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Salazar MM, Khera N, Chino F, Johnston E. Financial hardship for patients with cancer and caregivers at end of life in the USA: narrative review. BMJ Support Palliat Care 2024; 14:25-35. [PMID: 38123962 DOI: 10.1136/spcare-2023-004556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients and their families face financial hardship during cancer treatment, which may intensify at end of life (EOL) due to increased symptoms and care needs. We undertook a narrative literature review to describe the current understanding of the causes, impacts and factors associated with financial hardship at EOL. We identify gaps in research, policy and clinical practice and propose steps to mitigate financial hardship for patients and caregivers at EOL. METHODS We conducted a Medline search to identify US studies since 2000 that examined EOL financial hardship for patients with cancer and their caregivers. RESULTS Twenty-seven adult and four paediatric studies met review criteria. Adults with cancer and their caregivers face significant financial hardship at EOL and in bereavement, especially due to employment changes and informal caregiving time costs. Financial hardship may be higher for younger caregivers and for patients who are uninsured, low income, rural, with high symptom burdens or with certain cancer types. The few paediatric studies showed high financial hardship and employment impact lasting well beyond a child's death. CONCLUSIONS There is limited literature examining financial hardship at EOL in the USA, especially in paediatrics. Priorities for future research include longitudinal studies in diverse populations of patients with cancer and informal caregivers using standardised financial hardship measures. Policies to address financial hardship at EOL, especially with hospice care, should include insurance coverage for family caregiving and medical leave policies. There is need for increased financial hardship screening at EOL and in bereavement and a need for financial navigation interventions.
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Affiliation(s)
- Marisa Martinez Salazar
- School of Medicine, Mayo Clinic School of Medicine-Scottsdale Campus, Scottsdale, Arizona, USA
| | - Nandita Khera
- Mayo Clinic School of Medicine, Phoenix, Arizona, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Emily Johnston
- Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
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Bandeira-de Oliveira M, Aparicio-González T, Del Cura-González I, Suárez-Fernández C, Rodríguez-Barrientos R, Barrio-Cortes J. Adjusted morbidity groups and survival: a retrospective cohort study of primary care patients with chronic conditions. BMC PRIMARY CARE 2023; 24:103. [PMID: 37081395 PMCID: PMC10120109 DOI: 10.1186/s12875-023-02059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Chronic conditions are one of the main determinants of frailty, functional disability, loss of quality of life and the number one cause of death worldwide. This study aimed to describe the survival of patients with chronic conditions who were followed up in primary care according to the level of risk by adjusted morbidity groups and to analyse the effects of sex, age, clinician and care factors on survival. METHODS This was a longitudinal observational study of a retrospective cohort of patients with chronic conditions identified by the adjusted morbidity group stratifier of the electronic medical records in a primary health centre of the Region of Madrid, which has an assigned population of 18,107 inhabitants. The follow-up period was from June 2015 to June 2018. A description of survival according to the Kaplan-Meier method and Cox proportional hazards multivariate regression model was used to analyse the effects of sex, age, clinician and care factors. RESULTS A total of 9,866 patients with chronic conditions were identified; 77.4% (7,638) had a low risk, 18.1% (1,784) had a medium risk, and 4.5% (444) had a high risk according to the adjusted morbidity groups. A total of 477 patients with chronic conditions died (4.8%). The median survival was 36 months. The factors associated with lower survival were age over 65 years (hazard ratio [HR] = 1.3; 95% confidence interval [CI] = 1.1-1.6), receiving palliative care (HR = 3.4; 95% CI = 2.6-4.5), high versus low risk level (HR = 2.4; 95% CI = 1.60-3.7), five chronic conditions or more (HR = 1.5; 95% CI = 1.2-2), complexity index (HR = 1.01; 95% CI = 1.02-1.04) and polymedication (HR = 2.6; 95% CI = 2.0-3.3). CONCLUSIONS There was a gradual and significant decrease in the survival of patients with chronic conditions according to their level of risk as defined by adjusted morbidity groups. Other factors, such as older age, receiving palliative care, high number of chronic conditions, complexity, and polymedication, had a negative effect on survival. The adjusted morbidity groups are useful in explaining survival outcomes and may be valuable for clinical practice, resource planning and public health research.
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Affiliation(s)
| | | | - Isabel Del Cura-González
- Research Unit. Primary Care Management, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Department of Medical Specialties and Public Health, Rey Juan Carlos University, Madrid, Spain
- Research Network on Chronicity, Primary Care and Prevention and Health Promotion, Carlos III Health Institute, Madrid, Spain
| | - Carmen Suárez-Fernández
- University Hospital of La Princesa, Madrid, Spain
- Department of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Ricardo Rodríguez-Barrientos
- Research Unit. Primary Care Management, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Research Network on Chronicity, Primary Care and Prevention and Health Promotion, Carlos III Health Institute, Madrid, Spain
| | - Jaime Barrio-Cortes
- Research Unit. Primary Care Management, Madrid, Spain.
- Gregorio Marañón Health Research Institute, Madrid, Spain.
- Research Network on Chronicity, Primary Care and Prevention and Health Promotion, Carlos III Health Institute, Madrid, Spain.
- Foundation for Biosanitary Research and Innovation in Primary Care, Madrid, Spain.
- Faculty of Health, Camilo José Cela University, Madrid, Spain.
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Marupuru S, Axon DR. Association of Multimorbidity on Healthcare Expenditures Among Older United States Adults With Pain. J Aging Health 2021; 33:741-750. [PMID: 33881371 DOI: 10.1177/08982643211011841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: This cross-sectional study compared the healthcare expenditures associated with multimorbidity (having ≥2 chronic conditions) versus no multimorbidity among older United States (US) adults (aged ≥ 50 years) with self-reported pain in the past 4 weeks. Methods: This research used data from the 2018 Medical Expenditure Panel Survey. Adjusted linear regression models evaluated group differences in various annual healthcare expenditures. Results: Descriptive statistics indicated multimorbidity was associated with all personal characteristics (p < 0.05) except gender and smoking status (p > 0.05). Multimorbidity had 75.8% greater annual total health expenditures (p = 0.0083), 40.6% greater office-based expenditures (p = 0.0224), 100.6% greater prescription medication costs, (p = 0.0268), yet 47.3% lower inpatient expenditures (p = 0.0158), and 56.6% lower home healthcare expenditures (p < 0.0001) than no multimorbidity. Discussion: This study found greater healthcare expenditures among older US adults with pain and multimorbidity, which captures the financial burden of comorbidity in this population.
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Affiliation(s)
- Srujitha Marupuru
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, USA
| | - David R Axon
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, USA
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Nedzinskienė L, Jurevičienė E, Visockienė Ž, Ulytė A, Puronaitė R, Kasiulevičius V, Kazėnaitė E, Burneikaitė G, Navickas R. Structure and Distribution of Health Care Costs across Age Groups of Patients with Multimorbidity in Lithuania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052767. [PMID: 33803298 PMCID: PMC7967257 DOI: 10.3390/ijerph18052767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/13/2022]
Abstract
Background. Patients with multimorbidity account for ever-increasing healthcare resource usage and are often summarised as big spenders. Comprehensive analysis of health care resource usage in different age groups in patients with at least two non-communicable diseases is still scarce, limiting the quality of health care management decisions, which are often backed by limited, small-scale database analysis. The health care system in Lithuania is based on mandatory social health insurance and is covered by the National Health Insurance Fund. Based on a national Health Insurance database. The study aimed to explore the distribution, change, and interrelationships of health care costs across the age groups of patients with multimorbidity, suggesting different priorities at different age groups. Method. The study identified all adults with at least one chronic disease when any health care services were used over a three-year period between 2012 and 2014. Further data analysis excluded patients with single chronic conditions and further analysed patients with multimorbidity, accounting for increasing resource usage. The costs of primary, outpatient health care services; hospitalizations; reimbursed and paid out-of-pocket medications were analysed in eight age groups starting at 18 and up to 85 years and over. Results. The study identified a total of 428,430 adults in Lithuania with at least two different chronic diseases from the 32 chronic disease list. Out of the total expenditure within the group, 51.54% of the expenses were consumed for inpatient treatment, 30.90% for reimbursed medications. Across different age groups of patients with multimorbidity in Lithuania, 60% of the total cost is attributed to the age group of 65–84 years. The share in the total spending was the highest in the 75–84 years age group amounting to 29.53% of the overall expenditure, with an increase in hospitalization and a decrease in outpatient services. A decrease in health care expenses per capita in patients with multimorbidity after 85 years of age was observed. Conclusions. The highest proportion of health care expenses in patients with multimorbidity relates to hospitalization and reimbursed medications, increasing with age, but varies through different services. The study identifies the need to personalise the care of patients with multimorbidity in the primary-outpatient setting, aiming to reduce hospitalizations with proactive disease management.
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Affiliation(s)
- Laura Nedzinskienė
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
| | - Elena Jurevičienė
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
| | - Žydrūnė Visockienė
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
| | - Agnė Ulytė
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland;
| | - Roma Puronaitė
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
- Faculty of Mathematics and Informatics, Institute of Data Science and Digital Technologies, Vilnius University, Naugarduko g. 24, LT-03225 Vilnius, Lithuania
| | - Vytautas Kasiulevičius
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
| | - Edita Kazėnaitė
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
| | - Greta Burneikaitė
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
| | - Rokas Navickas
- Faculty of Medicine, Vilnius University, Čiurlionio Str. 21, LT-03101 Vilnius, Lithuania; (L.N.); (E.J.); (Ž.V.); (R.P.); (V.K.); (E.K.); (G.B.)
- Vilnius University Hospital, Santaros Klinikos, Santariškių Str. 2, LT-08661 Vilnius, Lithuania
- Correspondence: ; Tel.: +370-65-068366
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Yu CW, Alavinia SM, Alter DA. Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis. BMC Palliat Care 2020; 19:35. [PMID: 32293403 PMCID: PMC7087362 DOI: 10.1186/s12904-020-0538-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Socioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions. However, the extent to which they exist at end-of-life (EOL) remains unclear. METHODS Studies in MEDLINE, EMBASE, CINAHL, ProQuest, Web of Science, Web of Knowledge, and OpenGrey databases were searched through December 2019 with hand-searching of in-text citations. No publication date or language limitations were set. Studies assessing SES (e.g. income) in adults, correlated to EOL costs in last year(s) or month(s) of life were selected. Two independent reviewers performed data abstraction and quality assessment, with inconsistencies resolved by consensus. RESULTS A total of twenty articles met eligibility criteria. Two meta-analyses were performed on studies that examined total costs in last year of life - the first examined costs without adjustments for confounders (n = 4), the second examined costs that adjusted for confounders, including comorbidities (n = 2). Among studies which did not adjust for comorbidities, SES was positively correlated with EOL costs (standardized mean difference, 0.13 [95% confidence interval, 0.03 to 0.24]). However, among studies adjusting for comorbidities, SES was inversely correlated with EOL expenditures (regression coefficient, -$150.94 [95% confidence interval, -$177.69 to -$124.19], 2015 United States Dollars (USD)). Higher ambulatory care and drug expenditure were consistently found among higher SES patients irrespective of whether or not comorbidity adjustment was employed. CONCLUSION Overall, an inequality leading to higher end-of-life expenditure for higher SES patients existed to varying extents, even within countries providing universal health care, with greatest differences seen for outpatient and prescription drug costs. The magnitude and directionality of the relationship in part depended on whether comorbidity risk-adjustment methodology was employed.
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Affiliation(s)
- Caberry W. Yu
- School of Medicine, Faculty of Health Sciences, Queen’s University, 15 Arch St, Kingston, ON K7L 3N6 Canada
| | - S. Mohammad Alavinia
- Neural Engineering & Therapeutics Team, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, 27 King’s College Cir, Toronto, Canada
| | - David A. Alter
- Department of Medicine, University Health Network, 27 King’s College Cir, Toronto, ON M5S 1A1 Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6 Canada
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada
- Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON M5G 2A2 Canada
- IC/ES (Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, G1-06, Toronto, Ontario M4N 3M5 Canada
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Cheruvu VK, Chiyaka ET. Prevalence of depressive symptoms among older adults who reported medical cost as a barrier to seeking health care: findings from a nationally representative sample. BMC Geriatr 2019; 19:192. [PMID: 31319807 PMCID: PMC6639933 DOI: 10.1186/s12877-019-1203-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 07/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older adults aged 65 and over will make up more than 20% of U.S. residents by 2030, and in 2050, this population will reach 83.7 million. Depression among older adults is a major public health concern projected to be the second leading cause of disease burden. Despite having Medicare, and other employer supplements, the burden of out of pocket healthcare expenses may be an important predictor of depression. The current study aims to investigate whether delay in seeing a doctor when needed but could not because of medical cost is significantly associated with symptoms of current depression in older adults. METHODS Cross-sectional data from the 2011 Behavioral Risk Factor Surveillance System (BFRSS) from 12 states and Puerto Rico were used for this study (n = 24,018). RESULTS The prevalence of symptoms of current depression among older adults who reported medical cost as a barrier to seeking health care was significantly higher (17.8%) when compared to older adults who reported medical cost not being a barrier to seeking health care (5.5%). Older adults who reported medical cost as a barrier to seeking health care were more likely to report current depressive symptoms compared to their counterparts [Adjusted Odds Ratio (AOR): 2.2 [95% CI: 1.5-3.3]). CONCLUSIONS Older adults (≥ 65 years of age) who experience the burden of medical cost for health care are significantly more likely to report symptoms of depression. Health care professionals and policymakers should consider effective interventions to improve access to health care among older adults.
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Affiliation(s)
- Vinay K Cheruvu
- College of Public Health, Kent State University, 320 Lowry Hall, 750 Hilltop Drive, Kent, OH, 44242, USA.
| | - Edward T Chiyaka
- College of Public Health, Kent State University, 320 Lowry Hall, 750 Hilltop Drive, Kent, OH, 44242, USA
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Hajat C, Stein E. The global burden of multiple chronic conditions: A narrative review. Prev Med Rep 2018; 12:284-293. [PMID: 30406006 PMCID: PMC6214883 DOI: 10.1016/j.pmedr.2018.10.008] [Citation(s) in RCA: 414] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/21/2018] [Accepted: 10/14/2018] [Indexed: 01/19/2023] Open
Abstract
Globally, approximately one in three of all adults suffer from multiple chronic conditions (MCCs). This review provides a comprehensive overview of the resulting epidemiological, economic and patient burden. There is no agreed taxonomy for MCCs, with several terms used interchangeably and no agreed definition, resulting in up to three-fold variation in prevalence rates: from 16% to 58% in UK studies, 26% in US studies and 9.4% in Urban South Asians. Certain conditions cluster together more frequently than expected, with associations of up to three-fold, e.g. depression associated with stroke and with Alzheimer's disease, and communicable conditions such as TB and HIV/AIDS associated with diabetes and CVD, respectively. Clusters are important as they may be highly amenable to large improvements in health and cost outcomes through relatively simple shifts in healthcare delivery. Healthcare expenditures greatly increase, sometimes exponentially, with each additional chronic condition with greater specialist physician access, emergency department presentations and hospital admissions. The patient burden includes a deterioration of quality of life, out of pocket expenses, medication adherence, inability to work, symptom control and a high toll on carers. This high burden from MCCs is further projected to increase. Recommendations for interventions include reaching consensus on the taxonomy of MCC, greater emphasis on MCCs research, primary prevention to achieve compression of morbidity, a shift of health systems and policies towards a multiple-condition framework, changes in healthcare payment mechanisms to facilitate this change and shifts in health and epidemiological databases to include MCCs.
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Affiliation(s)
| | - Emma Stein
- Yale School of Public Health, United States of America
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Pont L, Jansen K, Schaufel MA, Haugen DF, Ruths S. Drug utilization and medication costs at the end of life. Expert Rev Pharmacoecon Outcomes Res 2016; 16:237-43. [PMID: 26919437 DOI: 10.1586/14737167.2016.1158106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the end stages of life, drug treatment goals shift to symptom control and quality of life and as such changes in drug utilization are expected. The aim of this paper is to review the extent to which costs are considered in drug utilization research at the end of life, with a particular focus on the outcome measures being used. This systematic review identified seven studies across varied settings studies reporting both drug utilization and medication cost outcome measures. The main factors identified that impacted medication use and cost were the time period considered and the provision of specialist palliative care services. Combining drug utilization and medication cost outcomes is critical for the allocation of healthcare resources and the development of a sound health policy.
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Affiliation(s)
- Lisa Pont
- a Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University , North Ryde , Australia
| | - Kristian Jansen
- b Research Unit for General Practice, Uni Research Health, University of Bergen , Bergen , Norway.,c Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
| | - Margrete Aase Schaufel
- b Research Unit for General Practice, Uni Research Health, University of Bergen , Bergen , Norway.,d Department of Thoracic Medicine , Haukeland University Hospital , Bergen , Norway
| | - Dagny Faksvåg Haugen
- e Regional Centre of Excellence for Palliative Care, Haukeland University Hospital , Bergen , Norway.,f Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Sabine Ruths
- b Research Unit for General Practice, Uni Research Health, University of Bergen , Bergen , Norway.,c Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
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Faes K, De Frène V, Cohen J, Annemans L. Resource Use and Health Care Costs of COPD Patients at the End of Life: A Systematic Review. J Pain Symptom Manage 2016; 52:588-599. [PMID: 27401511 DOI: 10.1016/j.jpainsymman.2016.04.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 03/21/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Patients with chronic obstructive pulmonary disease (COPD) in their final months of life potentially place a high burden on health care systems. Concrete knowledge about resources used and costs incurred by those patients at the end of life is crucial for policymakers. OBJECTIVES The aim of this systematic review was to describe the resources used and costs incurred by patients with COPD at the end of life. METHODS We performed a comprehensive literature search in MEDLINE, Web of Science, and EconLit. We screened 886 abstracts and subsequently reviewed 80 full-text articles. Inclusion criteria were at least one type of resource use and/or cost outcome reported in adults diagnosed with COPD during an end-of-life period. Subsequently, we performed quality appraisal consistent with the ISPOR checklist for retrospective database studies and accomplished comprehensive data extraction. RESULTS Ten articles fulfilled the inclusion criteria. Three, five, and two studies described European, North American, and Asian health care settings, respectively. All studies had a retrospective design and were published between 2006 and 2015. We observed a very variable resource use, an increased number of hospitalizations, intensive care unit stays, primary care consultations and medication prescriptions, as well as a lack of utilization of formal palliative care services in end-of-life COPD patients. Specific cost items were not well described. CONCLUSION The high use of health care resources in COPD patients in the final months of life suggests a focus on prolonging life and a tendency toward aggressive care. Limiting potentially inappropriate care and improving the quality of end-of-life care in advanced COPD are, therefore, important public health challenges.
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Affiliation(s)
- Kristof Faes
- Department of Public Health, Ghent University, Ghent, Belgium.
| | - Veerle De Frène
- Department of Public Health, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- Department of Family Medicine & Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieven Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
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10
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McPhail SM. Multimorbidity in chronic disease: impact on health care resources and costs. Risk Manag Healthc Policy 2016; 9:143-56. [PMID: 27462182 PMCID: PMC4939994 DOI: 10.2147/rmhp.s97248] [Citation(s) in RCA: 283] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.
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Affiliation(s)
- Steven M McPhail
- Centre for Functioning and Health Research, Metro South Health; Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
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Neutel CI, Johansen HL. Association between hypnotics use and increased mortality: causation or confounding? Eur J Clin Pharmacol 2015; 71:637-42. [PMID: 25845656 DOI: 10.1007/s00228-015-1841-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/24/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Many research studies have found associations between benzodiazepines and/or z-hypnotics (BZZ) and increasing mortality, leading to a discussion about causation or confounding. This study suggests a factor that could produce this association through confounding. METHODS The Norwegian population in 2010 supplied 8862 deaths ages 41-80 and 898,289 controls. Index dates were added to control records which corresponded to death dates. BZZ use was recorded for 2 years before death/index date. RESULTS Persons exposed to BZZ were more likely (OR = 2.3) to die than those who were not. With proximity of death, increasingly larger proportions of the prospective deaths received prescriptions for BZZ, until in the last 2 months 40-45% received BZZ. The frequency of BZZ use in controls increased with age as opposed to the death cohort where all ages showed similar rates of BZZ use. In the last few months before death, the youngest age group had an OR = 5.8 for BZZ use while the oldest age group an OR = 1.8, adjusted for age and sex. Opioid use showed a similar pattern of increasing use near death. CONCLUSIONS The increased use of BZZ with approaching death is consistent with increasing symptomatic treatment in terminal illness. Thus, the association of BZZ and mortality is more likely to be due to confounding than to causality. Further evidence from this and other research includes similar use patterns for other drugs such as opioids, the lack of specificity in cause of death and the size of the association regarding age and time to death.
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Affiliation(s)
- C Ineke Neutel
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, 451 Smyth Road (Room 3105) Roger-Guindon Building, Ottawa, K1H 8M5, Ontario, Canada,
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Vivas-Consuelo D, Usó-Talamantes R, Trillo-Mata JL, Mendez-Valera P. Methods to control the pharmaceutical cost impact of chronic conditions in the elderly. Expert Rev Pharmacoecon Outcomes Res 2015; 15:425-37. [DOI: 10.1586/14737167.2015.1017564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- David Vivas-Consuelo
- 1Research Centre for Health Economics and Management, Universitat Politècnica de València, Edificio7J, Campus de Vera s/n 46022-Valencia, Spain
| | - Ruth Usó-Talamantes
- 2Valencian Health Department (Conselleria de Sanitat), General Directorate of Pharmacy and Pharmaceutical Products, Valencia, Spain
| | - José Luis Trillo-Mata
- 2Valencian Health Department (Conselleria de Sanitat), General Directorate of Pharmacy and Pharmaceutical Products, Valencia, Spain
| | - Pablo Mendez-Valera
- 2Valencian Health Department (Conselleria de Sanitat), General Directorate of Pharmacy and Pharmaceutical Products, Valencia, Spain
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Heider D, Matschinger H, Müller H, Saum KU, Quinzler R, Haefeli WE, Wild B, Lehnert T, Brenner H, König HH. Health care costs in the elderly in Germany: an analysis applying Andersen's behavioral model of health care utilization. BMC Health Serv Res 2014; 14:71. [PMID: 24524754 PMCID: PMC3927831 DOI: 10.1186/1472-6963-14-71] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 02/12/2014] [Indexed: 11/24/2022] Open
Abstract
Background To analyze the association of health care costs with predisposing, enabling, and need factors, as defined by Andersen’s behavioral model of health care utilization, in the German elderly population. Methods Using a cross-sectional design, cost data of 3,124 participants aged 57–84 years in the 8-year-follow-up of the ESTHER cohort study were analyzed. Health care utilization in a 3-month period was assessed retrospectively through an interview conducted by trained study physicians at respondents’ homes. Unit costs were applied to calculate health care costs from the societal perspective. Socio-demographic and health-related variables were categorized as predisposing, enabling, or need factors as defined by the Andersen model. Multimorbidity was measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Mental health status was measured by the SF-12 mental component summary (MCS) score. Sector-specific costs were analyzed by means of multiple Tobit regression models. Results Mean total costs per respondent were 889 € for the 3-month period. The CIRS-G score and the SF-12 MCS score representing the need factor in the Andersen model were consistently associated with total, inpatient, outpatient and nursing costs. Among the predisposing factors, age was positively associated with outpatient costs, nursing costs, and total costs, and the BMI was associated with outpatient costs. Conclusions Multimorbidity and mental health status, both reflecting the need factor in the Andersen model, were the dominant predictors of health care costs. Predisposing and enabling factors had comparatively little impact on health care costs, possibly due to the characteristics of the German social health insurance system. Overall, the variables used in the Andersen model explained only little of the total variance in health care costs.
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Affiliation(s)
- Dirk Heider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg, 20246, Germany.
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Bock JO, Matschinger H, Brenner H, Wild B, Haefeli WE, Quinzler R, Saum KU, Heider D, König HH. Inequalities in out-of-pocket payments for health care services among elderly Germans--results of a population-based cross-sectional study. Int J Equity Health 2014; 13:3. [PMID: 24397544 PMCID: PMC3893415 DOI: 10.1186/1475-9276-13-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 12/23/2013] [Indexed: 11/25/2022] Open
Abstract
Introduction In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed. Methods This cross-sectional analysis used data of N = 3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family. Results Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one. Conclusions This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.
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Affiliation(s)
- Jens-Oliver Bock
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany.
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Socioeconomic variation in the financial consequences of ill health for older people with chronic diseases: A systematic review. Maturitas 2013; 74:313-33. [DOI: 10.1016/j.maturitas.2013.01.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 01/21/2013] [Indexed: 11/21/2022]
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Lehnert T, König HH. [Effects of multimorbidity on health care utilization and costs]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55:685-92. [PMID: 22526857 DOI: 10.1007/s00103-012-1475-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Multiple chronic conditions (multimorbidity) are common among elderly patients; however, little is known about the specific effects of multimorbidity on health care utilization and health care costs. This article reviews empirical studies from the international literature that investigated the relationship between multiple chronic conditions and health care utilization (e.g. ambulatory care, stationary care, pharmacotherapy) and/or health care costs in elderly general populations. Although synthesis of studies was complicated, especially because of ambiguous definitions and measurements of multimorbidity, almost all studies observed a positive association of multimorbidity and utilization and costs. Many studies found that utilization and costs significantly increased with each additional chronic condition. In light of these findings coupled with the fear that current care arrangements may be inappropriate for many multimorbid patients, important implications for research and policy are presented and discussed.
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Affiliation(s)
- T Lehnert
- Institut für Medizinische Soziologie, Sozialmedizin und Gesundheitsökonomie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Lehnert T, Heider D, Leicht H, Heinrich S, Corrieri S, Luppa M, Riedel-Heller S, König HH. Review: Health Care Utilization and Costs of Elderly Persons With Multiple Chronic Conditions. Med Care Res Rev 2011; 68:387-420. [PMID: 21813576 DOI: 10.1177/1077558711399580] [Citation(s) in RCA: 486] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This systematic literature review identified and summarized 35 studies that investigated the relationship between multiple chronic conditions (MCCs) and health care utilization outcomes (i.e. physician use, hospital use, medication use) and health care cost outcomes (medication costs, out-of-pocket costs, total health care costs) for elderly general populations. Although synthesis of studies was complicated because of ambiguous definitions and measurements of MCCs, and because of the multitude of outcomes investigated, almost all studies observed a positive association of MCCs and use/costs, many of which found that use/costs significantly increased with each additional condition. Several studies indicate a curvilinear, near exponential relationship between MCCs and costs. The rising prevalence, substantial costs, and the fear that current care arrangements may be inappropriate for many patients with MCCs, bring about a multitude of implications for research and policy, of which the most important are presented and discussed.
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Affiliation(s)
- Thomas Lehnert
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Hanna Leicht
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Heinrich
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Medikamentöse Behandlung von Mukoviszidose – Kostenstruktur und Einsparpotenzial der ambulanten Behandlung. ACTA ACUST UNITED AC 2011; 105:887-900. [DOI: 10.1007/s00063-010-1154-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 08/27/2010] [Indexed: 10/18/2022]
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Corrieri S, Heider D, Matschinger H, Lehnert T, Raum E, König HH. Income-, education- and gender-related inequalities in out-of-pocket health-care payments for 65+ patients - a systematic review. Int J Equity Health 2010; 9:20. [PMID: 20701794 PMCID: PMC2925341 DOI: 10.1186/1475-9276-9-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 08/11/2010] [Indexed: 11/18/2022] Open
Abstract
Background In all OECD countries, there is a trend to increasing patients' copayments in order to balance rising overall health-care costs. This systematic review focuses on inequalities concerning the amount of out-of-pocket payments (OOPP) associated with income, education or gender in the Elderly aged 65+. Methods Based on an online search (PubMed), 29 studies providing information on OOPP of 65+ beneficiaries in relation to income, education and gender were reviewed. Results Low-income individuals pay the highest OOPP in relation to their earnings. Prescription drugs account for the biggest share. A lower educational level is associated with higher OOPP for prescription drugs and a higher probability of insufficient insurance protection. Generally, women face higher OOPP due to their lower income and lower labour participation rate, as well as less employer-sponsored health-care. Conclusions While most studies found educational and gender inequalities to be associated with income, there might also be effects induced solely by education; for example, an unhealthy lifestyle leading to higher payments for lower-educated people, or exclusively gender-induced effects, like sex-specific illnesses. Based on the considered studies, an explanation for inequalities in OOPP by these factors remains ambiguous.
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Affiliation(s)
- Sandro Corrieri
- University of Leipzig, Health Economics Research Unit, Department of Psychiatry, Liebigstr, 26, 04103 Leipzig, Germany.
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Shaffer T, Simoni-Wastila L, Toler W, Stuart B, Doshi JA. Changing Patterns in Medication Use with Increasing Probability of Death for Older Medicare Beneficiaries. J Am Geriatr Soc 2010; 58:1549-55. [DOI: 10.1111/j.1532-5415.2010.02957.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using patient-level data: a critical review of the literature. Stroke 2008; 40:e18-23. [PMID: 19109540 DOI: 10.1161/strokeaha.108.529776] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria. METHODS A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups. RESULTS A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs. CONCLUSIONS This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.
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Affiliation(s)
- Ramon Luengo-Fernandez
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, USA.
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Fahlman C, Lynn J, Finch M, Doberman D, Gabel J. Potentially Inappropriate Medication Use by Medicaid+Choice Beneficiaries in the Last Year of Life. J Palliat Med 2007; 10:686-95. [PMID: 17592980 DOI: 10.1089/jpm.2006.0215] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Regardless of the payer and the period studied the prevalence of potentially inappropriate medication use in the elderly ranged from 21% to 40%. OBJECTIVE To look at potentially inappropriate prescribing in a group of Medicare+Choice beneficiaries in their last year of life (LYOL) in a large national managed care organization. RESEARCH DESIGN Retrospective review of Medicare+Choice decedents' drug claims and enrollment data collected between January 1998 and December 2000, supplemented by the Medicare denominator file and 1990 Census data. SUBJECTS Four thousand six hundred two beneficiaries in a large national managed care organization. MEASURES We analyzed the relationship between disagreement with the Beers' criteria and sociodemographic descriptors, insurance characteristics, and cause of death. We used logistic regression techniques to estimate factors associated with the disagreement. RESULTS Two thousand thirty-one beneficiaries (44%) had at least one claim in the LYOL that disagreed with a Beers' criterion, 15% experienced more than one unique Beers' disagreement. The most common disagreements were for the use of propoxyphene (15.0%), followed by zolpidem (3.8%), and amitriptyline (2.8%). Based on total claims, cancer patients were most likely to receive propoxyphene (35.3%) followed by patients with a heart condition (29.6%). A large proportion of the potentially inappropriate prescribing involves psychoactive drugs. The logistic model showed fewer Beers' criteria breaches associated with being male and being non-white. Beers' breaches were more common if the beneficiary has increasing prescription use or died from cancer. CONCLUSION This study showed that many beneficiaries have prescriptions that contravene the Beers' criteria.
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Affiliation(s)
- Cheryl Fahlman
- Mathematica Policy Research, Inc., Washington, DC 20024, USA.
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