Estimated cost savings associated with the use of valsartan in heart failure in a large US health plan

Summary

Results from a large, randomised clinical trial demonstrated reduced rates of hospitalisation and mortality, and reduced length of stay associated with valsartan added to the usual care of heart failure patients not currently receiving angiotensin-converting enzyme inhibitors (ACEIs). These results were used in a budget impact model for a large US health plan. Administrative claims data were used to estimate cost savings over 1 year. In the study health plan, 63,218 patients were identified with heart failure, with 55% not currently receiving ACEI or valsartan. Using health plan-specific cost data, care for the untreated heart failure patients with valsartan would reduce hospitalisation costs from $135 million to $43 million owing to averted heart failure-related hospitalisations and shortened length of stay for the remaining hospitalisations. Economic effects of other aspects of treatment with valsartan (e.g. outpatient or physician visits or adverse events) were not considered. Taking into account only hospitalisations and the costs of valsartan therapy, net savings in the study health plan would be expected to be $64 million.     

The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

Medical costs in patients with heart failure after acute heart failure events: one-year follow-up study

Aims: This study investigated annual medical costs using real-world data focusing on acute heart failure.

Methods: The data were retrospectively collected from six tertiary hospitals in South Korea. Overall, 330 patients who were hospitalized for acute heart failure between January 2011 and July 2012 were selected. Data were collected on their follow-up medical visits for 1 year, including medical costs incurred toward treatment. Those who died within the observational period or who had no records of follow-up visits were excluded. Annual per patient medical costs were estimated according to the type of medical services, and factors contributing to the costs using Gamma Generalized Linear Models (GLM) with log link were analyzed.

Results: On average, total annual medical costs for each patient were USD 6,199 (±9,675), with hospitalization accounting for 95% of the total expenses. Hospitalization cost USD 5,904 (±9,666) per patient. Those who are re-admitted have 88.5% higher medical expenditure than those who have not been re-admitted in 1 year, and patients using intensive care units have 19.6% higher expenditure than those who do not. When the number of hospital days increased by 1?day, medical expenses increased by 6.7%.

Limitations: Outpatient drug costs were not included. There is a possibility that medical expenses for AHF may have been under-estimated.

Conclusion: It was found that hospitalization resulted in substantial costs for treatment of heart failure in South Korea, especially in patients with an acute heart failure event. Prevention strategies and appropriate management programs that would reduce both frequency of hospitalization and length of stay for patients with the underlying risk of heart failure are needed.     

Advanced practice nurse outcomes 1990-2008: a systematic review

Advanced practice registered nurses have assumed an increasing role as providers in the health care system, particularly for underserved populations. The aim of this systematic review was to answer the following question: Compared to other providers (physicians or teams without APRNs) are APRN patient outcomes of care similar? This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.     

A preliminary look at readmission and mortality among chronically critically ill and other medically complex Medicare patients

Chronically critically ill and other medically complex patients (CCI/MC-Ps) are those who are hospitalized with long-term intensive care needs and require extended periods of hospital-level care. CCI/MC-Ps may be at higher risk for readmission and mortality than other populations due to the severe nature their illnesses. This article examines factors that lead to increased probability of hospital readmission or mortality among CCI/MC Medicare patients. Logistic regression analyses are used to examine mortality and readmissions among the CCI/MC population. Numerous factors including length of stay in the acute hospital, age and gender affect whether a patient is readmitted to the acute care hospital within 90 days of discharge or dies within 60 days following a hospital stay.     

Combined benchmarking of hospital outcomes and utilization

A strong case is made for developing quantitative benchmarks for hospital outcomes as well as utilization that includes both acute care re-admissions and lengths of stay. A number of hospitals in two distinctly different geographic health care environments [CA and NY] are studied as to the differences in outcomes and utilization for three of the most common high-cost DRGs. Unscheduled hospital readmissions (within 30 days of initial discharge) were employed as outcome indicators because they reflect both the quality of acute care and the need for case management in the post-discharge period. Benchmark targets were established for patients with a diagnosis of congestive heart failure, acute MI treated medically, or COPD using scattergrams that showed each hospital's mean acute LOS on the x axis and the re-admission rates on the y axis. "Benchmarks were identified as those points with the lowest values for both indicators, as demonstrated by points that were closest to the intersection of the two axes."     

Identifying the relationship between length of hospital stay and the probability of readmission

We estimate the effect of hospital length of stay (LOS) on the probability of 30-day readmission for 516,768 patients hospitalized with heart failure in California from 2005 to 2011. We use hospital crowding as an instrumental variable to control for bias from omitted health characteristics. Our results suggest that the literature, which has for 30 years identified readmission rates increasing with LOS, has not controlled for omitted variable bias when estimating the benefits from a patient’s hospital stay.     

Reduction in costs of inpatient stay associated with clozapine treatment: A retrospective study

Summary

Clozapine is an atypical antipsychotic drug used to treat the 10-25% of patients who suffer from schizophrenia who are treatment resistant or intolerant to standard antipsychotic drug treatment. A major issue associated with treatment is the high cost of the drug compared to standard antipsychotic drug treatment. Research carried out to date has suggested that despite the high cost of clozapine, it is overall a cost-effective treatment. This contention is based on the findings described elsewhere that clozapine treatment is associated with a dramatic decrease in psychiatric inpatient stay.

There are many ethical difficulties associated with a prospective double-blind controlled trial of clozapine treatment. We have therefore reported on a retrospective audit. A retrospective analysis was carried out by the examination of computerised patient records to determine if clozapine treatment had been associated with a reduction in psychiatric inpatient stay. Also examined was whether clozapine treatment had been associated with an overall shift from intensive therapeutic ward usage.

For example, patients are moved from intensive care and acute wards to wards with less intensive therapeutic input such as continuing care and rehabilitation wards. The inpatient stay details for 76 patients prescribed clozapine since early 1991 were examined before and after clozapine treatment commenced. The main problem with this retrospective analysis is that without any control group observed over the same time period, it is very difficult to assess how much of the decrease in bed usage is related to either the natural history of the disease and/or to changes in bed use over time associated with changes in mental health service provision and the development of community facilities.

Psychiatric inpatient stay decreased by a statistically non-significant average of 13.2 days (6%) in the first year of treatment (p=0.7692), a non-significant average of 34 days (15%) in the second year of treatment (p=0.0669), a significant average of 38.4 days (17%) in the third year of treatment (p=0.0007) and again by a significant average of 51.2 days (22%) in the fourth year of treatment (p=0.0011).

The average cost per inpatient bed-day for the main psychiatric hospital in the Health Board's area is £90.86 (based on 100% occupancy rate, 1994/95 prices). The reduction in bed days identified was equivalent to a saving of £1,200 per patient in the first year of treatment, £3,090 per patient in the second year, £3,490 per patient in the third year and £4,652 per patient in the fourth year. The average annual cost of clozapine per patient is approximately £2,500.

Clozapine treatment was also associated with a shift from intensive care and acute ward inpatient usage to continuing care and rehabilitative ward usage. In the year prior to clozapine treatment intensive care and acute ward stay accounted for 72.7% of total inpatient stay. In the first year of treatment this proportion decreased to 63.7%, in the second year to 39.5%, in the third year to 31.8% and in the fourth year to 24.6%. This represented potential savings of £500,000 per annum.

Overall, the data generated from this study indicated that clozapine treatment is associated with both a reduction in psychiatric bed usage and a shift to less therapeutically intensive care wards. However, the decrease identified is not as dramatic as the reduction quoted elsewhere in the literature. These findings provide useful costing information to support the view that clozapine is a cost-saving or cost-neutral treatment in terms of the provision of psychiatric services in the UK. However, the costs associated with the increased use of community services by the study group were not identified in this review. In order to establish whether or not clozapine is cost saving overall compared to standard antipsychotic treatment it would have been necessary to identify all costs, including the whole range of community costs, before and after treatment commenced.     

The burden of preserved ejection fraction heart failure in a real-world Swedish patient population

Objectives:

To evaluate resource use and associated costs in patients with a diagnosis of heart failure with preserved ejection fraction (HF-PEF) in Sweden.

Methods:

This retrospective study identified real-world patients with an ICD-10 diagnosis code for heart failure (I50) for the period between July 1, 2005 and December 31, 2006 from electronic medical records of primary care centers in Uppsala County Council, and in the Swedish patient registry data. Patients were categorized as having HF-PEF (left ventricle ejection fraction [LVEF] > 50%) during the index period. The study assessed medication utilization, outpatient visits, hospitalizations, and associated healthcare costs, as well as the incidence rates and time to all-cause and heart failure mortality following the index period.

Results:

The study included 137 HF-PEF patients with a mean age of 77.1 (SD?=?9.1) years. Over 50% of HF-PEF patients were female and hypertensive. Nearly all patients received ≥1 medication post-index. Patients had an average of 1.5 heart failure related hospitalizations per follow-up year. The average annual per patient cost for the management of a HF-PEF patient was found in Sweden to be Swedish Krona (SEK) 108,246 (EURO [EUR] 11,344). Hospitalizations contributed to more than 80% of the total cost. All-cause mortality over the 18-month study period was 25.5%, and more than 50% of these deaths occurred within 1 year of index.

Limitations:

Due to the limitations of registry data, it is not possible to confirm the HF diagnosis, and therefore the accuracy of registry records must be assumed. Other factors such as short follow-up time, the study-mandated LVEF assessment, and a lack of drug duration data may also have an impact on the study results.

Conclusions:

All-cause mortality was high in the HF-PEF population, with more than half of patients dying within 1 year of study follow-up. Study results also indicate that 60% of HF-PEF patients have ≥1 hospitalization during follow-up. Hospitalizations, especially heart failure related admissions, represent a substantial proportion of the total healthcare burden of patients with HF-PEF in Sweden.     

Factors associated with increased hospital costs in patients treated with lipid-based amphotericin B for empirical therapy

Summary

Lipid-based amphotericin B agents have been studied in a number of clinical settings and patient populations, most notably as empirical therapy for patients at-risk for systemic fungal infection and for patients with documented invasive disease. In clinical practice, lipid-based therapies have been considered second- or even third-line therapy due to concerns about costs. However, few analyses have been conducted to determine those factors associated with empirical antifungal therapy and lipid-based agents that are most likely to influence hospital costs and length of stay.

The purpose of this analysis is to determine which demographic, treatment, and clinical outcome factors contribute to increased hospital costs and length of stay in patients treated empirically with a lipid-based amphotericin B agent.

A retrospective analysis of 89 patients enrolled in the clinical study was performed to assess hospital costs and length of stay following the start of empirical antifungal therapy. Bivariate and multivariate regressions were performed to identify variables most likely to affect hospital costs and length of stay.

Allogeneic bone marrow transplant (BMT) status, days of treatment, doubling of baseline creatinine, and dialysis were found to be predictive both of increased hospital costs and length of stay. Length of stay and number of concomitant nephrotoxic agents also were found to affect hospital costs.

Overall, risk factors and clinical outcomes associated with nephrotoxicity increased hospital costs and length of stay in patients treated empirically with lipid-based antifungal agents. Renal dialysis also increased hospital cost significantly. For empirical antifungal therapy, providers should consider both patient-specific risk factors and product-specific outcomes in selecting an appropriate agent.     

Losartan: a pharmacoeconomic review

Summary

The angiotensin II antagonist losartan has been clinically studied in several patient populations including type 2 diabetes mellitus (T2DM) with nephropathy, hypertension with left ventricular hypertrophy, and the elderly with heart failure. The aim of this paper is to provide a review of the health economic evaluations based on the clinical trial results of losartan.

In patients with T2DM and nephropathy, losartan was shown to be cost saving in 14 countries and the EU. Net cost savings per patient, after factoring in the drug cost of losartan, ranged from $56 and $5,149 over a 3.5 year time horizon. For the two countries with published lifetime projections, the US and Mexico, net cost savings per patient were $24,632 and $2,223, respectively.

In patients with hypertension and left ventricular hypertrophy, losartan as compared with atenolol was found to be cost effective in five countries and cost saving in one country. The incremental cost-effectiveness ratios ranged from $1,274 to $5,764 per quality-adjusted life year gained for four of the countries and was $1,083 per life-year gained in one country. The other country evaluation reported a $20 net cost saving per patient.

Pharmacoeconomic evaluations in other patient populations comparing losartan with the angiotensin-converting enzyme inhibitor captopril generally did not demonstrate differences in health economic outcomes.     

The direct medical cost of rheumatoid arthritis in Hong Kong

Summary

Rheumatoid arthritis (RA) is an autoimmune disorder of unknown aetiology. Both treatment and rehabilitation for RA are costly. Knowledge of the cost of management of RA is important for better planning for allocation of medical resources, and the present study aimed to evaluate and describe the direct medical cost of the management of RA from the perspective of a public health organisation in Hong Kong.

A retrospective study was performed of RA patients at the Prince of Wales Hospital in Hong Kong. The study cohort consisted of randomly selected RA patients from the 1st January 2002 to the 31st December 2002. Cost items studied included hospital stay, outpatient clinic visits, diagnostic tests, medications, auxiliary care, and cost for management and prophylaxis of side effects induced by the drugs for RA management.

A total of 147 patients were included in the study. The average age and duration of disease of the subjects was 54.7 years (standard deviation 10.9 years) and 12.6 years (standard deviation 7.0 years), respectively. The annual direct medical cost per RA patient was HK$18,657 (US$1 = HK$7.8). Inpatient care contributed the highest proportion of the total cost (43.8%). The annual direct medical cost for the management of RA in Hong Kong was HK$443 million, which comprised 1.4% of the total healthcare budget in the year 2002.

The cost of RA has an economic impact on the healthcare budget in Hong Kong. Early and more aggressive measures could reduce the need for hospitalisation and hence reduce costs.     

Costs of bleeds relating to acute coronary syndrome therapies

Objective: To estimate the costs to manage selected types of bleeding complications in patients with acute coronary syndrome (ACS) treated with antithrombotics, including antiplatelet, and fibrinolytic therapies: decrease in haemoglobin >3 g/dL, puncture site, and bleeding requiring transfusion of blood products.

Methods: Retrospective chart reviews of ACS patients experiencing decrease in Hb, puncture site, or bleeding requiring transfusion were conducted in hospitals in France, Germany, Italy, Spain and Sweden to determine the total length of stay (LOS), stay post-bleeding, procedures to identify the extent of bleeding, number and types of transfusion products, patient demographics, reason for hospital admission and disposition upon discharge. Country-specific costs were applied to estimate the average cost per patient by type of bleeding event.

Results: Records of 158 ACS patients with the bleeding complications were examined (26.9% decrease in Hb, 35.5% puncture site, and 37.8% transfusion). The average LOS was 10.6 days for decreasing Hb, 7.7 days for puncture site bleeding, and 11.3 days for patients receiving transfusions due to these bleeding events. The average costs per patient ranged between €3,986 and €10,252. The LOS ranged widely both within and across countries.

Limitations: The study has a small sample size and costs are confounded by co-morbidities.

Conclusions: The estimated costs for decreasing Hb, puncture site bleeding and bleeding resulting in transfusions provide a tool for researchers to conduct economic analyses of bleeding events associated with therapies for ACS.     

Inpatient nursing unit volume, length of stay, cost, and mortality

Nursing unit volume-outcome relationships exist for patients assigned selected DRGs. This finding suggests that, in some cases, aggregating inpatients with similar clinical conditions may result in lower cost of care, shorter length of stay, and fewer hospital deaths.     

The burden of illness of hepatorenal syndrome (HRS) in the United States: a retrospective analysis of electronic health records

Objectives: Hepatorenal Syndrome (HRS) is characterized by renal failure in patients with advanced chronic liver disease (CLD) and is the leading cause of hospitalizations in CLD. This study examines the clinical and economic burden, outcomes, and unmet need of HRS treatment in US hospitals.

Method: A retrospective cohort study was conducted based on a large electronic health records database (Cerner HealthFacts) with records for hospitalized HRS patients from January 2009–June 2015. Demographics, clinical characteristics, treatment patterns, and economic outcomes were analyzed. Prognostic indicators of cirrhosis, kidney injury, end-stage liver disease, and acute-on-chronic liver failure were used to determine mortality risk.

Results: A total of 2,542 patients hospitalized with HRS were identified (average age = 57.9 years, 61.8% males, 74.2% Caucasian), with an average total hospital charge of $91,504 per patient and a mean length of stay (LOS) of 30.5?days. The mortality rate was 36.9% with 8.9% of patients discharged to hospice. Of all patients, 1,660 patients had acute kidney injury, 859 with Stage 3 disease, and 26.7% had dialysis. The 30-day readmission rate was 33.1%, 41% of which were unplanned. Nearly one-third of study patients had commercial insurance (30.2%), followed by Medicare (29.9%); hospital charges varied by LOS, receipt of dialysis, and discharge status. Regression analysis demonstrated that HRS costs are associated with LOS, dialysis, and hospital mortality.

Conclusion: HRS is associated with poor outcomes and high hospital costs. Analysis of HRS cost drivers demonstrated an unmet need for additional treatment options to improve outcomes in this patient population.     

Hospital-based inpatient resource utilization associated with autosomal dominant polycystic kidney disease in the US

Abstract

Objective:

Polycystic kidney disease (PKD) is a clinically and genetically heterogeneous class of genetic disorders characterized by development of renal cysts leading to renal failure and end stage renal disease (ESRD). Autosomal dominant polycystic kidney disease (ADPKD) accounts for the majority of PKD cases and is the predominant monogenic cause of ESRD. Limited information on patient characteristics and healthcare resource utilization is available in this population. This study assessed hospital-based inpatient utilization of patients with ADPKD in the US to help further understand the disease, which may lead to treatments that delay progression and reduce healthcare resource utilization.

Methods:

A cross-sectional analysis was conducted using MedAssets Health System Data to investigate inpatient resource utilization for a total of 1876 patients hospitalized with ADPKD or chronic kidney disease (CKD). Patient characteristics and inpatient resource utilization were compared between hospitalized patients with ADPKD and CKD, including demographic and clinical characteristics, overall health, rates of complications and surgical interventions, and average length of hospital and intensive care unit stay.

Results:

Compared with patients with CKD, patients with ADPKD were more likely to have commercial insurance as their primary payer (36.1 vs 17.8%) and were significantly younger (mean age 57.9 vs 69.5 years) and generally healthier (Charlson Comorbidity Score of 2.0 vs 3.3). Patients with ADPKD also had a substantially shorter average length of hospital stay (6.3 vs 10.3 days). However, patients with ADPKD experienced more kidney-related complications and a higher surgical procedure rate (mainly for transplant and complete nephrectomy).

Conclusions:

Although patients with ADPKD were generally healthier than patients with CKD, specific kidney function complications were more frequent. Patients with ADPKD had a higher rate of major kidney procedures, which may contribute to the high burden of ADPKD-related hospital-based inpatient resource utilization.     

Direct treatment cost of atrial fibrillation in the elderly American population: a Medicare perspective

Abstract

Objective: Although atrial fibrillation (AF) is the most commonly sustained arrhythmia in adults, few studies have examined the direct treatment cost of AF.

Methods: A Medicare database of a 5% random national sample of all beneficiaries was used to identify patients diagnosed with AF in 2003 and to follow them for 1 year after diagnosis. These patients were matched on a 1:1 basis by age, gender and race. The incremental cost of treating AF was calculated with multivariate regression models adjusting for covariates.

Results: In total, 55,260 subjects developed new AF, of which 69% were ≥75 years old, 54% were female and 91% were White. The adjusted mean incremental treatment cost of AF was $14,199 (95% confidence interval $13,201–15,001; p<0.01). Some of this cost was attributable to the incidence of stroke and heart failure at the 1-year post-AF diagnosis. A significantly higher proportion of AF patients experienced stroke (23.1 vs. 13.3%; p<0.01) and heart failure (36.7 vs. 10.4%; p<0.01) compared with Medicare beneficiaries without AF.

Conclusions: Mean incremental direct treatment costs for Medicare beneficiaries with AF were higher than previously reported. Interventions that can reduce the incidence of AF and its complications may also reduce the national economic impact of AF.