98%. CONCLUSIONS: The cost of investigation of syncope is high. The ILR may reduce health care resource utilization by providing a diagnosis permitting definitive therapy. The cost per diagnosis profile of current diagnostic tests commonly used in patients with syncope is highly variable. A cost-effective approach to diagnosing this disorder can retain a high diagnostic yield with a reduction in resource utilization compared with a conventional approach.
Cost of Illness↗
Practice patterns and outcomes of percutaneous coronary interventions in the United States: 1995 to 1997.
Randomized trials have demonstrated the superiority of coronary stents in combination with a platelet-focused pharmacologic approach in percutaneous coronary intervention (PCI). However, nationally representative data examining the impact of these technologies on patient outcomes and costs remain scarce. This study sought to determine the real-world impact of changes in the use of stents and anticoagulant agents in PCI on outcomes and costs. A nationally representative sample of 37,088 patients who underwent PCI from October 1995 to October 1997 was identified from in-patient hospital claims data acquired from HCIASachs. Utilization of coronary stents, antiplatelet and anticoagulant agents, and outcome measurements of in-hospital death, coronary artery bypass grafting (CABG), repeat PCI, bleeding, and costs were analyzed in 6-month intervals. Acute events (death, urgent CABG, or PCI) decreased (p <0.001), whereas use of stents, abciximab, or both, increased (p <0.001). Dosages of heparin and bleeding complications declined significantly (p <0.001) over the 2-year period. Heparin dosages were higher in patients who experienced bleeding or death than in those who did not (p <0.001). The average hospital length of stay decreased significantly (p <0.001), largely driven by a reduction in time between the procedure and hospital discharge. By the end of the study period, bleeding was the most frequent (5.5%) complication of PCI and was associated with considerable costs, adding $10,225 to baseline costs.
Anticoagulants↗
A case-control study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia in persons with GERD.
BACKGROUND: This study assessed whether EGD reduces mortality from adenocarcinoma of the esophagus or gastric cardia for patients with gastroesophageal reflux. METHODS: A case-control study was performed. A total of 245 incident cases of death caused by adenocarcinoma of the esophagus or gastric cardia (1995-1999) in which reflux was present were identified using Veterans Health Administration databases. A total of 980 controls with reflux but no death from adenocarcinoma were frequency matched for age, gender, and race. The occurrences of EGD from 1990 onward were compared for cases and controls. Logistic regression analysis with adjustment for potential confounding factors was performed. RESULTS: All the subjects were men. Cases were significantly less likely to have had an EGD in the time period of interest as compared with controls (adjusted odds ratio 0.66: 95% CI [0.45, 0.96], p = 0.03). This negative association was as strong for any EGD performed within 1 to 8 years before diagnosis as for a more recent EGD. However, there were no controls that included esophagectomy and no controls with a nonfatal diagnosis of adenocarcinoma, raising the question of whether EGD and reduced mortality are causally linked. The risk of dying from adenocarcinoma was significantly lower for men with a diagnosis of GERD as an inpatient relative to men in whom the diagnosis was made as an outpatient (adjusted odds ratio 0.21: 95% CI [0.15, 0.31], p < 0.01). CONCLUSIONS: For patients with GERD, performing an EGD is associated with reduced mortality from adenocarcinoma of the esophagus or gastric cardia, but whether this is a causative association remains unclear.
Adenocarcinoma↗
Endoscopic screening and surveillance for Barrett's esophagus: can claims data determine its effectiveness?
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Barrett Esophagus↗
The relationship between stress and health care use: an investigation of the buffering roles of personality, social support and exercise.
The main and interactive effects of social support, physical exercise, and personal hardiness on objective measures of health were investigated using a longitudinal research design. Data were collected from 192 working adults. Results showed main effects for hardiness and exercise on the dependent variables of health care costs and the number of health insurance claims filed. Hardiness appeared to be associated with fewer health problems. Contrary to prediction, those who exercised more appeared to have greater health care use. Three-way interactions suggested that health care use was lowest for those high in all three resistance resources: exercise: hardiness: and social support. But, the converse of this reasoning, that absence of these resources is associated with higher levels of illness, was not entirely supported. The interactions suggested that hardiness in the absence of exercise and social support was associated with the highest health care costs. The highest number of claims was apparent for those exhibiting hardiness and exercise. Thus, the presence of exercise, hardiness, and social support seemed to decrease health care use, but the factors contributing to greater health costs and claims were more complicated to interpret.
Adaptation, Psychological↗
Outcome and resource use associated with myomectomy.
OBJECTIVE: To evaluate the outcomes and cost of myomectomy through retrospective claims data analysis. METHODS: The study was performed using a retrospective database of private insurance claims from 1995 to 1997. Records were selected for analysis based on the presence of ICD-9-CM procedure and/or CPT-4 codes associated with myomectomy. In addition, diagnosis of uterine leiomyoma and related symptoms for these patients were confirmed through ICD-9-CM diagnosis codes. Inpatient, outpatient, and physician costs were estimated. All cost data were converted into 1997 dollars. RESULTS: A total of 4394 women, between the ages of 14 and 70, were available for analysis. Of these, 3305 were classified by type of myomectomy procedure, and complete data were available on 820 at 1 year and 236 at 2 years. Abdominal myomectomies were the most common procedures, followed by hysteroscopic and laparoscopic myomectomies. Conversion to a more invasive procedure occurred in 5.4% of the patients. The rate of additional surgeries was 8.3% in 6 months, 10.6% in 1 year, and 16.5% in 2 years. Overall cost increased from an initial 6,737 dollars per patient to 7,575 dollars in 1 year and to 8,001 dollars in 2 years. CONCLUSION: The repeat procedures required after the initial myomectomy add significantly to total cost and highlight the importance of assessing post-procedure health care use. This comprehensive analysis facilitates the systematic evaluation of myomectomy with current and emerging alternative treatments for uterine leiomyomas.
Adolescent↗
Reduced medicolegal risk by compliance with obstetric clinical pathways: a case--control study.
OBJECTIVE: To estimate whether guideline compliance affected medicolegal risk in obstetrics and whether malpractice claims data can provide useful information on guideline noncompliance by focusing on the claims experience of a large health system delivering approximately 12000 infants annually. METHODS: We retrospectively identified 290 delivery-related (diagnosis-related groups 370-374) malpractice claims and 262 control deliveries at the health system during the period from 1988 to 1998. Clinical pathways for vaginal and cesarean delivery implemented in 1998 were used as a "standard of care." We compared rates of noncompliance with the pathways in the claims and control groups, calculated an odds ratio for increased risk of being sued given departure from the guideline standards, and calculated the elevated risk of litigation introduced by noncompliance. We also compared the frequencies of different types of departures across claims and control groups. RESULTS: Claims closely resembled controls on several descriptive measures (mother's age, location of delivery, type of delivery, and complication rates), but noncompliance with the clinical pathway was significantly more common among claims than controls (43.2% versus 11.7%, P <.001; odds ratio = 5.76, 95% confidence interval 3.59, 9.2). In 81 (79.4%) of the claims involving noncompliance with the pathway, the main allegation in the claim related directly to the departure from the pathway. The excess malpractice risk attributable to noncompliance explained approximately one third (104 of 290) of the claims filed (attributable risk = 82.6%). There were no significant differences in the types of deviation from the guidelines across claims and control groups. CONCLUSION: In addition to reducing clinical variation and improving clinical quality of care, adherence to clinical pathways might protect clinicians and institutions against malpractice litigation. Malpractice data might also be a useful resource in understanding breakdowns in processes of care.
Adult↗
Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis.
OBJECTIVE: To assess adherence to antiretroviral therapy with the use of Medicaid pharmacy claims data for human immunodeficiency virus (HIV)-infected pregnant women and to identify associated maternal and health care factors. METHODS: We retrospectively studied a cohort of 2714 HIV-infected women in New York State who delivered live infants from 1993-96. Among 682 women prescribed antiretroviral therapy in the last two trimesters, we studied 549 who started therapy more than 2 months before delivery. Adherence was defined as adequate if the supplied drug covered at least 80% of the days from the first prescription in the last two trimesters until delivery. Multivariable analyses were used to examine associations between maternal and health care factors and adherence. RESULTS: Only 34.2% of 549 subjects had at least 80% adherence based on pharmacy data, a rate that remained stable over time. The adjusted odds ratios (ORs) of adherence for black (OR 0.47, 95% confidence interval [CI] 0.30, 0.75) and Hispanic (OR 0.49, 95% CI 0.29, 0.82) women were nearly 50% lower than for white women. The OR of adherence was 0.32 (95% CI 0.12, 0.90) for teenagers compared with women aged 25-29 years and 0.56 (95% CI 0.34, 0.92) for women in New York City versus those residing elsewhere. Women on antiretroviral therapy before pregnancy were more likely to adhere (OR 1.55, 95% CI 1.02, 2.35). CONCLUSION: Teenagers, women of minority groups, and women living in New York City had greater risks of poor antiretroviral adherence, whereas women already prescribed antiretrovirals before pregnancy had better adherence. Our conservative pharmacy data-based measure showed that most HIV-infected women adhered poorly and adherence did not improve over the 4-year study.
Adolescent↗
Economic consequences of comorbid depression, anxiety, and allergic rhinitis.
The present study extends prior work on the association between allergic rhinitis (AR) and common mental disorders by testing three related hypotheses: 1) that AR is associated with increased rates of depression and anxiety disorders in a large insured population, 2) comorbid AR, depression, and anxiety are associated with increased health and mental health expenditures, and 3) allergy treatment moderates the association between increased expenditures and comorbid AR, depression, and anxiety. Data are from MARKETSCAN, a large health care claims database of over 600,000 privately insured persons. Results indicate that AR is associated with higher rates of depression and anxiety disorder. Outpatient health care expenditures were increased by an average annual amount of $207 when AR and anxiety disorder were comorbid and $363 when AR and depression were comorbid. Finally, prescription treatment of AR moderated the increased expenditures associated with comorbidity.
Adolescent↗
Risk management issues in glaucoma: diagnosis and treatment.
This article is based on the analysis of 194 claims in cases with a diagnosis of glaucoma. Half of these resulted in indemnity payments, and these payments were nearly 20% higher than the average paid for ophthalmology claims. Risk management guidelines are given.
Glaucoma↗
Measurement and management of quality in managed care organizations: alive and improving.
Leatherman et al, Schlackman, and McGuirk-Porell et al all provide important examples of how managed care organizations (MCOs) will measure quality in this decade (except for health care status, which none have yet incorporated). All three organizations rely on insurance claims as a data source and quality management as a tool for improving quality; United Health Care and US Health-care use claims data to improve care for the entire membership, a still unrealized potential for MCOs. All three programs, relatively new, can be only minimally evaluated in terms of measurement validity, cost-efficiency, and improvement in the quality of care. The impact of such MCOs depends on policy initiatives, improvements in outcome and process measures, and MCOs' commitment to serve the total population, including the uninsured and Medicaid populations.
Health Services Research↗
A performance-based quality evaluation system for preferred provider organizations.
This article describes a performance-based quality evaluation program developed by a partnership of insurers for a nationwide preferred provider organization (PPO) which uses indicators to monitor for practice deviations from PPO standards representing four components of patient care--administrative efficiency, patient satisfaction, medical practice standards, and clinical outcome. Quality improvement efforts to eliminate deviant practices through indirect organizational strategies and direct communication with preferred physicians are also described. The program's strengths are its effective use of available data, its potential application to other organizations with a loosely connected network of providers, and its ability to simultaneously monitor care received over time by individual patients in various settings (hospitals, physician offices).
Humans↗
Methodology for identifying patients at high risk for osteoporotic fracture.
BACKGROUND: Osteoporotic fractures are associated with significant morbidity, mortality, and health care costs. OBJECTIVE: The purpose of this paper is to present and validate a mathematical model that managed care organizations can apply to administrative claims data to help locate members at risk for osteoporotic fracture and estimate future fracture rates. METHODS: Using known risk factors from previous clinical studies, 92,000 members of a large Midwest health plan were placed in 1 of 4 risk categories based on historical claims markers: demographic/lifestyle (age, sex, smoking, alcoholism); steroid use; medical history (previous osteoporotic fracture, ordinary bone fracture, osteoporosis diagnosis, bone mineral density test); or steroid use with medical history. Logistic regression was used to assign a probability of fracture for the 4 groups over the next 2 years. These predictions were compared with actual fracture rates, and refined models were produced. The models were then validated by applying them to current data and comparing the predicted fracture rate for each group to known results. RESULTS: The model predicted that 1.26% of the study members would experience osteoporotic fracture over the next 2 years; the actual result was 1.27%. Within the 4 risk groups, the predicted fracture rates were lower than the actual rates for the demographic risk group (0.87% predicted vs 0.97% actual) and higher than the actual rates for the steroid use (1.78% predicted vs 1.58% actual), medical history (5.90% predicted vs 4.94% actual), and the steroid use with medical history groups (7.80% predicted vs 6.42% actual). CONCLUSION: The application of this risk model to an administrative claims database successfully identified plan members at risk for osteoporotic fracture.
Aged↗
A comparison of asthma-related expenditures for patients started on montelukast versus fluticasone propionate as monotherapy.
BACKGROUND: The prevalence of asthma is increasing, and this chronic condition imposes a substantial economic burden worldwide. It is not known whether newer therapies, such as leukotriene receptor antagonists (LTRAs), can ease this burden. OBJECTIVE: This analysis examined the association between choice of first-line asthma control therapy and health care resource utilization and expenditures in patients with mild asthma. METHODS: A retrospective cohort analysis of claims data for patients who started therapy with fluticasone propionate or montelukast between January 1, 1997, and February 28, 1999, was performed, adjusting for baseline differences. RESULTS: Data from 343 patients (229 fluticasone; 114 montelukast) were analyzed. Patients starting therapy with fluticasone were significantly older (33.3 vs 27.6 years; P = 0.015) and significantly less likely than patients starting therapy with montelukast to have been started on control therapy by an asthma specialist (52.0% vs 69.3%; P = 0.007). There were no significant differences in mean changes in total asthma-related health care expenditures, oral steroid and antibiotic prescriptions, hospitalizations, or emergent care visits. The mean increase in total asthma-related pharmacy expenses was significantly greater for patients who were prescribed montelukast than for those prescribed fluticasone (P < 0.001). Treatment adherence was better in patients prescribed montelukast versus fluticasone (5.1 vs 3.1 prescriptions filled per year, respectively; P < 0.001). Montelukast patients had a significantly lower increase in the number of beta-agonist prescriptions filled per year than fluticasone patients (0.19 vs 0.66; P = 0.03). In the subsequent year, 4% (10/229) of fluticasone patients added or switched to an LTRA. No montelukast patients added to or switched control therapy. CONCLUSION: The mean change in total asthma-related health care expenditures was not significantly different in patients started on fluticasone propionate versus montelukast. Montelukast patients had better adherence to their treatment regimen and required fewer beta-agonist prescriptions, which is an indicator of asthma control and possibly therapeutic effectiveness.
Acetates↗
Differential effects of antipsychotic agents on the risk of development of type 2 diabetes mellitus in patients with mood disorders.
BACKGROUND: Atypical antipsychotics are being used increasingly in the management of mood disorders. OBJECTIVE: The objective of this study was to investigate the association between exposure to antipsychotic therapy and newly reported type 2 diabetes mellitus in patients with mood disorders. METHODS: Claims data for the period January 1996 through December 1997 were analyzed for patients with mood disorders in 2 large US health plans. Logistic regression models were used to determine the odds of reporting diabetes in patients exposed to risperidone, olanzapine, or high- or low-potency conventional antipsychotics compared with untreated patients, taking into account duration of treatment and dosage. Some of the covariates used in the models were concurrent use of antipsychotics, use of other psychotropic drugs, age, sex, and length of observation. RESULTS: Based on the claims data, 849 patients were exposed to risperidone, 656 to olanzapine, 785 to high-potency conventional antipsychotics, and 302 to low-potency conventional antipsychotics; 2644 patients were untreated. The odds of newly reported type 2 diabetes in patients who received risperidone were not significantly different from those in untreated patients (12-month odds ratio [OR] = 1.024; 95% CI, 0.351-3.015). The odds in patients treated with high-potency conventional antipsychotics also did not differ significantly from those of untreated patients (12-month OR = 1.945; 95% CI, 0.794-4.786). Unlike patients who received risperidone or high-potency conventional antipsychotics, patients who received olanzapine (12-month OR = 4.289; 95% CI, 2.102-8.827) and low-potency conventional antipsychotics (12-month OR = 4.972; 95% CI, 1.967-12.612) had significantly higher odds for the development of type 2 diabetes compared with untreated patients. CONCLUSIONS: These findings suggest that some antipsychotics may increase the risk for the development of type 2 diabetes in patients with mood disorders and that the effect may vary by drug. In contrast to olanzapine and low-potency conventional antipsychotics, risperidone and high-potency conventional antipsychotics were not associated with an increased risk for development of type 2 diabetes in this patient population.
Adult↗