Healthcare resource utilization by patients with treatment-refractory myasthenia gravis in England

Aims: To examine healthcare resource utilization associated with refractory myasthenia gravis (MG) in England.

Materials and methods: This was a retrospective cohort study of linked data from the Clinical Practice Research Datalink and the Hospital Episode Statistics database collected between 1997 and 2016. Included patients were ≥18?years of age at the index MG diagnosis. Patients with refractory MG were identified using an algorithm based on treatments received. Healthcare resource utilization since the index date was compared between refractory and non-refractory cohorts.

Results: The study included 1149 patients with MG, of whom 66 (5.7%) were refractory. Sex and age at diagnosis did not significantly differ between the refractory and non-refractory cohorts. Rates of healthcare resource utilization per person-year were significantly higher (p?p?Limitations: The algorithm for identifying refractory patients did not include clinical criteria. Also, treatments administered in hospitals or by specialists were not available in the databases.

Conclusions: Patients in England with refractory MG more often visit healthcare providers, are hospitalized and visit an emergency room than patients with non-refractory MG.     

The impact of persistence with therapy on inpatient admissions and emergency room visits in the US among patients with multiple sclerosis

Objective:

Disease-modifying therapy (DMT) for multiple sclerosis (MS) can reduce relapses and delay progression; however, poor adherence and persistence with DMT can result in sub-optimal outcomes. The associations between DMT adherence and persistence and inpatient admissions and emergency room (ER) visits were investigated.

Methods:

Patients with MS who initiated a DMT in a US administrative claims database were followed for 1 year. Persistence to initiated DMT was measured as the time from DMT initiation to discontinuation (a gap of >60 days without drug ‘on hand’) or end of 1-year follow-up. Adherence to initiated DMT was measured during the persistent period and was operationalized as the medication possession ratio (MPR). Patients with an MPR <0.80 were considered non-adherent. Claims during the 1-year follow-up period were evaluated for the presence of an all-cause inpatient admission or an ER visit. Adjusted odds ratios (AORs) for inpatient admission or ER visit comparing persistent vs non-persistent and adherent vs non-adherent patients were estimated using logistic regression models adjusted for patient characteristics.

Results:

The final sample included 16,218 patients. During the 1-year follow-up period, 35.3% of patients discontinued their initiated DMT and 13.9% were not adherent while on therapy. During that same period, 10.0% of patients had an inpatient admission and 24.9% had an ER visit. The likelihoods of inpatient admission and ER visit were significantly decreased in persistent patients (AOR [95% CI]?=?0.50 [0.45, 0.56] and 0.65 [0.60, 0.69], respectively) and in adherent patients (AOR [95% CI]?=?0.83 [0.71, 0.97] and 0.86 [0.77, 0.95], respectively).

Conclusions:

Persistence and adherence with initiated DMT are associated with decreased likelihoods of inpatient admission or ER visit, which may translate to improved clinical outcomes.     

Costs of hospital visits among patients with deep vein thrombosis treated with rivaroxaban and LMWH/warfarin

Background:

For many years, the standard of care for patients diagnosed with deep vein thrombosis (DVT) has been low-molecular-weight heparin (LMWH) bridging to an oral Vitamin-K antagonist (VKA). The availability of new non-VKA oral anticoagulants (NOAC) agents as monotherapy may reduce the likelihood of hospitalization for DVT patients.

Objective:

To compare hospital visit costs of DVT patients treated with rivaroxaban and LMWH/warfarin.

Methods:

A retrospective claim analysis was conducted using the MarketScan Hospital Drug Database for care provided between January 2011 and December 2013. Adult patients using rivaroxaban or LMWH/warfarin with a primary diagnosis of DVT during the first day of a hospital visit were identified (i.e., index hospital visit). Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients. The hospital-visit cost difference between these groups was evaluated for the index hospital visit, as well as for total hospital-visit costs (i.e., including index and subsequent hospital visit costs).

Results:

All rivaroxaban users (n?=?134) in the database were well-matched with four LMWH/warfarin users (n?=?536). The mean hospital-visit costs were $5257 for the rivaroxaban cohort and $6764 in the matched-cohort of patients using LMWH/warfarin. The $1508 cost difference was statistically significant between cohorts (95% CI?=?[?$2296; ?$580]; p-value?=?0.002). Total hospital-visit costs were lower for rivaroxaban compared to LMWH/warfarin users within 1, 2, 3, and 6 months after index visit (significantly lower within 1 and 3 months, p-values <0.05)

Limitations:

Limitations were inherent to administrative-claims data, completeness of baseline characteristics, adjustments restricted to observational factors, and lastly the sample size of the rivaroxaban cohort.

Conclusion:

The availability of rivaroxaban significantly reduced the costs of hospital visits in patients with DVT treated with rivaroxaban compared to LMWH/warfarin.     

Healthcare resource utilization with ixazomib or placebo plus lenalidomide-dexamethasone in the randomized,double-blind,phase 3 TOURMALINE-MM1 study in relapsed/refractory multiple myeloma

Aims: The aim of this analysis was to assess healthcare resource utilization in the pivotal phase 3 TOURMALINE-MM1 study of the oral proteasome inhibitor ixazomib or placebo plus lenalidomide and dexamethasone (Rd) in relapsed and/or refractory multiple myeloma (RRMM).

Methods: In this double-blind, placebo-controlled, randomized study (NCT01564537), 722 patients with RRMM following 1–3 prior lines of therapy received Rd plus ixazomib (ixazomib-Rd; n?=?360) or matching placebo (placebo-Rd; n?=?362) until disease progression or unacceptable toxicity. Healthcare resource utilization data were captured on Day 1 of each 28-day cycle, every 4 weeks during follow-up for progression-free survival, and every 12 weeks during subsequent follow-up, and included medical encounters (length of stay, inpatient, outpatient, and reason) and number of missing days from work or other activities for patients and caregivers.

Results: Exposure-adjusted rates of hospitalization were similar between the ixazomib-Rd and placebo-Rd arms, at 0.530 and 0.564 per patient year (ppy), respectively, as were outpatient visit rates (3.305 and 3.355 ppy). Mean length of hospitalization per patient was 10.0 and 10.8 days, respectively. In both arms, hospitalization and outpatient visit rates were higher in patients with two or three prior lines of treatment (ixazomib-Rd: 0.632 and 3.909 ppy; placebo-Rd: 0.774 and 3.539 ppy) compared with patients with one prior line (ixazomib-Rd: 0.460 and 2.888 ppy; placebo-Rd: 0.436 and 3.243 ppy). Patients and their caregivers who missed any work or other activity missed a median of 7 and 5 days in the ixazomib-Rd arm, respectively, vs 8 and 4 days with placebo-Rd.

Limitations: The study was not powered for a statistical comparison of healthcare resource utilization between treatment arms, nor did it capture costs associated with utilization of the identified healthcare resources.

Conclusions: This pre-specified analysis demonstrated that the all-oral triplet regimen of ixazomib added to Rd did not increase healthcare resource utilization compared with placebo-Rd.     

Office triage and the physician's supply curve

This paper contains a theoretical and empirical model of the physician firm. The utility maximizing physician chooses the number of hours of labor to supply and the mix between patient visits and time per visit. Theory suggests that a serious specification error may occur if one estimates the labor supply curve and patient demand curve without simultaneously estimating the mix between patient visits and time per visit. A Chi-Square specification test reveals that this “triage” model statistically dominates the simple supply/demand model. Estimation results indicate relevant backward-bending labor and negatively sloped service supply functions.     

Economic Assessment of the Recreational Value of Ecosystems: Methodological Development and National and Local Application

We present a novel methodology for spatially sensitive prediction of outdoor recreation visits and values for different ecosystems. Data on outset and destination characteristics and locations are combined with survey information from over 40,000 households to yield a trip generation function (TGF) predicting visit numbers. A new meta-analysis (MA) of relevant literature is used to predict site specific per-visit values. Combining the TGF and MA models permits spatially explicit estimation of visit numbers and values under present and potential future land use. Applications to the various land use scenarios of the UK National Ecosystem Assessment, as well as to a single site, are presented.     

A real-world,multi-site,observational study of infusion time and treatment satisfaction with rheumatoid arthritis patients treated with intravenous golimumab or infliximab

Objectives: To assess real-world infusion times for golimumab (GLM-IV) and infliximab (IFX) for rheumatoid arthritis (RA) patients and factors associated with treatment satisfaction.

Methods: An observational study assessed infusion time including: clinic visit duration, RA medication preparation and infusion time, and infusion process time. Satisfaction was assessed by a modified Treatment Satisfaction Questionnaire for Medication (patient) and study-specific questionnaires (patient and clinic personnel). Comparative statistical testing for patient data utilized analysis of variance for continuous measures, and Fisher’s exact or Chi-square test for categorical measures. Multivariate analysis was performed for the primary time endpoints and patient satisfaction.

Results: One hundred and fifty patients were enrolled from six US sites (72 GLM-IV, 78 IFX). The majority of patients were female (80.0%) and Caucasian (88.7%). GLM-IV required fewer vials per infusion (3.7) compared to IFX (4.9; p?=?.0001). Clinic visit duration (minutes) was shorter for GLM-IV (65.1) compared to IFX (153.1; p?<?.0001), as was total infusion time for RA medication (32.8 GLM-IV, 119.5 IFX; p?<?.0001) and infusion process times (45.8 GLM-IV, 134.1 IFX; p?<?.0001). Patients treated with GLM-IV reported higher satisfaction ratings with infusion time (p?<?.0001) and total visit time (p?=?.0003). Clinic personnel reported higher satisfaction with GLM-IV than IFX specific to medication preparation time, ease of mixing RA medication, frequency of patients requiring pre-medication, and infusion time.

Limitations: Findings may not be representative of care delivery for all RA infusion practices or RA patients.

Conclusions: Shorter overall clinic visit duration, infusion process, and RA medication infusion times were observed for GLM-IV compared to IFX. A shorter duration in infusion time was associated with higher patient and clinic personnel satisfaction ratings.     

How do income and education affect health inequality: evidence from four developing countries

Using household survey data from four countries ? Albania, Nepal, Tajikistan and Tanzania ? this article calculates income-related inequality in health care utilization. We measure health disparity separately for generally and chronically ill individuals by constructing two models: one for the probability of a visit to a physician and another for the number of visits. Following model-based measurements, we decompose inequality into two major parts: one accounted for by identity-related factors and another by socioeconomic and other factors such as education, geography and distance to a clinic. We propose a new method to quantify the effect of changes in income and education on health disparity. One of our important findings suggests that health disparity is pro-rich in all our sample countries. The pro-rich disparity is prevalent among generally ill as well as chronically ill patients, in both visit probability and visit frequency models. Health inequality seems primarily driven by income differences followed by nonidentity factors. Further, the principle of equal treatment for equal need is not fulfilled in any of our countries. Among policy implications, increasing average income and education in a way that also reduces disparity in income and education, respectively, will substantially shrink inequality in health care utilization.     

Healthcare utilization and costs among chronic bronchitis patients treated with maintenance medications from a US managed care population

Abstract

Objectives:

This study aimed to examine the real-world healthcare resource utilization (HCRU) and direct costs among chronic bronchitis (CB) patients treated with chronic obstructive pulmonary disease (COPD) maintenance medications.

Methods:

This retrospective analysis utilized administrative claims data from 14 US commercial managed care plans. Eligible patients were ≥40 years old, had ≥2 years of continuous enrollment, ≥1 CB (ICD-9-CM code 491.xx) hospitalization or emergency department (ED) visit or ≥2 office visits between 1/1/2004 and 5/31/2011, and had ≥2 pharmacy fills for COPD medications during follow-up (first fill served as the index date). All-cause and COPD-related HCRU and costs were assessed during follow-up. Multivariate models were utilized to identify predictors of total costs.

Results:

Treated CB patients (n?=?17,382; 50.6% female; mean age 66.7 (SD?=?11.4) years) had a mean of 7.6 (SD?=?6.3) COPD maintenance medication fills during follow-up. Overall, 32.6% of patients had ≥1 COPD-related inpatient hospitalizations, 12.9% had ≥1 ED visit, and 81.8% had ≥1 office visit. Mean all-cause and COPD-related total costs were $25,747 (SD?=?$51,105) and $12,609 (SD?=?$36,801), respectively, during follow-up. Among the sub-group with ≥1 exacerbation during baseline year, 42.3% had ≥1 COPD-related inpatient hospitalization, 18.5% had ≥1 ED visit, and 88.2% had ≥1 office visit. Mean follow-up all-cause and COPD-related total costs were $29,861 (SD?=?$49,799) and $16,784 (SD?=?$34,170), respectively. The number of baseline exacerbations was a significant predictor of all-cause and COPD-related total costs during follow-up.

Limitations:

This study lacked standard measures of CB severity; however, severity proxies were utilized.

Conclusion:

HCRU and costs among CB patients were substantial during follow-up, despite treatment with COPD maintenance medications. Additional interventions aiming to prevent or reduce HCRU and costs among CB patients warrant exploration.     

Estimating the cost of an emergency room visit for migraine headache

SUMMARY

To provide a more comprehensive accounting of direct cost of treating headaches, it is imperative to quantify the cost of emergency room (ER) services specific to treating headaches. Published cost estimates for migraine-specific ER visits are currently not available. This study estimated the cost of treating migraine headaches in the ER from a payer's perspective, using ER discharge data for migraine from the 2000 National Hospital Ambulatory Medical Care Survey (NHAMCS). Costs were estimated using Medicare reimbursement rates. The total cost of an ER visit for migraine headache, defined as the ER visit and all additional services and procedures, was US$238.16. Based on the migraine prevalence of 9% to 27%, the annual estimate for total ER visit costs for migraine headache in the US in 2000 ranged from US$646 million to US$1.94 billion, which is substantial. ER costs for migraine may be much larger then previously estimated.     

Capital Mobility and Investor Confidence: The Case of Hong Kong's Reversion to China's Sovereignty

The paper hypothesizes that capital flows to and from Hong Kong in the years prior to its reversion to Chinese sovereignty were determined in part by the credibility of China's economic and political policies towards Hong Kong. During the transition period, several events occurred that caused investors, foreign and domestic, to reexamine and revise their perceptions about concentrating their investment in Hong Kong. These events were the ongoing negotiations between China and Great Britain that resulted in the signing of the Joint Resolution and the Basic Law, the 1989 Tiananmen Square incident, and Deng Xaioping's visit to China's southern provinces in 1992. As a result, Hong Kong provides a particularly relevant example of the impact government policies can have on investor confidence and capital mobility.     

Users and non-users of conservation areas: Are there differences in WTP,motives and the validity of responses in CVM surveys?

It is commonly assumed that respondents' lack of familiarity with the valued resource causes invalid and unreliable responses in contingent valuation surveys. With non-users' valuations, mainly motivated by non-use values, the issue is also closely linked to the discussion of the measurement of non-use values. This paper re-examines the impact of previous use on respondents' willingness to support nature conservation, their motives for valuing the resource and the validity of responses. The users' and non-users' characteristics differed, but there was no difference between the groups in their willingness to support sustained conservation. However, those planning to visit the area in the near future were more likely to pay for conservation than other respondents, even if they did not have previous use experience. Users considered their income constraint somewhat more carefully and were more aware of conservation-related issues than non-users. However, there was no difference in the validity of the WTP responses of the groups. Thus, there seems to be no rationale from a point of view of validity to restrict CVM analysis only to those individuals who have previous experience of the resource, which is in line with the basic premise of CVM. Furthermore, non-use values remained as significant motives for valuing the resource even if the use of the resource was intensive. Therefore, if the existence of a large non-use value component is considered as problematic in general, the problem is likely to exist for all respondent groups and not only for non-users.     

Economic outcomes with prasugrel versus clopidogrel in acute coronary syndrome patients: observations from prasugrel users and matched clopidogrel users

Abstract

Objective:

To compare healthcare costs between clopidogrel and prasugrel over 30-day and 365-day periods after discharge from the hospital or emergency room (ER) in patients treated with prasugrel who were hospitalized or had an ER visit for an acute coronary syndrome (ACS) event.     

开放式公园管理是促进社会和谐矿区稳定发展的有效途经

开放式公园管理是黑龙江大庆石化公司园林公司在落实党的十六届四中全会提出的构建社会主义＂和谐社会＂新理念的具体体现。也是落实党的十七大精神和科学发展观,创建和谐矿区,保持社会稳定的真实写照。通过调研和社会实践表明,开放式的公园管理是促进社会和谐矿区稳定发展的有效途经。     

Final development and validation of the BOMET-QoL questionnaire for assessing quality of life in patients with malignant bone disease due to neoplasia

SUMMARY

This paper describes the final development and validation of the BOMET-QoL questionnaire for assessing health-related quality of life (HRQoL) in patients with malignant bone disease due to neoplasia (MBDN).

An observational prospective study was conducted of 263 patients with MBDN. Sociodemographic and clinical variables, Eastern Cooperative Oncology Group (ECOG) Performance Scale Index and Pain Management Index (PMI) were gathered. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and BOMET-QoL questionnaires and the perception of general health status. Both questionnaires were completed again 15 days after the baseline visit by 98 clinically stable patients (Group A), and 3 months and 6 months after the baseline visit by 165 clinically unstable patients (Group B). Prior to validation of the BOMETQoL questionnaire, a factor analysis and psychometric selection of the original items was developed by means of Rasch analysis.

The BOMET-QoL questionnaire consisting of 25 items was reduced to an integrated version of 10 items. Scores on the BOMET-QoL-10 questionnaire were shown to be related to the presence, number and duration of irruptive pain crises, the PMI and the ECOG index (p<0.001), and with changes in the perception of general health status and ECOG index (p<0.01). The internal consistency of the questionnaire and the intraclass correlation coefficient (ICC) were high (Cronbach's α=0.93; ICC =0.97). BOMET-QoL-10 is an easy to manage and valid questionnaire in clinical practice conditions.