Publications by authors named "Robert L Ohsfeldt"

83 Publications

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

Am J Emerg Med 2021 Apr 30;48:183-190. Epub 2021 Apr 30.

Population Informatics Lab, Texas A&M University, College Station, TX, USA; Texas A&M University, School of Public Health, Department of Health Policy & Management, College Station, TX, USA.

Background: One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York.

Methods: We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses.

Results: After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries.

Conclusion: Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.
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April 2021

Cost-impact analysis of baroreflex activation therapy in chronic heart failure patients in the United States.

BMC Cardiovasc Disord 2021 Mar 26;21(1):155. Epub 2021 Mar 26.

Medical University of South Carolina, Charleston, SC, USA.

Background: The study evaluated the cost of baroreflex activation therapy plus guideline directed therapy (BAT + GDT) compared to GDT alone for HF patients with reduced ejection fraction and New York Heart Association Class III or II (with a recent history of III). Baroreflex activation therapy (BAT) is delivered by an implantable device that stimulates the baroreceptors through an electrode attached to the outside of the carotid artery, which rebalances the autonomic nervous system to regain cardiovascular (CV) homeostasis. The BeAT-HF trial evaluated the safety and effectiveness of BAT.

Methods: A cost impact model was developed from a U.S. health care payer or integrated delivery network perspective over a 3-year period for BAT + GDT versus GDT alone. Expected costs were calculated by utilizing 6-month data from the BeAT-HF trial and existing literature. HF hospitalization rates were extrapolated based on improvement in NT-proBNP.

Results: At baseline the expected cost of BAT + GDT were $29,526 per patient more than GDT alone due to BAT device and implantation costs. After 3 years, the predicted cost per patient was $9521 less expensive for BAT + GDT versus GDT alone due to lower rates of significant HF hospitalizations, CV non-HF hospitalizations, and resource intensive late-stage procedures (LVADs and heart transplants) among the BAT + GDT group.

Conclusions: BAT + GDT treatment becomes less costly than GDT alone beginning between years 1 and 2 and becomes less costly cumulatively between years 2 and 3, potentially providing significant savings over time. As additional BeAT-HF trial data become available, the model can be updated to show longer term effects.
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March 2021

Comparative analysis of long-term organ damage in patients with systemic lupus erythematosus using belimumab versus standard therapy: a post hoc longitudinal study.

Lupus Sci Med 2020 10;7(1)

Value Evidence & Outcomes, GlaxoSmithKline, Collegeville, Pennsylvania, USA.

Objective: Long-term extension (LTE) studies of belimumab in SLE do not include a comparator arm, preventing comparisons between belimumab plus standard therapy and standard therapy alone for organ damage accrual. Propensity score matching can be used to match belimumab-treated patients from LTE studies with standard therapy-treated patients from observational cohort studies. This analysis was designed to compare organ damage progression between treatment groups (belimumab plus standard therapy vs standard therapy alone) in patients with SLE with ≥5 years of follow-up, reproducing our previous study with more generalisable data.

Methods: This exploratory post hoc analysis used a heterogeneous population of US and non-US patients receiving monthly intravenous belimumab from pooled BLISS LTE trials (BEL112234/NCT00712933) and standard therapy-treated patients from the Toronto Lupus Cohort. Sixteen clinical variables were selected to calculate the propensity score.

Results: The 592 LTE and 381 Toronto Lupus Cohort patients were highly dissimilar across the 16 variables; an adequately balanced sample of 181 LTE and 181 matched Toronto Lupus Cohort patients (mean bias=3.7%) was created using propensity score matching. Belimumab treatment was associated with a smaller increase in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) over 5 years than standard therapy alone (mean treatment difference=-0.453 (95% CI -0.646 to -0.260); p<0.001). Patients treated with belimumab were 60% less likely to progress to a higher SDI score over any given year of follow-up, compared with standard therapy alone (HR (95% CI) 0.397 (0.275 to 0.572); p<0.001).

Conclusion: Using propensity score matching, this highly heterogeneous sample was sufficiently matched to the Toronto Lupus Cohort, suggesting that patients treated with intravenous belimumab may have reduced organ damage progression versus standard therapy alone. This analysis of a large and diverse pooled SLE population was consistent with our previously published US-focused study.
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October 2020

Predictors of Multiple Emergency Department Utilization Among Frequent Emergency Department Users in 3 States.

Med Care 2020 02;58(2):137-145

Department of Health Policy & Management, School of Public Health.

Background: Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals.

Objective: The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior.

Research Design: We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions.

Results: Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites.

Conclusions: Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.
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February 2020

Cost-Effectiveness Analysis of Erenumab Versus OnabotulinumtoxinA for Patients with Chronic Migraine Attacks in Greece.

Clin Drug Investig 2019 Oct;39(10):979-990

Laboratory of Health Economics and Management, Economics Department, University of Piraeus, Karaoli ke Dimitriou 80, 185 34, Pireas, Greece.

Background: Migraine is a common, chronic neurovascular brain disorder with non-negligible multifaceted economic costs. Existing preventive treatments involve the selective use of onabotulinumtoxinA, which aims at migraine morbidity reduction for patients who have failed initial preventive treatment with oral agents. Erenumab is a new preventive treatment for migraines.

Objective: To evaluate the differences in costs and outcomes of the preventive treatment with erenumab versus onabotulinumtoxinA in patients with chronic migraines (CM) in Greece to assess the economic value of this treatment.

Methods: We conducted a cost-effectiveness analysis from both the payer and the societal perspective using a decision-tree analytic model. Outcomes were expressed in migraines avoided and in quality-adjusted life-years (QALYs). We obtained model inputs from the existing literature. The decision path adjusted for variation in the probability of adherence and the resulting differential effectiveness between the two treatments. Direct costs included the cost of the two drugs and administration costs, the costs of acute drugs used under usual care, and the costs of hospitalization, physician, and emergency department visits. Indirect costs for the societal perspective analyses included wages lost on workdays. The time-horizon of the analysis was 1 year and all costs were calculated in 2019 euros (€). Sensitivity analyses were conducted to control for parameter uncertainty and to evaluate the robustness of the findings.

Results: Our results indicate that treatment of CM with erenumab compared to onabotulinumtoxinA resulted in incremental cost-effectiveness ratios (ICERs) of €218,870 and €231,554 per QALY gained and €620 and €656 per migraine avoided, from the societal and the payer's perspective, respectively. Using a common cost-effectiveness threshold equal to three times the local gross domestic product (GDP) per capita (€49,000), for the erenumab ICERs to fall below this threshold, the erenumab price would have to be no more than €192 (societal perspective) or €173 (payer perspective).

Conclusion: The prophylactic treatment of CM with erenumab in Greece might be cost effective compared to the existing alternative of onabotulinumtoxinA from both the payer and the societal perspective, but only at a highly discounted price. Nevertheless, erenumab could be considered a therapeutic option for patients who fail treatment with onabotulinumtoxinA.
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October 2019

Self-Reported Quality, Health, and Cost-Related Outcomes of Care Coordination Among Patients with Complex Health Needs.

Popul Health Manag 2020 02 20;23(1):59-67. Epub 2019 May 20.

Department of Health Management and Policy, School of Public Health, Texas A&M Health Science Center, Texas A&M University, College Station, Texas.

Care coordination is an increasingly popular strategy to help patients with complex health conditions manage their diseases more effectively. The purpose of the current study was to assess associations between patient-reported receipt of care coordination and their experiences of health, health care quality, and cost-related outcomes. Regression analyses of data from 431 patients across 13 Texas providers indicate that patients who reported receiving care coordination had higher odds of perceiving having enough information about how to manage their conditions (OR 2.02,  < .01), having information about education and treatments available (OR 1.87,  < .01), and reporting better access to care (beta = .27,  < .01). Receipt of care coordination was not associated with patients' reports of how up-to-date their doctors were about care from other providers, patients' health-related functioning, or patients' intention to return to the emergency department. Patients' reasons for intending to return to the emergency department included the speed of care there relative to alternatives and satisfaction with the quality of care they had received previously in the emergency department. Results suggest that care coordination in usual practice may improve patient preventive care, but not some other health or cost-related outcomes.
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February 2020

Characteristics and predictors of adult frequent emergency department users in the United States: A systematic literature review.

J Eval Clin Pract 2019 Jun 2;25(3):420-433. Epub 2019 May 2.

Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station, TX, USA.

Study Objective: We conducted a systematic literature review to identify and to update patient characteristics and contextual factors for adult frequent emergency department users (FEDUs) compared with non-FEDU in an era where the US health care system underwent substantial changes.

Methods: We searched MEDLINE, CINAHL, and EMBASE to identify all relevant articles after 2010 through July 2018 that describe FEDU. We included US studies on adult FEDU only and excluded studies on specific subgroups of FEDU. We included demographic, clinical, and health care utilization information, and two reviewers independently evaluated the studies using the Joanna Briggs Institute Critical Appraisal tool.

Results: The 11 studies included in the review indicated that FEDU were 4% to 16% of total ED users but accounted for 14% to 47% of ED visits, with six to nine visits per year on average. The majority of FEDU were young or middle-aged adults, females, of low socioeconomic status and high school or less education, with public insurance, multiple primary care provider visits, and chronic conditions. Fair or poor self-perceived health status, unemployment, unmet needs from primary care providers (PCPs), mental health, and substance abuse were predictors of FEDU.

Conclusion: FEDUs are disproportionally sicker and are also heavy users of non-ED health care service providers. The limited data for non-ED health services use in facility-specific studies of FEDU may contribute to findings in such studies that complex and unmet needs from PCPs contributed to ED visits. This suggests the need for more comprehensive data analysis beyond a few sites that can inform systemic management approaches.
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June 2019

Hepatocellular Carcinoma Screening Is Associated With Increased Survival of Patients With Cirrhosis.

Clin Gastroenterol Hepatol 2019 04 26;17(5):976-987.e4. Epub 2018 Oct 26.

Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas. Electronic address:

Background & Aims: Hepatocellular carcinoma (HCC) screening of patients with cirrhosis is recommended by professional societies to increase detection of early stage tumors and survival, but is underused in clinical practice.

Methods: We conducted a retrospective cohort study of 13,714 patients diagnosed with HCC from 2003 through 2013 included in the Surveillance, Epidemiology, and End Results Program-Medicare database. We characterized receipt of HCC screening in the 3 years before HCC diagnosis using mutually exclusive categories (consistent vs inconsistent vs no screening) and the proportion of time covered with screening. Correlates for screening receipt were assessed using a multivariable 2-part regression model. We examined the association between screening receipt and early detection of tumors using multivariable logistic regression. We evaluated associations between screening receipt and overall survival using a Cox proportional hazards model, after adjustments for effects of lead-time bias and length-time bias on survival rate estimators.

Results: Most patients with cirrhosis (51.1%) did not receive any screening in the 3 years before a diagnosis of HCC, and only 6.8% of patients underwent consistent annual screening. The proportion with consistent screening increased from 5.4% in 2003 to 2006 to 8.8% in 2011 to 2013 (P < .001). The mean proportion of time covered was 13.4% overall, which increased from 11.7% in 2003 to 2006 to 15.2% in 2011 to 2013. Receipt of consistent screening was associated with detection of early stage tumors (odds ratio, 1.98; 95% CI, 1.68-2.33) and a reduced risk of death after correction for lead-time bias (hazard ratio, 0.76; 95% CI, 0.70-0.83). Inconsistent screening was associated with a slightly smaller increase in early detection of HCC (odds ratio, 1.31; 95% CI, 1.20-1.43) and a reduced risk of death (hazard ratio, 0.86; 95% CI, 0.83-0.90). After correction for lead- and length-time biases, higher proportions of patients with consistent (23%; 95% CI, 21%-25%) and inconsistent screening (19%; 95% CI, 19%-20%) survived for 3 years compared with patients without screening (13%; 95% CI, 12%-14%).

Conclusions: In an analysis of the Surveillance, Epidemiology, and End Results Program-Medicare database, we found HCC screening to be underused for patients with cirrhosis. This contributes to detection of liver tumors at later stages and shorter times of survival. However, the proportion of patients screened for HCC has increased over time.
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April 2019

Organ damage in patients treated with belimumab versus standard of care: a propensity score-matched comparative analysis.

Ann Rheum Dis 2019 03 4;78(3):372-379. Epub 2019 Jan 4.

Value Evidence & Outcomes, GSK, Philadelphia, Pennsylvania, USA.

Objectives: The study (206347) compared organ damage progression in patients with systemic lupus erythematosus (SLE) who received belimumab in the BLISS long-term extension (LTE) study with propensity score (PS)-matched patients treated with standard of care (SoC) from the Toronto Lupus Cohort (TLC).

Methods: A systematic literature review identified 17 known predictors of organ damage to calculate a PS for each patient. Patients from the BLISS LTE and the TLC were PS matched posthoc 1:1 based on their PS (±calliper). The primary endpoint was difference in change in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score from baseline to 5 years.

Results: For the 5- year analysis, of 567 (BLISS LTE n=195; TLC n=372) patients, 99 from each cohort were 1:1 PS matched. Change in SDI score at Year 5 was significantly lower for patients treated with belimumab compared with SoC (-0.434; 95% CI -0.667 to -0.201; p<0.001). For the time to organ damage progression analysis (≥1 year follow-up), the sample included 965 (BLISS LTE n=259; TLC n=706) patients, of whom 179 from each cohort were PS-matched. Patients receiving belimumab were 61% less likely to progress to a higher SDI score over any given year compared with patients treated with SoC (HR 0.391; 95% CI 0.253 to 0.605; p<0.001). Among the SDI score increases, the proportion of increases ≥2 was greater in the SoC group compared with the belimumab group.

Conclusions: PS-matched patients receiving belimumab had significantly less organ damage progression compared with patients receiving SoC.
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March 2019

Racial Disparities in Type of Heart Failure and Hospitalization.

J Immigr Minor Health 2019 Feb;21(1):98-104

Office of Health Policy and Legislative Affairs, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555-0920, USA.

Heart failure (HF) is one of the leading causes of hospitalization and readmissions. Our study aimed to examine racial disparities in heart failure patients including onset, mortality, length of stay (LOS), direct costs, and readmission rates. This is a secondary data analysis. We analyzed the risk-adjusted inpatient data of all patients admitted with HF to one health academic center. We compared five health outcomes among three racial groups (white, black, and Hispanic). There were 1006 adult patients making 1605 visits from 10/01/2011 to 09/30/2015. Most black patients were admitted in younger age than other racial groups which indicates the needs for more public health preventions. With risk adjustments, the racial differences in LOS and readmission rates remain. We stratified health outcomes by race/ethnic and type of HF. The findings suggest that further studies to uncover underlying causes of these disparities are necessary. Using risk-adjusted hospitalization data allows for comparisons of quality of care across three racial groups. The study suggests that more prevention and protection services are needed for African American patients with heart failure.
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February 2019

The Diabetes Management Education Program in South Texas: An Economic and Clinical Impact Analysis.

Front Public Health 2017 18;5:345. Epub 2017 Dec 18.

School of Public Health, Texas A&M University, College Station, TX, United States.

Introduction: Diabetes is a major chronic disease that can lead to serious health problems and high healthcare costs without appropriate disease management and treatment. In the United States, the number of people diagnosed with diabetes and the cost for diabetes treatment has dramatically increased over time. To improve patients' self-management skills and clinical outcomes, diabetes management education (DME) programs have been developed and operated in various regions.

Objective: This community case study explores and calculates the economic and clinical impacts of expanding a model DME program into 26 counties located in South Texas.

Methods: The study sample includes 355 patients with type 2 diabetes and a follow-up hemoglobin A1c level measurement among 1,275 individuals who participated in the DME program between September 2012 and August 2013. We used the Gilmer's cost differentials model and the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine methodology to predict 3-year healthcare cost savings and 10-year clinical benefits of implementing a DME program in the selected 26 Texas counties.

Results: Changes in estimated 3-year cost and the estimated treatment effect were based on baseline hemoglobin A1c level. An average 3-year reduction in medical treatment costs per program participant was $2,033 (in 2016 dollars). The total healthcare cost savings for the 26 targeted counties increases as the program participation rate increases. The total projected cost saving ranges from $12 million with 5% participation rate to $185 million with 75% participation rate. A 10-year outlook on additional clinical benefits associated with the implementation and expansion of the DME program at 60% participation is estimated to result in approximately 4,838 avoided coronary heart disease cases and another 392 cases of avoided strokes.

Conclusion: The implementation of this model DME program in the selected 26 counties would contribute to substantial healthcare cost savings and clinical benefits. Organizations that provide DME services may benefit from reduction in medical treatment costs and improvement in clinical outcomes for populations with diabetes.
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December 2017

Potentially Preventable Hospitalizations and the Burden of Healthcare-Associated Infections.

Health Serv Res Manag Epidemiol 2017 Jan-Dec;4:2333392817721109. Epub 2017 Aug 30.

Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX, USA.

Background: An estimated 4% of hospital admissions acquired healthcare-associated infections (HAIs) and accounted for $9.8 (USD) billion in direct cost during 2011. In 2010, nearly 140 000 of the 3.5 million potentially preventable hospitalizations (PPHs) may have acquired an HAI. There is a knowledge gap regarding the co-occurrence of these events.

Aims: To estimate the period occurrences and likelihood of acquiring an HAI for the PPH population.

Methods: Retrospective, cross-sectional study using logistic regression analysis of 2011 Texas Inpatient Discharge Public Use Data File including 2.6 million admissions from 576 acute care hospitals. Agency for Healthcare Research and Quality Prevention Quality Indicator software identified PPH, and existing administrative data identification methodologies were refined for infection, central line-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia. Odds of acquiring HAIs when admitted with PPH were adjusted for demographic, health status, hospital, and community characteristics.

Findings: We identified 272 923 PPH, 14 219 HAI, and 986 admissions with PPH and HAI. Odds of acquiring an HAI for diabetic patients admitted for lower extremity amputation demonstrated significantly increased odds ratio of 2.9 (95% confidence interval: 2.16-3.91) for infection. Other PPH patients had lower odds of acquiring HAI compared to non-PPH patients, and results were frequently significant.

Conclusions: Clinical implications include increased risk of HAI among diabetic patients admitted for lower extremity amputation. Methodological implications include identification of rare events for inpatient subpopulations and the need for improved codification of HAIs to improve cost and policy analyses regarding allocation of resources toward clinical improvements.
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August 2017

Outcomes of Surgeries Performed in Physician Offices Compared With Ambulatory Surgery Centers and Hospital Outpatient Departments in Florida.

Health Serv Insights 2017 20;10:1178632917701025. Epub 2017 Apr 20.

Avalon Health Economics LLC, Morristown, NJ, USA.

Background: The proportion of outpatient surgeries performed in physician offices has been increasing over time, raising concern about the impact on outcomes.

Objective: To use a private insurance claims database to compare 7-day and 30-day hospitalization rates following relatively complex outpatient surgical procedures across physician offices, freestanding ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPDs).

Methods: A multivariable logistic regression model was used to compare the risk-adjusted probability of hospitalization among patients after any of the 88 study outpatient procedures at physician offices, ASCs, and HOPDs over 2008-2012 in Florida.

Results: Risk-adjusted hospitalization rates were higher following procedures performed in physician offices compared with ASCs for all procedures grouped together, for most procedures grouped by type, and for many individual procedures.

Conclusions: Hospitalizations following surgery were more likely for procedures performed in physician offices compared with ASCs, which highlights the need for ongoing research on the safety and efficacy of office-based surgery.
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April 2017

Cost impact of unexpected disposition after orthopedic ambulatory surgery associated with category of anesthesia provider.

J Clin Anesth 2016 Dec 17;35:157-162. Epub 2016 Aug 17.

Avalon Health Economics LLC, 26 Washington St., Floor 3, Morristown, NJ 07960, USA. Electronic address:

Study Objective: To provide estimates of the costs and health outcomes implications of the excess risk of unexpected disposition for nurse anesthetist (NA) procedures.

Design: A projection model was used to apply estimates of costs and health outcomes associated with the excess risk of unexpected disposition for NAs reported in a recent study.

Setting: Ambulatory and inpatient surgery.

Patients: Base-case model parameters were based on estimates taken from peer-reviewed publications when available, or from other sources including data for all hospital stays in the United States in 2013 from the Healthcare Cost and Utilization Project Web site. The impact of parameter uncertainty was assessed using 1-way and 2-way sensitivity analyses.

Interventions: Not applicable.

Measurements: Major complication rates, relative risks of complications, anesthesia costs, costs of complications, and cost-effectiveness ratios.

Main Results: In the base-case model, there were on average 2.3 fewer unexpected dispositions for physician anesthesiologists compared with NAs. Overall, anesthesia-related costs (including the cost of managing unexpected dispositions) were estimated to be about $31 higher per procedure for physician anesthesiologists compared with NAs. Alternative model scenarios in the sensitivity analysis produced estimates of smaller additional costs associated with physician anesthesia administration, to the point of cost savings in some scenarios.

Conclusions: Provision of anesthesia for ambulatory knee and shoulder procedures by physician anesthesiologists results in better health outcomes, at a reasonable additional cost, compared with procedures with NA-administered anesthesia, at least when using updated cost-effectiveness willingness-to-pay benchmarks.
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December 2016

Women, family medicine, and career choice: An opportunity cost analysis.

JAAPA 2016 Sep;29(9):44-8

Alison C. Essary is director of academic partnerships in the College of Health Solutions, associate director and a clinical associate professor in the School for the Science of Healthcare Delivery, and a faculty member of Barrett, the honors college at Arizona State University in Phoenix. Bettie H. Coplan is director of online graduate education and a clinical associate professor in the School for the Science of Healthcare Delivery at Arizona State University. James F. Cawley is a professor in the Department of Prevention and Community Health in the School of Public Health and Health Services and professor in the PA program at George Washington University in Washington, D.C. Eugene S. Schneller is a professor and Dean's Council of 100 Distinguished Scholars in the Department of Supply Chain Management in the W.P. Carey School of Business at Arizona State University. Robert L. Ohsfeldt is a professor in the Department of Health Policy and Management in the School of Rural Public Health at Texas A&M Health Science Center in College Station, Tex.

Objective: This study compared the cost of physician versus physician assistant (PA) education for women practicing in family medicine.

Methods: Using 2013 salary survey data from both the Medical Group Management Association and the American Academy of PAs as well as other publicly available data sources, the authors compared the current net present value (NPV) of physician and PA training for women practicing in family medicine.

Results: Considering a base case scenario involving a 24-year-old woman, the NPV to become a family medicine physician was $2,015,000 compared with an NPV of $1,751,000 to become a family medicine PA. Alternative projections produced an NPV for PA training that slightly exceeded the NPV for family medicine physician training.

Conclusions: For a woman practicing in family medicine, becoming a physician or a PA offers similar financial rewards.
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September 2016

Hospital Characteristics are Associated With Readiness to Attain Stage 2 Meaningful Use of Electronic Health Records.

J Rural Health 2017 06 18;33(3):275-283. Epub 2016 Jul 18.

Department of Epidemiology, School of Medicine, University of California-Irvine, Irvine, California.

Purpose: To examine the difference between rural and urban hospitals as to their overall level of readiness for stage 2 meaningful use of electronic health records (EHRs) and to identify other key factors that affect their readiness for stage 2 meaningful use.

Methods: A conceptual framework based on the theory of organizational readiness for change was used in a cross-sectional multivariate analysis using 2,083 samples drawn from the HIMSS Analytics survey conducted with US hospitals in 2013.

Findings: Rural hospitals were less likely to be ready for stage 2 meaningful use compared to urban hospitals in the United States (OR = 0.49) in our final model. Hospitals' past experience with an information exchange initiative, staff size in the information system department, and the Chief Information Officer (CIO)'s responsibility for health information management were identified as the most critical organizational contextual factors that were associated with hospitals' readiness for stage 2. Rural hospitals lag behind urban hospitals in EHR adoption, which will hinder the interoperability of EHRs among providers across the nation. The identification of critical factors that relate to the adoption of EHR systems provides insights into possible organizational change efforts that can help hospitals to succeed in attaining meaningful use requirements.

Conclusion: Rural hospitals have increasingly limited resources, which have resulted in a struggle for these facilities to attain meaningful use. Given increasing closures among rural hospitals, it is all the more important that EHR development focus on advancing rural hospital quality of care and linkages with patients and other organizations supporting the care of their patients.
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June 2017

In-office magnetic resonance imaging (MRI) equipment ownership and MRI volume among medicare patients in orthopedic practices.

Health Econ Rev 2015 Dec 20;5(1):31. Epub 2015 Oct 20.

CEO, Avalon Health Economics, 20 South Street, Suite 2B, Morristown, NJ, 07960, USA.

Background: Concerns have been raised about physician ownership of onsite advanced imaging equipment as allowed under Stark laws by the in-office ancillary service exception (IOASE).

Methods: A web-based survey of orthopedic practices in the United States was used to assign a first date of onsite MRI capacity acquisition (if any) to specific orthopedic practices. Medicare claims data for 2006-2010 was obtained for providers in orthopedic practices acquiring onsite MRI capacity and in matched orthopedic practices without an onsite MRI over the same period of time. Multivariate regression was used to estimate the change in provider Medicare MRI volume one year before and one year after the onsite MRI acquisition year for providers in MRI practices compared to providers in propensity-score matched non-MRI practices.

Results: In all of the MRI volume change models estimated, the association between onsite MRI acquisition and the change in provider Medicare MRI volume (one-year post-onsite-MRI-acquisition less one year pre-acquisition) was consistently small and not statistically significant. This lack of association was robust to changes in model specification in terms of types of MRI exams considered, specific covariates included in the multivariate model, or the process used to confirm individual provider affiliation with study practices in study years.

Conclusions: Our analysis of Medicare claims data provides no empirical support for the proposition that acquisition of onsite MRI capacity within an orthopedic surgery practice induces an increase in the rate of MRI use for Medicare patients among practice providers, relative to physicians in practices without MRI capacity over the same time period.
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December 2015

Do rural and urban women experience differing rates of maternal rehospitalizations?

Rural Remote Health 2015 Jul-Sep;15(3):3335. Epub 2015 Aug 18.

Texas A&M Health Science Center, School of Public Health, Department of Health Policy and Management, College Station, TX, USA.

Introduction: Conditions such as postpartum complications and mental disorders of new mothers contribute to a relatively large number of maternal rehospitalizations and even some deaths. Few studies have examined rural-urban differences in hospital readmissions, and none of them have addressed maternal readmissions. This research directly compares readmissions for patients who delivered in rural versus urban hospitals.

Methods: The data for this cross-sectional study were drawn from the 2011 California Healthcare Cost and Utilization Project. Readmission rates were reported to demonstrate rural-urban differences. Generalized estimating equation models were also used to estimate the likelihood of a new mother being readmitted over time.

Results: The 323 051 women who delivered with minor assistance and 158 851 women who delivered by cesarean section (C-section) were included in this study. Of those, seven maternal mortalities occurred after vaginal deliveries and 14 occurred after C-section procedures. Fewer than 1% (0.98% or 3171) women with normal deliveries were rehospitalized. The corresponding number for women delivering via C-section was 1.41% (2243). For both types of deliveries, women giving birth in a rural hospital were more likely to be readmitted.

Conclusions: This is the first study examining rural-urban differences in maternal readmissions. The results indicate the importance of monitoring and potentially improving the quality of maternal care, especially when the delivery involves a C-section. More studies investigating rural health disparities in women's health are clearly necessary.
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October 2016

Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective.

Clin Chem Lab Med 2015 Mar;53(4):583-92

Background: Whether or not antibiotic stewardship protocols based on procalcitonin levels results in cost savings remains unclear. Herein, our objective was to assess the economic impact of adopting procalcitonin testing among patients with suspected acute respiratory tract infection (ARI) from the perspective of a typical US integrated delivery network (IDN) with a 1,000,000 member catchment area or enrollment.

Methods: To conduct an economic evaluation of procalcitonin testing versus usual care we built a cost-impact model based on patient-level meta-analysis data of randomized trials. The meta-analytic data was adapted to the US setting by applying the meta-analytic results to US lengths of stay, costs, and practice patterns. We estimated the annual ARI visit rate for the one million member cohort, by setting (inpatient, ICU, outpatient) and ARI diagnosis.

Results: In the inpatient setting, the costs of procalcitonin-guided compared to usual care for the one million member cohort was $2,083,545, compared to $2,780,322, resulting in net savings of nearly $700,000 to the IDN for 2014. In the ICU and outpatient settings, savings were $73,326 and $5,329,824, respectively, summing up to overall net savings of $6,099,927 for the cohort. RESULTS were robust for all ARI diagnoses. For the whole US insured population, procalcitonin-guided care would result in $1.6 billion in savings annually.

Conclusions: Our results show substantial savings associated with procalcitonin protocols of ARI across common US treatment settings mainly by direct reduction in unnecessary antibiotic utilization. These results are robust to changes in key parameters, and the savings can be achieved without any negative impact on treatment outcomes.
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March 2015

Is diabetes color-blind? Growth of prevalence of diagnosed diabetes in children through 2030.

Popul Health Manag 2015 Jun 7;18(3):172-8. Epub 2014 Oct 7.

Diabetes knows no age and affects millions of individuals. Preventing diabetes in children is increasingly becoming a major health policy concern and focus. The objective of this study is to project the number of children, aged 0-17 years, with diagnosed diabetes in the United States through 2030, accounting for changing demography, and diabetes and obesity prevalence rates. The study team combined historic diabetes and obesity prevalence data with US child population estimates and projections. A times-series regression model was used to forecast future diabetes prevalence and to account for the relationship between the forecasted diabetes prevalence and the lagged prevalence of childhood obesity. Overall, the prevalence of diagnosed diabetes is projected to increase 67% from 0.22% in 2010 to 0.36% in 2030. Lagged obesity prevalence in Hispanic boys and non-Hispanic black girls was significantly associated with increasing future diabetes prevalence. The study results showed that a 1% increase in obesity prevalence among Hispanic boys from the previous year was significantly associated with a 0.005% increase in future prevalence of diagnosed diabetes in children (P ≤ 0.01). Likewise, a unit increase in obesity prevalence among non-Hispanic black girls was associated with a 0.003% increase in future diabetes prevalence (P < 0.05). Obesity rates for other race/ethnicity combinations were not associated with increasing future diabetes prevalence. To mitigate the continued threat posed by diabetes, serious discussions need to focus on the pediatric population, particularly non-Hispanic black girls and Hispanic boys whose obesity trends show the strongest associations with future diabetes prevalence in children.
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June 2015

Can an Internet-based health risk assessment highlight problems of heart disease risk factor awareness? A cross-sectional analysis.

J Med Internet Res 2014 Apr 18;16(4):e106. Epub 2014 Apr 18.

School of Public Health, Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Station, TX, United States.

Background: Health risk assessments are becoming more popular as a tool to conveniently and effectively reach community-dwelling adults who may be at risk for serious chronic conditions such as coronary heart disease (CHD). The use of such instruments to improve adults' risk factor awareness and concordance with clinically measured risk factor values could be an opportunity to advance public health knowledge and build effective interventions.

Objective: The objective of this study was to determine if an Internet-based health risk assessment can highlight important aspects of agreement between respondents' self-reported and clinically measured CHD risk factors for community-dwelling adults who may be at risk for CHD.

Methods: Data from an Internet-based cardiovascular health risk assessment (Heart Aware) administered to community-dwelling adults at 127 clinical sites were analyzed. Respondents were recruited through individual hospital marketing campaigns, such as media advertising and print media, found throughout inpatient and outpatient facilities. CHD risk factors from the Framingham Heart Study were examined. Weighted kappa statistics were calculated to measure interrater agreement between respondents' self-reported and clinically measured CHD risk factors. Weighted kappa statistics were then calculated for each sample by strata of overall 10-year CHD risk. Three samples were drawn based on strategies for treating missing data: a listwise deleted sample, a pairwise deleted sample, and a multiple imputation (MI) sample.

Results: The MI sample (n=16,879) was most appropriate for addressing missing data. No CHD risk factor had better than marginal interrater agreement (κ>.60). High-density lipoprotein cholesterol (HDL-C) exhibited suboptimal interrater agreement that deteriorated (eg, κ<.30) as overall CHD risk increased. Conversely, low-density lipoprotein cholesterol (LDL-C) interrater agreement improved (eg, up to κ=.25) as overall CHD risk increased. Overall CHD risk of the sample was lower than comparative population-based CHD risk (ie, no more than 15% risk of CHD for the sample vs up to a 30% chance of CHD for the population).

Conclusions: Interventions are needed to improve knowledge of CHD risk factors. Specific interventions should address perceptions of HDL-C and LCL-C. Internet-based health risk assessments such as Heart Aware may contribute to public health surveillance, but they must address selection bias of Internet-based recruitment methods.
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April 2014

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: a survival analysis model.

Patient Educ Couns 2014 Apr 13;95(1):111-7. Epub 2014 Jan 13.

Department of Epidemiology & Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, USA; Department of Health Promotion & Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, USA; Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, USA.

Objective: This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization.

Methods: Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization.

Results: Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm.

Conclusion: CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM.

Practice Implications: Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.
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April 2014

Can chronic disease management programs for patients with type 2 diabetes reduce productivity-related indirect costs of the disease? Evidence from a randomized controlled trial.

Popul Health Manag 2014 Apr 23;17(2):112-20. Epub 2013 Oct 23.

1 Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center , College Station, Texas.

The objective was to assess the impacts of diabetes self-management programs on productivity-related indirect costs of the disease. Using an employer's perspective, this study estimated the productivity losses associated with: (1) employee absence on the job, (2) diabetes-related disability, (3) employee presence on the job, and (4) early mortality. Data were obtained from electronic medical records and survey responses of 376 adults aged ≥18 years who were enrolled in a randomized controlled trial of type 2 diabetes self-management programs. All study participants had uncontrolled diabetes and were randomized into one of 4 study arms: personal digital assistant (PDA), chronic disease self-management program (CDSMP), combined PDA and CDSMP, and usual care (UC). The human-capital approach was used to estimate lost productivity resulting from 1, 2, 3, and 4 above, which are summed to obtain total productivity loss. Using robust regression, total productivity loss was modeled as a function of the diabetes self-management programs and other identified demographic and clinical characteristics. Compared to subjects in the UC arm, there were no statistically significant differences in productivity losses among persons undergoing any of the 3 diabetes management interventions. Males were associated with higher productivity losses (+$708/year; P<0.001) and persons with greater than high school education were associated with additional productivity losses (+$758/year; P<0.001). Persons with more than 1 comorbid condition were marginally associated with lower productivity losses (-$326/year; P=0.055). No evidence was found that the chronic disease management programs examined in this trial affect indirect productivity losses.
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April 2014

Squeezing the balloon: propensity scores and unmeasured covariate balance.

Health Serv Res 2013 Aug 6;48(4):1487-507. Epub 2012 Dec 6.

College of Pharmacy and College of Public Health, University of Iowa, Iowa City, IA 52242, USA.

Objective: To assess the covariate balancing properties of propensity score-based algorithms in which covariates affecting treatment choice are both measured and unmeasured.

Data Sources/study Setting: A simulation model of treatment choice and outcome.

Study Design: Simulation.

Data Collection/extraction Methods: Eight simulation scenarios varied with the values placed on measured and unmeasured covariates and the strength of the relationships between the measured and unmeasured covariates. The balance of both measured and unmeasured covariates was compared across patients either grouped or reweighted by propensity scores methods.

Principal Findings: Propensity score algorithms require unmeasured covariate variation that is unrelated to measured covariates, and they exacerbate the imbalance in this variation between treated and untreated patients relative to the full unweighted sample.

Conclusions: The balance of measured covariates between treated and untreated patients has opposite implications for unmeasured covariates in randomized and observational studies. Measured covariate balance between treated and untreated patients in randomized studies reinforces the notion that all covariates are balanced. In contrast, forced balance of measured covariates using propensity score methods in observational studies exacerbates the imbalance in the independent portion of the variation in the unmeasured covariates, which can be likened to squeezing a balloon. If the unmeasured covariates affecting treatment choice are confounders, propensity score methods can exacerbate the bias in treatment effect estimates.
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August 2013

Economics of cancer biomarkers.

Per Med 2012 Nov;9(8):829-837

Health Economics & Outcomes Research, Abbott Diagnostics, IL, USA.

Cancer accounts for approximately 13% of all deaths worldwide, and in 2010 the estimated total cost of cancer in the USA was more than US$263 billion. Biomarker use for screening, monitoring, diagnosis and treatment optimization has the potential to improve patient outcomes and reduce costs associated with inappropriate (or suboptimal) therapeutic regimens. Since a new technology may have additional initial cost, a policy question arises regarding whether the improvement in outcomes is attained at a 'reasonable' additional cost compared with existing technology. This paper presents an overview of health economic issues surrounding biomarkers in general, with a focus on cancer care and treatment optimization in particular. While this article is not a systematic review of the literature, it includes relevant examples to provide a real-world perspective.
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November 2012

Organizational boundaries of medical practice: the case of physician ownership of ancillary services.

Health Econ Rev 2012 Apr 5;2(1). Epub 2012 Apr 5.

Oxford Outcomes Ltd,, Morristown, USA.

Physician ownership of in-office ancillary services (IOASs) has come under increasing scrutiny. Advocates of argue that IOASs allow physicians to supervise the quality and coordination of care. Critics have argued that IOASs create financial incentives for physicians to increase ancillary service volume. In this paper we develop a conceptual framework to evaluate the tradeoffs associated with physician ownership of IOASs. There is some evidence supporting the existence of scope and transaction economies in IOASs. Improvement in flow and continuity of care are likely to generate scope economies and improvements in quality monitoring and reductions in consumer transaction costs are likely to generate transaction economies. Other factors include the capture of upstream and downstream profits, but these incentives are likely to be small compared to scope and transaction economies. Policy debates on the merits of IOASs should include an explicit assessment of these tradeoffs.This research was supported in part by funding from the American Association of Orthopaedic Surgeons (AAOS).
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April 2012

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients.

Health Serv Res 2012 Aug 21;47(4):1642-59. Epub 2012 Feb 21.

Program on Aging, Long Term Care and Disability, Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center (TAMU 1266), College Station, TX 77843, USA.

Objectives: To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care.

Data Sources/study Setting: Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas.

Study Design: Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods.

Data Collection/extraction Methods: The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006.

Principal Findings: Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries.

Conclusions: More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.
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August 2012

Use of a health information exchange system in the emergency care of children.

BMC Med Inform Decis Mak 2011 Dec 30;11:78. Epub 2011 Dec 30.

Health Policy & Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, 501 Forest Drive, Statesboro, GA 30460, USA.

Background: Children may benefit greatly in terms of safety and care coordination from the information sharing promised by health information exchange (HIE). While information exchange capability is a required feature of the certified electronic health record, we known little regarding how this technology is used in general and for pediatric patients specifically.

Methods: Using data from an operational HIE effort in central Texas, we examined the factors associated with actual system usage. The clinical and demographic characteristics of pediatric ED encounters (n = 179,445) were linked to the HIE system user logs. Based on the patterns of HIE system screens accessed by users, we classified each encounter as: no system usage, basic system usage, or novel system usage. Using crossed random effects logistic regression, we modeled the factors associated with basic and novel system usage.

Results: Users accessed the system for 8.7% of encounters. Increasing patient comorbidity was associated with a 5% higher odds of basic usage and 15% higher odds for novel usage. The odds of basic system usage were lower in the face of time constraints and for patients who had not been to that location in the previous 12 months.

Conclusions: HIE systems may be a source to fulfill users' information needs about complex patients. However, time constraints may be a barrier to usage. In addition, results suggest HIE is more likely to be useful to pediatric patients visiting ED repeatedly. This study helps fill an existing gap in the study of technological applications in the care of children and improves knowledge about how HIE systems are utilized.
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December 2011

Cost-effectiveness of rosuvastatin 20 mg for the prevention of cardiovascular morbidity and mortality: a Swedish economic evaluation of the JUPITER trial.

J Med Econ 2012 4;15(1):125-33. Epub 2011 Nov 4.

Texas A&M Health Science Center, College Station, TX, USA.

Objective: This study estimated the long-term health outcomes, healthcare costs, and cost-effectiveness of rosuvastatin 20 mg therapy in primary prevention of major cardiovascular disease (CVD) in a Swedish population.

Methods: Based on data from the JUPITER trial, long-term CVD outcomes with rosuvastatin vs no active treatment were estimated for patients with an elevated baseline CVD risk (Framingham CVD score >20%, sub-population of JUPITER population) and for a population similar to the total JUPITER population. Using a decision-analytic model, trial CVD event rates were combined with epidemiological and cost data specific for Sweden. First and subsequent CVD events and death were estimated over a lifetime perspective. The observed relative risk reduction was extrapolated beyond the trial duration. Incremental effectiveness was measured as life-years gained (LYG) and quality-adjusted life-years (QALYs) gained.

Results: Treating 100,000 patients with rosuvastatin 20 mg was estimated to avoid 14,692 CVD events over the lifetime (8021 non-fatal MIs, 3228 non-fatal strokes, and 4924 CVD deaths) compared to placebo. This translated into an estimated gain of 42,122 QALYs and 36,865 total life years (LYG). Rosuvastatin was both more effective and less costly over a lifetime perspective, and rosuvastatin is subsequently a dominant alternative compared to no treatment in the assessed population. Using the overall JUPITER population, rosuvastatin was dominant for the lifetime horizon. In the sensitivity analysis, rosuvastatin was the dominant treatment strategy over a 20-year time horizon, and cost-effective with an incremental cost-effectiveness ratio (cost per QALY) of SEK 1783 over a 10-year time horizon.

Limitations: Some model inputs were derived from literature or other data sources, but uncertainty was controlled by sensitivity analyses.

Conclusions: Results indicate that rosuvastatin 20 mg treatment is a cost-effective option vs no-treatment in patients with Framingham CVD risk >20% in Sweden and might even be cost saving if taking a long-term perspective.
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June 2012

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.

BMC Geriatr 2011 Oct 21;11:65. Epub 2011 Oct 21.

Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa, USA.

Background: It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.

Methods: Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.

Results: We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).

Conclusions: We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.
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October 2011