Examining the association between pain severity and quality-of-life,work-productivity loss,and healthcare resource use among European adults diagnosed with pain

Objective: The goal of this research was to quantify the association between pain severity and several health outcomes in a large sample of patients diagnosed with some form of pain.

Methods: Responses from patients who had been diagnosed with some form of pain (n?=?14,459) were drawn from the 2013 EU National Health and Wellness Survey (NHWS; n?=?62,000). Respondents reported their subjective pain severity in the past week on a numerical rating scale (0–10) as well as the Medical Outcomes Study Short Form (SF-36), Work Productivity and Activity Impairment Questionnaire (WPAI), and healthcare resource utilization in the past 6 months (healthcare professional (HCP) visits, emergency room (ER) visits, and hospitalizations). Associations between pain severity and health outcomes were examined via a series of regression models controlling for a set of demographic and health-related covariates.

Results: After controlling for demographics and comorbidities, pain severity in the past week was shown to be significantly negatively associated with Health Utilities (b = ?0.022, p?b?=?0.18, p?b?=?0.13, p?b?=?0.14, p?b?=?0.08, p?Limitations: This study was a self-report cross-sectional study which may have biased the results and does not allow for causal inferences to be made. Finally, the regression models run were limited to available covariates and, hence, some potentially important covariates may not have been included in these models.

Conclusions: The findings suggest that reducing pain severity could result in an increase in patients’ quality-of-life and work productivity, and a decrease in healthcare resource use. The equations, linking pain and outcomes, were presented in an accessible format so they could be readily applied in healthcare decision-making.     

Fiscal dependence on trade taxes and the level of economic development:: a comment

We test for fractional dynamics in US monetary series, their various formulations and components, and velocity series. Using the spectral regression method, we find evidence of a fractional exponent in the differencing process of the monetary series (both simple-sum and Divisia indices), in their components (with the exception of demand deposits, savings deposits, overnight repurchase agreements, and term repurchase agreements), and the monetary base and money multipliers. No evidence of fractional behaviour is found in the velocity series. Granger's (Journal of Econometrics, 25, 1980) aggregation hypothesis is evaluated and implications of the presence of fractional monetary dynamics are drawn.     

The diversity of models as a means to better explanations in economics

ABSTRACT

In Economics Rules, Rodrik [(2015). Economics rules: Why economics works, when it fails, and how to tell the difference. Oxford: Oxford University Press] argues that what makes economics powerful despite the limitations of each and every model is its diversity of models. Rodrik suggests that the diversity of models in economics improves its explanatory capacities, but he does not fully explain how. I offer a clearer picture of how models relate to explanations of particular economic facts or events, and suggest that the diversity of models is a means to better economic explanations.     

Health care utilization and self-assessed health: specification of bivariate models using copulas

The discernment of relevant factors driving health care utilization constitutes one important research topic in health economics. This issue is frequently addressed through specification of regression models for health care use (y—often measured by number of doctor visits) including, among other covariates, a measure of self-assessed health (sah). However, the exogeneity of sah within those models has been questioned, due to the possible presence of unobservables influencing both y and sah, and because individuals’ health assessments may depend on the quantity of medical care received. This article addresses the possible simultaneity of (sah, y) by adopting a full information approach, through specification of the bivariate probability function (p.f.) of these discrete variables, conditional on a set of exogenous covariates (x). The approach is implemented with copula functions, which afford separate consideration of each variable margin and their dependence structure. The specification of the joint p.f. of (sah, y) enables estimation of several quantities of potential economic interest, namely features of the conditional p.f. of y given sah and x. The adopted models are estimated through maximum likelihood, with cross-sectional data from the Portuguese National Health Survey of 1998–1999. Estimates of the margins’ parameters do not vary much among different copula models, while, in accordance with theoretical expectations, the dependence parameter is estimated to be negative across the various joint models.     

Overeducation,undereducation, and the theory of career mobility

The theory of career mobility (Sicherman and Galor, Journal of Political Economy, 98(1), 169–92, 1990) claims that wage penalties for overeducated workers are compensated by better promotion prospects. Sicherman (Journal of Labour Economics, 9(2), 101–22, 1991) was able to confirm this theory in an empirical study using panel data. However, the only retest using panel data so far (Robst, Eastern Economic Journal, 21, 539–50, 1995 Robst, J. 1995. Career mobility, job match, and overeducation. Eastern Economic Journal, 21: 539–50.  ) produced rather ambiguous results. In the present paper, random effects models to analyse relative wage growth are estimated using data from the German Socio-Economic Panel. It is found that overeducated workers in Germany have markedly lower relative wage growth rates than adequately educated workers. The results cast serious doubt on whether the career mobility model is able to explain overeducation in Germany. The plausibility of the results is supported by the finding that overeducated workers have less access to formal and informal on-the-job training, which is usually found to be positively correlated with wage growth even when controlling for selectivity effects (Pischke, Journal of Population Economics, 14, 523–48, 2001).     

The impact of pain on labor force participation,absenteeism and presenteeism in the European Union

Abstract

Objectives:

The aims of this paper are to generate estimates of the association between the experience and burden of pain, by severity and frequency, with (1) labor force participation and workforce status in five EU countries (the UK, France, Spain, Germany and Italy) and (2) patterns of absenteeism and presenteeism for the employed workforce.

Methods:

Data are from the internet-based 2008 National Health and Wellness Survey (NHWS). This survey covers both those who report experiencing pain in the last month as well as the no pain population. A series of regression models are developed with the no pain group as the reference category. The impact of pain, categorized by severity and frequency reported, is assessed within a labor supply framework for (1) labor force participation and (2) absenteeism and presenteeism. In the former case both binomial and multinomial logistic models are estimated; in the latter case ordered logit models are estimated.

Results:

The results demonstrate that, in the context of health status, the experience of frequent severe and moderate pain has a dominant, independent and negative association with labor force participation and employment status as well as absenteeism and presenteeism. The presence of severe daily pain is associated with a 20-point reduction in the probability of being employed full-time; with moderate daily pain associated with a 10-point reduction. The impact of pain is far greater than the potential impact of other health status measures (e.g., chronic comorbidities and BMI). The experience of pain, notably severe and frequent pain, also outstrips the impact of other health status factors in absenteeism and presenteeism.

Conclusions:

The experience of pain, in particular severe daily pain, has a substantial negative association with labor force participation in these five European countries as well as reported absenteeism and presenteeism. As a measure of health status, it clearly outweighs other health status measures. Whether or not pain is considered as a disease in its own right, the experience of chronic pain, as defined here, presents policy makers with a major challenge. Programs to relieve the burden of pain in the community clearly have the potential for substantial benefits from societal, individual and employer perspectives.     

Dynamic conditional score models: a review of their applications

ABSTRACT

In this paper, applications of dynamic conditional score (DCS) models are reviewed and those models are discussed in relation to classical time series models from the literature. DCS models are robust to outliers, which improves their statistical performance compared to classical models. Three applications are presented in order to compare the statistical performances of DCS and classical models in three very different contexts: (i) The QAR (quasi-autoregressive) plus Beta-t-EGARCH (exponential autoregressive conditional heteroscedasticity) model is presented, which is a score-driven expected return plus volatility model. This model is used for daily returns on the DAX (Deutscher Aktienindex) equity index for the period of January 1988 to December 2017. (ii) The score-driven local level and seasonality plus Beta-t-EGARCH model is presented, which is used for daily AFN/USD (Afghan Afghani/United States Dollar) currency exchange rates for the period of March 2007 to July 2017. (iii) The Seasonal-t-QVAR (quasi-vector autoregressive) model is presented, which is a score-driven multivariate dynamic model of location. For this model, monthly US inflation rate and US unemployment rate are used for the period of January 1948 to December 2017. For all applications, the statistical performance of each DCS model is superior to that of a corresponding classical alternative.     

The power of asymmetric unit root tests under threshold and consistent-threshold estimation

The asymmetric unit root tests of Enders and Granger (Journal of Business and Economic Statistics, 16, 304–11, 1998) are examined using consistent threshold estimation and the original two-step procedure. In contrast to earlier studies, the ability of the tests to jointly reject the unit root and symmetry hypotheses is examined, thus permitting a fuller analysis of the tests' properties. Whilst the threshold autoregressive test is found to have little power in either its consistent or original forms, the consistent momentum-threshold autoregressive test is found to exhibit high power against a range of plausible alternatives when using newly derived critical values.     

Modelling the dynamics of Bitcoin and Litecoin: GARCH versus stochastic volatility models

We examine and compare a large number of generalized autoregressive conditional heteroskedastic (GARCH) and stochastic volatility (SV) models using series of Bitcoin and Litecoin price returns to assess the model fit for dynamics of these cryptocurrency price returns series. The various models examined include the standard GARCH(1,1) and SV with an AR(1) log-volatility process, as well as more flexible models with jumps, volatility in mean, leverage effects, t-distributed and moving average innovations. We report that the best model for Bitcoin is SV-t while it is GARCH-t for Litecoin. Overall, the t-class of models performs better than other classes for both cryptocurrencies. For Bitcoin, the SV models consistently outperform the GARCH models and the same holds true for Litecoin in most cases. Finally, the comparison of GARCH models with GARCH-GJR models reveals that the leverage effect is not significant for cryptocurrencies, suggesting that these do not behave like stock prices.     

Trend breaks and the fisher hypothesis in canada and the United States

Using the sequential estimation methodology developed by Banerjee, Lumsdaine and Stock (Journal of Business and Economic Statistics, 10(3), 271–87, 1992), Zivot and Andrews (Journal of Business and Economic Statistics, 10(3), 251–70, 1992) and extended by Lumsdaine and Papell (Review of Economics and Statistics, 79(2), 212–18, 1997), empirical evidence is found consistent with the hypothesis that the 90-day Treasury Bill rate and the inflation rate in Canada and the US are stationary around a deterministic trend with two breaks. When the breaks are filtered out, the data is consistent with partial long-run adjustment of the nominal interest rate to an inflation shock, but not of the size predicted by the Fisher Effect.     

Healthcare resource utilization and direct costs associated with frequent nausea in episodic migraine: results from the American Migraine Prevalence and Prevention (AMPP) Study

Abstract

Background:

Nausea is a common migraine symptom that is associated with impaired quality-of-life and functional disability. In this study, population-based data were used to elucidate the relationship between nausea frequency and headache-related healthcare utilization and costs in persons with migraine.

Research design and methods:

Participants with episodic migraine who completed the 2009 American Migraine Prevalence and Prevention (AMPP) Study survey rated their headache-related nausea as occurring never, rarely, <half the time, or ≥half the time with their headaches, and completed questions on symptom frequency and healthcare resource utilization.

Main outcomes measures:

Ordinal logistic regression models were used to assess the association between nausea frequency and headache-related healthcare utilization. Healthcare cost equivalents were calculated.

Results:

Among the 6488 respondents with episodic migraine, the number of respondents observed across headache-related nausea frequency strata were 6.9% for never, 14.5% for rarely, 29.1% for <half the time, and 49.5% for ≥half the time. In unadjusted models, the odds of having ≥1 healthcare encounter for headache in the preceding year increased with frequency of nausea for primary care/obstetrics-gynecology visits (OR?=?1.41; 95% CI?=?1.30–1.52, p?<?0.001), nurse practitioner/physician assistant visits (OR?=?1.52; 95% CI?=?1.25–1.85, p?<?0.001), neurology/headache clinic visits (OR?=?1.33, 95% CI?=?1.18–1.51, p?<?0.001), pain clinic visits (OR?=?1.31, 95% CI?=?1.01–1.71, p?<?0.05), emergency department visits (OR?=?1.85; 95% CI?=?1.56–2.19, p?<?0.01), and overnight hospital stays (OR?=?1.50, 92% CI?=?1.12–2.00, p?<?0.01). The odds of having ≥1 lifetime CT scan or MRI also increased with the frequency of nausea (p?<?0.001 for both). Results remained significant in these analyses when controlling for sociodemographics and overall symptom severity except in the case of pain clinic visits (p?<?0.107). Visits for Mental Health and visits for Chiropractic/Alternative care did not differ significantly by nausea group in unadjusted or adjusted models. Mean estimated direct headache-related healthcare cost equivalents per person per year generally increased with increasing headache-related nausea frequency across categories of healthcare utilization. Average per person healthcare cost for nausea ≥half the time vs nausea never was $179 and $49 yearly for outpatient services, $183 vs $20 yearly for overnight hospital stays, and $314 vs $257 for lifetime diagnostic services/imaging.

Conclusions:

Direct costs of migraine increase with increasing frequency of migraine-associated nausea. Both frequency and severity of headache-related nausea should be monitored as part of ongoing care of persons with migraine. Headache-related nausea, like headache pain, should be considered an area of central concern during clinical, diagnostic, and treatment optimization assessments.

Study limitations:

This study relied on self-reported headache frequency and healthcare costs which are subject to recall bias and under-reporting; however, reporting bias is unlikely to be different as a function of nausea frequency. In addition, medication use costs and indirect costs (which may be higher than direct costs for migraine) were not assessed.     

Topological upper limits of mixed Nash equilibria

Our purpose in this article is to prove that given any integer n ≥ 2 and any non-empty compact Polish spaces S ₁, ..., S _n , if for any u ∈ C( S ₁ × ... × S _n , R) ⁿ , we denote by MNE(u) the set of mixed Nash equilibria of (S ₁, ..., S _n , u), then MNE(u) is a non-empty compact subset of P(S ₁) × ... × P(S _n ) and if u ^k → u in C(S ₁ × ... × S _n , R) ⁿ as k → ∞, then lim sup _{k → ∞} MNE (u ^k ) MNE(u). The author would like to thank the referee for offering critical comments on this paper.     

The societal impact of pain in the European Union: health-related quality of life and healthcare resource utilization

Abstract

Objectives:

This paper reports on the results of a series of quantitative assessments of the association of severe and frequent pain with health-related quality of life and healthcare resource utilization in five European countries.

Methods:

The analysis contrasts the contribution of the increasing severity and frequency of pain reported against respondents reporting no pain in the previous month. The data are taken from the 2008 National Health and Wellness Survey. Single-equation generalized linear regression models are used to evaluate the association of pain with the physical and mental component scores of the SF-12 questionnaire as well as health utilities generated from the SF-6D. In addition, the role of pain is assessed in its association with healthcare provider visits, emergency room visits and hospitalizations.

Results:

The results indicate that the experience of pain, notably severe and frequent pain, is substantial and is significantly associated with the SF-12 physical component scores, health utilities and all aspects of healthcare resource utilization, which far outweighs the role of demographic and socioeconomic variables, health risk factors (in particular body mass index) and the presence of comorbidities. In the case of severe daily pain, the marginal contribution of the SF-12 physical component score is a deficit of ?17.86 compared to those reporting no pain (population average score 46.49), while persons who are morbidly obese report a deficit of only ?6.63 compared to those who are normal weight. The corresponding association with health utilities is equally dramatic with a severe daily pain deficit of ?0.19 compared to those reporting no pain (average population utility 0.71).

Conclusions:

For the five largest EU countries, the societal burden of pain is considerable. The experience of pain far outweighs the contribution of more traditional explanations of HRQoL deficits as well as being the primary factor associated with increased provider visits, emergency room visits and hospitalizations.     

The societal burden of pain in Germany: Health-related quality-of-life,health status and direct medical costs

Abstract

Objectives:

The purpose of this paper is to estimate the impact of the severity and frequency of pain on health-related quality-of-life (HRQoL), self-reported health status, and direct medical costs in Germany.

Methods:

Data are from the internet-based 2010 National Health and Wellness Survey (NHWS). Estimates of the impact of pain experience are generated by a series of regression models. In the case of HRQoL the physical and mental summary scores from the SF-12, together with SF-6D utilities, are evaluated within an ordinary least squares framework. Health status is assessed through an ordered logit model. Direct medical costs are estimated through a semi-logarithmic healthcare cost function. Socioeconomic characteristics, health risk behaviors, and the Charlson Comorbidity Index (CCI) are introduced as control variables in all regressions.

Results:

An estimated 23.96% of the adult German population (16.39 million) reported experiencing pain in the last 30 days. Of these 13.16% reported severe pain. The experience of frequent severe and moderate pain has a significant deficit impact on HRQoL. For those experiencing severe daily pain, the deficit in the SF-12 physical component score (PCS) is ?17.930 (95% CI: ?18.720 to ?17.140), the SF-12 mental component score (MCS) is ?8.787 (05% CI: ?9.857 to ?7.716), and SF-6D absolute utilities ?0.201 (95% CI: ?0.214 to ?0.188); with self-reported health status the deficit impact of severe daily pain is also substantial (OR?=?29.000; 95% CI: 23.000–36.580). In the case of direct medical costs severe daily pain increases healthcare provider costs by 101.6% and total direct costs by 123.9%.

Limitations:

The NHWS is an internet survey. The principal limitation is that as a self-report there is no separate validation of pain severity or chronicity.

Conclusions:

The experience of pain has a substantial negative impact on HRQoL, health status, and resource utilization in Germany. If pain is considered as a disease in its own right, the experience of chronic pain presents policy-makers with a major challenge.     

The impact of rheumatoid arthritis on the burden of disease in urban China

Abstract

Objectives:

The aim of this study is to assess the burden of disease associated with the impact of rheumatoid arthritis in urban China. Burden of disease is considered from four perspectives: (i) health-related quality-of-life (HRQoL); (ii) health status; (iii) employment status; and (iv) absenteeism and presenteeism.

Methods:

Data are from the 2009 National Health and Wellness Survey (NHWS) of urban China. This is an internet-based survey and details the health experience of 13,007 respondents. The survey is representative of the urban China population at 18 years of age and over (18.1% of the total population). Of those responding to the survey, a total of 353 reported that they had been diagnosed with rheumatoid arthritis – an unweighted estimate of 2.65%. The sample design allows a comparison of those reporting rheumatoid arthritis with those not reporting this disease and, hence, a quantitative assessment of the burden of disease. Estimates of the quantitative impact of the presence of rheumatoid arthritis are through a series of generalized linear regression models. HRQoL is evaluated through the SF-12 instrument together with responses to the first item of the SF-12, self-reported health status. The SF-12 instrument generates three measures of HRQoL: the physical component summary (PCS), the mental component summary (MCS) and SF-6D utilities. Health status is captured as a self-report on a 5-point scale. Employment status is considered in terms of self-reported labor force participation, while absenteeism and presenteeism are estimated from the Work Productivity Activity Index (WPAI). Apart from a binary variable capturing the presence or absence of rheumatoid arthritis, control variables were included to capture the impact of other potential determinants of HRQoL and health status.

Results:

The presence of rheumatoid arthritis in urban China has a significant deficit impact on HRQoL as measured by the PCS and MCS components of the SF-12, SF-6D absolute utilities and on self-assessed health status. In the case of PCS, the deficit impact of rheumatoid arthritis is ?2.289 (95%CI: ?3.042 to ?1.536); for MCS ?1.472 (95%CI: ?2.338 to ?0.605) and for utilities ?0.025 (95% CI: ?0.036 to ?0.014). In the case of health status the odds ratio for the presence of rheumatoid arthritis is 1.275 (95%CI 1.031–1.576). The presence of rheumatoid arthritis has a marked negative effect, just under 8%, on the likelihood of workforce participation. Finally, the presence of rheumatoid arthritis is associated with an increased likelihood of absenteeism and presenteeism.

Limitations:

The NHWS survey has a number of limitations. As the NHWS is an internet-based survey, biases may be present due to the lack of internet penetration in the urban China population. The extent to which individuals and households have internet access is unknown. In addition, the NHWS relies upon respondents reporting they have been diagnosed with one or more specific disease states. These are not, given the nature of the survey, clinically verified. This also introduces a degree of uncertainty. Care should be taken in uncritically generalizing these results to the wider China population.

Conclusions:

The burden of disease associated with self-reported, diagnosed rheumatoid arthritis in urban China is substantial. Utilizing a series of multivariate models, substantial deficits are associated not only in reported HRQoL and health status but also in respect of employment status and, for those in employment, rates of absenteeism and presenteeism.     

Empirical Regularities of Financial Market Volatility and Good Modelling Process: Developing Countries’ Exchange Rate Markets Perspective

A survey of contemporary literature suggests that empirical studies on developing economies are few or almost non-existent. Engle and Patton (2001, What good is a volatility model. Quantitative Finance, 1, 237–245) as well as Poon (2005, A Practical Guide to Forecasting Financial Market Volatility. New Jersey: Wiley.) suggest that a good volatility model is one that utilizes the empirical regularities of financial market volatility (of which most were observed on industrialized economies markets). This paper uses exchange rate series from Ghana, Mozambique and Tanzania to show that;

1. they are not different from other financial markets as they exhibit most of the empirical regularities including volatility sign asymmetry, non-normal distribution and volatility clustering. It is however observed that the three exchange rate series are very volatile, with induced volatile shocks highly persistent and asymmetric, and extreme prices commonplace;

2. the ARCH technique (which has been well documented to capture these empirical regularities and produce good forecasts) generally produced a good fit to the three exchange rate series when compared with volatility forecasts generated using the EWMA technique. In the simple analysis of a day-ahead volatility forecast abilities of estimated models, it was observed that best fit does not necessarily ensure best forecast.

     

Modeling hard clinical end-point data in economic analyses

Abstract

Objective:

The availability of hard clinical end-point data, such as that on cardiovascular (CV) events among patients with type 2 diabetes mellitus, is increasing, and as a result there is growing interest in using hard end-point data of this type in economic analyses. This study investigated published approaches for modeling hard end-points from clinical trials and evaluated their applicability in health economic models with different disease features.

Methods:

A review of cost-effectiveness models of interventions in clinically significant therapeutic areas (CV diseases, cancer, and chronic lower respiratory diseases) was conducted in PubMed and Embase using a defined search strategy. Only studies integrating hard end-point data from randomized clinical trials were considered. For each study included, clinical input characteristics and modeling approach were summarized and evaluated.

Results:

A total of 33 articles (23 CV, eight cancer, two respiratory) were accepted for detailed analysis. Decision trees, Markov models, discrete event simulations, and hybrids were used. Event rates were incorporated either as constant rates, time-dependent risks, or risk equations based on patient characteristics. Risks dependent on time and/or patient characteristics were used where major event rates were >1%/year in models with fewer health states (<7). Models of infrequent events or with numerous health states generally preferred constant event rates.

Limitations:

The detailed modeling information and terminology varied, sometimes requiring interpretation.

Conclusions:

Key considerations for cost-effectiveness models incorporating hard end-point data include the frequency and characteristics of the relevant clinical events and how the trial data is reported. When event risk is low, simplification of both the model structure and event rate modeling is recommended. When event risk is common, such as in high risk populations, more detailed modeling approaches, including individual simulations or explicitly time-dependent event rates, are more appropriate to accurately reflect the trial data.     

Nilotinib versus dasatinib as second-line therapy in patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase who are resistant or intolerant to imatinib: a cost-effectiveness analysis based on real-world data

Objective: To evaluate the cost-effectiveness of second-line nilotinib vs dasatinib among patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase (Ph+?CML-CP) who are resistant or intolerant to imatinib, from a US third-party perspective.

Methods: A lifetime partitioned survival model was developed to compare the costs and effectiveness of nilotinib vs dasatinib, which included four health states: CP on treatment, CP post-discontinuation, progressive disease (accelerated phase [AP] or blast crisis [BC]), and death. Time on treatment, progression-free survival, and overall survival of nilotinib and dasatinib were estimated using real-world comparative effectiveness data. Parametric survival models were used to extrapolate outcomes beyond the study period. Drug treatment costs, medical costs, and adverse event costs were obtained from the literature and publicly available databases. Utilities of health states were derived from the literature. Incremental cost-effectiveness ratios, including incremental cost per life-year (LY) gained and incremental cost per quality-adjusted life-year (QALY) gained, were estimated comparing nilotinib and dasatinib. Deterministic sensitivity analyses were performed by varying patient characteristics, cost, and utility inputs.

Results: Over a lifetime horizon, nilotinib-treated patients were associated with 11.7 LYs, 9.1 QALYs, and a total cost of $1,409,466, while dasatinib-treated patients were associated with 9.5 LYs, 7.3 QALYs, and a total cost of $1,422,122. In comparison with dasatinib, nilotinib was associated with better health outcomes (by 2.2 LYs and 1.9 QALYs) and lower total costs (by $12,655). Deterministic sensitivity analysis results showed consistent findings in most scenarios.

Limitations: In the absence of long-term real-world data, the lifetime projection could not be validated.

Conclusions: Compared with dasatinib, second-line nilotinib was associated with better life expectancy, better quality-of-life, and lower costs among patients with Ph+?CML-CP who were resistant or intolerant to imatinib.     

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.     

The association of pain with labor force participation,absenteeism, and presenteeism in Spain

Abstract

Objectives:

The aims of this paper are to generate estimates of the association between the severity and frequency of pain in Spain and (i) labor force participation and workforce status and (ii) patterns of absenteeism and presenteeism for the employed workforce.

Methods:

Data are from the internet-based 2010 National Health and Wellness Survey (NHWS). This survey covers both those who report experiencing pain in the last month as well as the no-pain population. An estimated 17.25% of adults in Spain report experiencing pain in the past month. A series of regression models are developed with the no-pain group as the reference category. The impact of pain, categorized by severity and frequency, is assessed within a labor supply framework for (i) labor force participation and (ii) absenteeism and presenteeism. Both binomial and multinomial logistic models are estimated.

Results:

The results demonstrate that severe and moderate pain has a significant, substantive, and negative association with labor force participation and, together with the experience of mild pain, a substantive impact on absenteeism and presenteeism within the employed workforce. Compared to no-pain controls, the strongest association is seen in the case of severe pain, notably severe daily pain and labor force participation (odds ratio 0.363; 95% CI: 0.206–0.637). The association of severe pain with labor force participation is also significant (odds ratio 0.356; 95% CI: 0.217–0.585). There is a clear gradient in the association of pain severity and frequency with labor force participation. The impact of pain is far greater than the potential impact of other health status measures (e.g., chronic comorbidities and BMI). Labor force participation is also adversely associated with pain experience. Persons reporting severe daily pain are far more likely not to be in the labor force (relative probabilities 0.339 vs 0.611). The experience of pain, notably severe and frequent pain, also outstrips the impact of other health status factors in absenteeism and presenteeism. In the former case, the odds ratio associated with severe daily pain is 16.216 (95% CI: 5.127–51.283), which contrasts to the odds ratio for the Charlson comorbidity index of 1.460 (95%CI: 1.279–1.666). Similar results hold for presenteeism. The contribution of moderate and mild pain to absenteeism and presenteeism is more marked than for labor force participation.

Conclusions:

The experience of pain, in particular severe daily pain, has a substantial negative impact both on labor force participation in Spain as well as reported absenteeism and presenteeism. As a measure of health status, it clearly has an impact that outstrips other health status measures. Whether or not pain is considered as a disease in its own right, the experience of chronic pain, as defined here, presents policy-makers with a major challenge. Programs to relieve the burden of pain in the community clearly have the potential for substantial benefits from societal, individual, and employer perspectives.