Evaluating medical resource utilization and costs associated with thrombocytopenia in chronic liver disease patients

Abstract

Objective:

Thrombocytopenia (TCP), defined as platelet counts <150,000/µL, is a common complication of severe chronic liver disease (CLD). This retrospective study estimated the prevalence of thrombocytopenia in a large population of CLD patients and compared medical resource utilization and medical care costs by TCP status.

Methods:

A retrospective analysis was conducted on a longitudinal administrative claims database from a large US commercial health plan. Patients assigned CLD diagnosis codes from January 1, 2000–December 31, 2003 were identified; annual ambulatory visits, ER visits, inpatient stays, and general and CLD-related medical care costs for patients with vs without TCP (identified using diagnosis codes and platelet count data if available) were compared.

Results:

Of 56,445 patients with an ICD-9-CM diagnosis for CLD, 1289 (2.3%) had a diagnosis for TCP. CLD patients with vs without a TCP diagnosis had >2.5-times the annual number of liver disease-related ambulatory visits (3.6 vs 1.4; odds ratio [OR]?=?2.6, p?<?0.01); were 13-times more likely to have a liver-related inpatient stay (OR?=?13.0, p?<?0.01); were nearly 4-times more likely to have a liver-related ER visit (OR?=?3.9, p?<?0.01); had 3.5-fold greater mean annual overall medical care costs ($43,560 vs $12,270, p?<?0.01); and had 7-fold greater annual liver disease-related medical care costs ($9940 vs $1420, p?<?0.01). Similar results were seen for patients with platelet count data indicating TCP.

Limitations:

CLD and TCP are not always diagnosed, nor is diagnosis uniform or standardized; administrative claims data are subject to coding errors, and individuals covered are not necessarily representative of the general US population. The number of CLD patients in this study with TCP (n?=?1289) is small relative to that expected in the general US population.

Conclusions:

In this analysis, CLD patients with TCP used significantly more medical resources and incurred significantly higher medical care costs than those without TCP.     

Predictors of high healthcare resource utilization and liver disease progression among patients with chronic hepatitis C

Background:

Since hepatitis C virus therapy is typically prioritized for patients with more advanced disease, predicting which patients will progress could help direct scarce resources to those likely to benefit most. This study aims to identify demographics and clinical characteristics associated with high healthcare resource utilization (HRU) and liver disease progression among CHC patients.

Methods:

Using health insurance claims (January 2001–March 2013), adult patients with ≥2 CHC claims (ICD-9-CM: 070.44 or 070.54), and ≥6 months of continuous insurance coverage before and ≥36 months after the first CHC diagnosis were included. Patients with human immunodeficiency virus were excluded. Generalized estimating equations were used to identify the demographic and clinical characteristics of being in the 20% of patients with the highest HRU. Factors predicting liver disease progression were also identified.

Results:

In the study population (n?=?4898), liver disease severity and both CHC- and non–CHC-related comorbidities and conditions were strong predictors of high healthcare costs, with odds ratios (ORs; 95% confidence interval [CI]) for ≥2 CHC-related and ≥2 non-CHC-related comorbidities/conditions of 2.78 (2.48–3.12) and 2.19 (1.76–2.72), respectively. CHC- and non-CHC-related comorbidities and conditions were also strong predictors of liver disease progression with ORs (95% CI) for ≥2 CHC-related and ≥2 non-CHC-related comorbidities and conditions of 2.18 (1.83–2.60) and 1.50 (1.14–1.97), respectively.

Limitations:

Potential inaccuracies in claims data, information or classification bias, and findings based on a privately insured population.

Conclusion:

This study suggests that CHC patients with high healthcare resource utilization have a high level of comorbidity at baseline and also that non-CHC comorbidities and conditions are strong predictors of high HRU. Non-cirrhotic CHC patients with one or more comorbidities are at high risk of progressing to cirrhosis or end-stage liver disease.     

CARBON LEAKAGE,THE GREEN PARADOX,AND PERFECT FUTURE MARKETS*

Policies of lowering carbon demand may aggravate instead of alleviate climate change (green paradox). In a two‐period, three‐country general equilibrium model with finite endowment of fossil fuel, one country enforces an emissions cap in the first or second periods. When that cap is tightened, the extent of carbon leakage depends on the interaction of various parameters and elasticities. Conditions for the green paradox are specified. All determinants of carbon leakage resulting from tightening the first‐period cap work in the opposite direction when the second‐period cap is tightened. Tightening the second‐period cap does not necessarily lead to the green paradox.     

Bias-corrected estimates of reduction of post-surgery length of stay and corresponding cost savings through the widespread national implementation of fast-tracking after liver transplantation: a quasi-experimental study

Background: Fast-tracking is an approach adopted by Mayo Clinic in Florida’s (MCF) liver transplant (LT) program, which consists of early tracheal extubation and transfer of patients to surgical ward, eliminating a stay in the intensive care unit in select patients. Since adopting this approach in 2002, MCF has successfully fast-tracked 54.3% of patients undergoing LT.

Objectives: This study evaluated the reduction in post-operative length of stay (LOS) that resulted from the fast-tracking protocol and assessed the potential cost saving in the case of nationwide implementation.

Methods: A propensity score for fast-tracking was generated based on MCF liver transplant databases during 2011–2013. Various propensity score matching algorithms were used to form control groups from the United Network of Organ Sharing Standard Analysis and Research (STAR) file that had comparable demographic characteristics and health status to the treatment group identified in MCF. Multiple regression and matching estimators were employed for evaluation of the post-surgery LOS. The algorithm generated from the analysis was also applied to the STAR data to determine the proportion of patients in the US who could potentially be candidates for fast-tracking, and the potential savings.

Results: The effect of the fast-tracking on the post-transplant LOS was estimated at approximately from 2.5 (p-value?=?0.001) to 3.2 (p-value?Conclusion: The fast-track program was found to be effective in reducing post-transplant LOS, although the reduction appeared to be less than previously reported. Nationwide implementation of fast-tracking could result in substantial cost savings without compromising the patient outcome.     

Carcinoma of the ampulla of Vater: Sonographic and CT diagnosis

Twenty patients with carcinoma of the ampulla of Vater were studied with sonography (N = 9) or both sonography and CT (N = 11). The tumor was shown by sonography in 16 patients (80%) as a small, round or oval, fairly well delineated mass in between the dilated distal common bile duct and duodenum which was delineated owing to luminal fluid or gas (N = 13); or as a polypoid mass within the dilated distal common bile duct resulting in abrupt obstruction (N = 3). In the remaining four patients, the mass was not delineated. Bile ducts were dilated down to the level of mass or ampullary region in all cases (100%), while the pancreatic duct was dilated in five cases (45%). We believe that sonography is the technique of initial choice in the diagnosis of carcinoma of the ampulla of Vater by identifying the mass at the distal end of the dilated common bile duct and/or pancreatic duct.     

Carbon leakage revisited: unilateral climate policy with directed technical change

Using a stylized theoretical model, we argue that current economic analyses of climate policy tend to over-estimate the degree of carbon leakage, as they abstract from the effects of induced technological change. We analyse carbon leakage in a two-country model with directed technical change, where only one of the countries enforces an exogenous cap on emissions. Climate policy induces changes in relative prices, that cause carbon leakage through a terms-of-trade effect. However, these changes in relative prices also affect the incentives to innovate in different sectors. This leads to a counterbalancing induced-technology effect, which always reduces carbon leakage. We therefore conclude that the leakage rates reported in the literature may be too high, as these estimates neglect the effect of price changes on the incentives to innovate.      

The burden associated with thrombocytopenia and platelet transfusions among patients with chronic liver disease

Abstract

Background: Thrombocytopenia (TCP), a common complication of chronic liver disease (CLD), can cause uncontrolled bleeding during procedures. As such, CLD patients with TCP and platelet counts <50,000/μL often receive prophylactic platelet transfusions before invasive procedures. However, platelet transfusions are associated with clinical complications, which may result in increased healthcare utilization and costs.

Objective: This retrospective database analysis describes the clinical and economic burden in CLD patients with TCP, CLD patients without TCP, and CLD patients with TCP who receive platelet transfusions.

Methods: Adult CLD patients with or without TCP were identified in the IBM MarketScan Commercial Claims and Medicare Supplemental data from 1 January 2012 to 31 December 2015. CLD patients with or without TCP were propensity-score matched (1:1) for the analysis of annual healthcare utilization and costs. Platelet transfusions among CLD patients with TCP were identified using procedure codes.

Results: Of the 601,626 patients with CLD, 8,292 (1.4%) patients with TCP were matched to patients without TCP. Among CLD patients with TCP, 981 (11.8%) patients received ≥1 platelet transfusions and met inclusion/exclusion criteria. Compared to patients without TCP, CLD patients with TCP had more complications, including higher prevalence of neutropenia (11.4% vs 2.9%) and bleeding events (21.4% vs 10.9%), greater resource utilization including greater average hospital admissions (1.2 vs 0.7, p?<?.01), greater average ER visits (2.1 vs 1.3, p?<?.01), higher average outpatient office visits (20.1 vs 18.4, p?<?.01), and higher average healthcare costs including total costs (p?<?.01), inpatient costs (p?<?.01), ER visit costs (p?<?.01), and outpatient office visit costs (p?<?.01). The mean annual total costs in CLD and TCP patients with platelet transfusions were $206,396.

Conclusions: CLD patients with TCP, and particularly those who received platelet transfusions, experienced significantly greater clinical and economic burden compared to CLD patients without TCP. Safer and more cost-effective treatments to increase platelets are necessary.     

Radiological findings of human fascioliasis

Fasciola hepatica is a trematode of herbivorous mammals. Humans are accidentally infected by the ingestion of water or raw aquatic vegetables contaminated with the metacercaria. Radiological findings of six patients with fascioliasis (five hepatic fascioliasis, one biliary fascioliasis) were analyzed. The diagnosis was based on serologic testing and/or histopathologic findings of eosinophilic abscess in five patients and identification of the adult worm in one patient. The characteristic radiological features of hepatic fascioliasis were (1) cluster of microabscesses arranged in tract-like fashion (burrow tract), (2) subcapsular location of the hepatic lesions, and (3) very slow evolution of the lesion on follow-up examinations. In biliary fascioliasis, there were multiple conglomerated filling defects in the common bile duct. The authors believe that the demonstration of these features, together with peripheral eosinophilia or eosinophilic aspirate from the hepatic lesion, is very helpful in making the correct diagnosis.     

Measuring transnational leakage of forest conservation

Forest conservation in one country can influence the degree of conservation or deforestation in other countries because of international linkages of the forest products industry and markets and a lack of global coordination. Thus leakage and offsetting losses of environmental quality may be present. This paper develops an analytical framework for measuring this leakage and estimates its magnitude via general equilibrium modeling. We find that the magnitude of leakage depends upon the price elasticities of supply of and demand for forestry products across the countries and degree of cooperation in forest conservation. We estimate that a significant portion (42%-95%) of the reduced forestry production implemented in a country/region can be transferred to elsewhere, offsetting environmental gains. Leakage generally diminishes as more countries cooperate, but cooperation among only a few countries does not always dramatically reduce leakage. Thus forest conservation efforts and associated environmental quantity gains in a country or group of countries can be seriously undermined in terms of global net conservation gain in the absence of effective global cooperation. Our results also point to the importance of taking leakage into account in evaluating local or regional forest carbon sequestration projects.     

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.     

Systemic lupus erythematosus and associated healthcare resource consumption in selected cities from the Russian Federation,Republic of Kazakhstan and Ukraine: the ESSENCE study

Objectives: To evaluate healthcare resource (HR) consumption associated with Systemic Lupus Erythematosus (SLE) management in adult patients with active autoantibody positive disease in the Russian Federation, Republic of Kazakhstan, and Ukraine.

Methods: The ESSENCE was a retrospective, observational study, and included data on patients’ clinical characteristics and SLE-related HR use (laboratory, biopsy, imaging tests, medications, visits to specialists, outpatient visits, hospitalizations) during 2010 from the 12 specialized rheumatologic centers.

Results: A total of 436 SLE patients were included in the analyses, with 232 patients being enrolled in Russia, 110 in Kazakhstan, and 94 in Ukraine. The mean age was 36–42 years and median SLE duration was 3–6.8 years across the countries. Extrapolation to total country population showed that, in 2010, visits to specialists (who assign treatment for organs involved/damaged by SLE) were the most frequently used HR (from 13,439 visits in Kazakhstan to 23,510 in Russia), followed by hospitalizations (from 2,950 in Kazakhstan to 6,267 in Russia) and outpatient visits (from 1,654 visits in Russia to 8,064 in Kazakhstan). Compared to chronic active patients (SLE persistent during last year), patients with relapsing-remitting SLE (at least one flare alternated by one remission per year) had a higher rate of visits to specialists (100% vs 60.8%, p?<?.001) and hospitalizations (98.9% vs 60.8%, p?<?.001). Compared to patients without flares, patients experiencing flares had a higher rate of unplanned visits to specialists (86.2% vs 6.3%, p?<?.001), were more often hospitalized (both ICU and non-ICU) (100.0% vs 50.0%, p?<?.001), and had a longer duration of ICU hospitalization (25.9 days vs 17.5 days, p?<?.001).

Conclusions: Specialist visits are the most frequently consumed SLE-related healthcare recourse in the Commonwealth of Independent States (CIS) countries. A relapsing-remitting SLE profile and the occurrence of flares significantly raise healthcare resource consumption.     

Does CTAP prior to hepatic resection improve patient survival rates?

The purpose of our study was to compare survival rates of colon carcinoma patients who had undergone attempted curative hepatic resection based on liver staging by computed tomographic angiography (CTA) or portography (CTAP) with previously reported survival rates of patients who underwent similar surgery without preoperative CTAP evaluations. A total of 404 CTAP studies performed at three institutions were reviewed. Of this group, 197 had colon carcinoma. Sixty-nine of the colon patients went to surgery. Actuarial adjusted yearly survival rates were calculated for the prior CTAP colon group and compared to historical controls. The control survival data were taken from reports published prior to the CTAP era. Our study demonstrated no difference in the 1-year survival data between the groups. However, the CTAP patients had greater survival in years 2–4. This greater survival may be multifactorial but in part due to better surgical selection caused by CTAP.     

金融漏损、效率修正与"反哺效应"——中国转轨经济金融低效率与经济高增长研究的新视角

在我国渐进式的转轨经济过程中,在政府强控制金融与高额储蓄条件下,体制内经济体发生金融漏损并由体制外经济顺守,修正了金融初次配置效率,形成了金融低效率与经济高增长并存的结果。理论与实践表明,体制内金融的外向漏损间接支持了体制外经济的成长发展,形成了"反哺效应",构成了一个非正规的经济增长良性循环模式。文章从金融效率与经济增长角度分析了我国转轨过程中的金融漏损、效率修正与经济增长,对我国转轨经济中金融低效率与经济高增长现象进行了分析。文章认为应通过进一步推进国有企业与国有银行产权改革、加快民间金融发展等措施改进与提高我国的金融效率。     

独占机制对创新绩效的影响:知识泄露与竞争对手吸收能力的调节效应

独占机制与知识泄露在企业创新活动中的重要作用日益受到关注。基于问卷调研数据,通过实证手段分析企业独占性机制对创新绩效的影响,及竞争对手吸收能力和知识泄露在其中的调节作用。研究发现：企业独占机制对创新绩效有显著正向影响,知识泄露和竞争对手吸收能力在企业独占性机制对创新绩效影响过程中分别起负向和正向调节作用。研究结论既可帮助企业重视独占机制和竞争对手吸收能力带来的创新效应,也可帮助企业通过有效规避或降低知识泄露风险提升创新绩效。     

怎样加强对回扣和现金管理混乱的治理

在账外暗中给予单位或个人钱或物的叫回扣,因回扣而造成的国有资产流失、假冒伪劣泛滥、腐败现象丛生等问题一直是困扰我国经济生活中的难题,明白了商品购销回扣的产生及如何落入个人腰包的原因后,就必须加强管理。现金专指企业的库存现金,现金管理中的疏漏是造成经济犯罪的重要原因之一,为堵塞漏洞必须强化现金管理。     

What matters in technology leakage in small and medium enterprises: the case of Korea

Technology leakage in small and medium enterprises (SMEs) is a critical issue because while the number of main technologies in SMEs is small, these technologies are crucial to their survival. Related factors must be identified to prevent technology leakage from SMEs. In this paper, we use logistic regression to find significant factors in Korean SMEs, focusing on three aspects: characteristics of the technology, prevention strategy, and firm’s R&D characteristics. We use a survey conducted by related national institutions. According to the results of our empirical study, interaction effects among the factors of technology characteristics have highly significant effects on technology leakage. In particular, the interaction effect between the time needed to imitate the technology and the stage of business growth appears to have the highest influence on technology leakage. Based on our results, detailed strategies for preventing technology leakage are inferred in order to help SMEs prioritise their resources.     

Welfare Leakage and Immigration Policy

This paper analyzes the interaction between the welfare stateand immigration policy. We establish a negative relationshipbetween the number of dependents and the extent of the welfarestate due to the leakage of benefits. We also explain the determinationof immigration policy as the outcome of a lobbying game betweendomestic interest groups and the government. Our results indicatethat there is evidence for welfare leakage and for lobbyingas a determinant of immigration policy. In our baseline specification,a 10 percentage points increase in the share of dependents leadsto a 7–10 percentage point decrease in the labor tax rate.Furthermore, an increase by 10 percentage points in union densityleads to a decrease of one percentage point in the share ofimmigrants in the population. In the context of EU enlargementand the ensuing migration flows, our model predicts a reductionin the size of the welfare state in the old member countries.(JEL H5, J1, J61)     

Circulation and effective demand: a comment on Nell

In a recent paper in this Journal, Ed Nell presented a theoryof circulation intended to unify ‘the theories of money,production, and effective demand’. The current commentuses a very simple leakage and injection approach to arriveat some of Nell's results. In doing so, we are able to correcta small slip in Nell's original paper. More importantly, withthe slip corrected, the money supply and multiplier processesare seen to be one and the same.     

Medical resource utilisation and healthcare costs in patients with chronic hepatitis C viral infection and thrombocytopenia

Abstract

Background:

Thrombocytopenia is a significant risk for patients with chronic HCV infection and a common side-effect of treatment with pegylated (PEG) interferon (IFN). Thrombocytopenia predisposes patients to bleeding and requirements for platelet transfusions, and may thus place an increased burden on patients and on medical resource utilisation.

Scope:

In a retrospective analysis of an integrated, longitudinal database of medical and pharmacy claims and laboratory results in a US commercial health (insurance) plan, patients with chronic hepatitis C viral (HCV) infection were identified by reviewing ICD-9-CM HCV-, chronic liver disease-, and cirrhosis-related diagnoses. Medical resource utilisation and laboratory results were evaluated during the year following the HCV diagnosis index date as well as during the baseline year prior to that index date. Medical resource utilisation was determined by comparing outpatient visits, emergency department (ER) visits, and inpatient hospital stays for HCV patients with or without thrombocytopenia.

Findings:

HCV patients diagnosed with thrombocytopenia had a greater incidence of bleeding events (27.3 vs. 9.9%), platelet transfusions (8.5 vs. <1%), liver disease-related ambulatory visits (10.4 vs. 4.4; odds ratio [OR]?=?2.3; p?<?0.001), ER visits (OR?=?8.6; p?<?0.01), and inpatient hospital stays (OR?=?17.7; p?<?0.01) during the study period compared with HCV patients without a thrombocytopenia diagnosis. HCV patients with thrombocytopenia had significantly higher overall healthcare costs ($37,924 vs. $12,174; p?<?0.001) and liver disease-related costs ($14,569 vs. $4107; p?<?0.001) than patients without thrombocytopenia.

Limitations:

Administrative claims data are subject to coding errors; additionally, the patient population may not be completely representative of the general chronic HCV population.

Conclusions:

Diagnosis of thrombocytopenia in patients with HCV is associated with increased incidence of certain comorbidities, complications, and medical interventions, and significantly increased medical resource utilisation.     

关于我国现金投放量的研究

在我国货币政策体系中,流通中现金M0是最重要的观测目标之一。分析了影响我国现金投放量的各种基本因素,同时,对现金漏损进行了分析和测算。在此基础上,通过分析1999年第一季度至2008年第四季度的相关历史数据,建立了我国现金投放量计量模型,并对2010～2014年我国的现金投放量进行了预测。认为加强现金的监控与管理对于确保金融稳定和促进经济发展有着十分重要的意义。