Comparison of approaches for estimating prevalence costs of care for cancer patients: what is the impact of data source?

Kidney Stone Prevalence Based on Self-Report and Electronic Health Records: Insight into the Prevalence of Active Medical Care for Kidney Stones

OBJECTIVE

To compare rates of patient-reported kidney stone disease to Electronic Health Records (EHR) kidney stone diagnosis using a common dataset to evaluate for socio-demographic differences, including between those with and without active care.

METHODS

From the All of Us research database, we identified 21,687 adult participants with both patient-reported and EHR data. We compared differences in age, sex, race, education, employment status and healthcare access between patients with self-reported kidney stone history without EHR data to those with EHR-based diagnoses.

RESULTS

In this population, the self-reported prevalence of kidney stones was 8.6% overall (n = 1877), including 4.6% (n = 1004) who had self-reported diagnoses but no EHR data. Among those with self-reported kidney stone diagnoses only, the median age was 66. The EHR-based prevalence of kidney stones was 5.7% (n = 1231), median age 67. No differences were observed in age, sex, education, employment status, rural/urban status, or ability to afford healthcare between groups with EHR diagnosis or self-reported diagnosis only. Of patients who had a self-reported history of kidney stones, 24% reported actively seeing a provider for kidney stones.

CONCLUSION

Kidney stone prevalence by self-report is higher than EHR-based prevalence in this national dataset. Using either method alone to estimate kidney stone prevalence may exclude some patients with the condition, although the demographic profile of both groups is similar. Approximately 1 in 4 patients report actively seeing a provider for stone disease.

Additional medical costs of chronic conditions among adolescent and young adult cancer survivors

PURPOSE

Adolescent and young adult (AYA) cancer survivors are more likely to have multiple chronic conditions compared to AYAs without history of cancer. The financial hardship of chronic conditions associated with cancer can substantially impact cancer survivors. We aim to assess health risk behaviors and health care access factors associated with increased medical expenses in AYA cancer survivors.

METHODS

We utilized 2011-2016 Medical Expenditure Panel Survey (MEPS) data to identify the prevalence of chronic conditions, health risk behaviors, and health care access in 2326 AYA cancer survivors. The association between health risk behaviors, health care access factors, and chronic conditions with medical expenditures was assessed using multivariable regression with gamma distribution and log link. Analyses were adjusted for age, sex, race/ethnicity, education, and marital status. Expenses were adjusted for inflation to 2016 dollars.

RESULTS

Most AYA cancer survivors had ≥1 chronic condition (74%) and were diagnosed with cancer ≥10 years prior to the survey (76%). AYA cancer survivors with chronic conditions spent an additional $2777 (95% CI, $480 to $5958) annually compared to survivors with no chronic conditions. Additional annual expenses also were associated with physical inactivity ($3558; 95% CI, $2200 to $4606) and being unable to get care when needed ($1291; 95% CI, $198 to 3335).

CONCLUSIONS

Chronic conditions are associated with a substantial increase in medical expenses well after cancer diagnosis in AYA cancer survivors.

IMPLICATION FOR CANCER SURVIVORS

Getting care when needed and adopting healthy behaviors, particularly exercise, may reduce medical expenses associated with chronic conditions in AYAs.

Cost-of-illness studies in rare diseases: a scoping review

OBJECTIVE

The aim of this scoping review was to overview the cost-of-illness studies conducted in rare diseases.

METHODS

We searched papers published in English in PubMed from January 2007 to December 2018. We selected cost-of-illness studies on rare diseases defined as those with prevalence lower than 5 per 10,000 cases. Studies were selected by one researcher and verified by a second researcher. Methodological characteristics were extracted to develop a narrative synthesis.

RESULTS

We included 63 cost-of-illness studies on 42 rare diseases conducted in 25 countries, and 9 systematic reviews. Most studies (94%) adopted a prevalence-based estimation, where the predominant design was cross-sectional with a bottom-up approach. Only four studies adopted an incidence-based estimation. Most studies used questionnaires to patients or caregivers to collect resource utilisation data (67%) although an important number of studies used databases or registries as a source of data (48%). Costs of lost productivity, non-medical costs and informal care costs were included in 68%, 60% and 43% of studies, respectively.

CONCLUSION

This review found a paucity of cost-of-illness studies in rare diseases. However, the analysis shows that the cost-of-illness studies of rare diseases are feasible, although the main issue is the lack of primary and/or aggregated data that often prevents a reliable estimation of the economic burden.

Cost-of-illness studies in rare diseases: a scoping review

OBJECTIVE

The aim of this scoping review was to overview the cost-of-illness studies conducted in rare diseases.

METHODS

We searched papers published in English in PubMed from January 2007 to December 2018. We selected cost-of-illness studies on rare diseases defined as those with prevalence lower than 5 per 10,000 cases. Studies were selected by one researcher and verified by a second researcher. Methodological characteristics were extracted to develop a narrative synthesis.

RESULTS

We included 63 cost-of-illness studies on 42 rare diseases conducted in 25 countries, and 9 systematic reviews. Most studies (94%) adopted a prevalence-based estimation, where the predominant design was cross-sectional with a bottom-up approach. Only four studies adopted an incidence-based estimation. Most studies used questionnaires to patients or caregivers to collect resource utilisation data (67%) although an important number of studies used databases or registries as a source of data (48%). Costs of lost productivity, non-medical costs and informal care costs were included in 68%, 60% and 43% of studies, respectively.

CONCLUSION

This review found a paucity of cost-of-illness studies in rare diseases. However, the analysis shows that the cost-of-illness studies of rare diseases are feasible, although the main issue is the lack of primary and/or aggregated data that often prevents a reliable estimation of the economic burden.

Elderly Black Non-Hispanic Patients With Head and Neck Squamous Cell Cancer Have the Worst Survival Outcomes

BACKGROUND

In this population study, we compared head and neck cancer (HNC) prognosis and risk factors in 2 underserved minority groups (Hispanic and Black non-Hispanic patients) with those in other racial/ethnicity groups.

METHODS

In this SEER-Medicare database study in patients with HNC diagnosed in 2006 through 2015, we evaluated cancer-specific survival (CSS) between different racial/ethnic cohorts as the main outcome. Patient demographics, tumor factors, socioeconomic status, and treatments were analyzed in relation to the primary outcomes between racial/ethnic groups.

RESULTS

Black non-Hispanic patients had significantly worse CSS than all other racial/ethnic groups, including Hispanic patients, in unadjusted univariate analysis (Black non-Hispanic patients: hazard ratio, 1.48; 95% CI, 1.33-1.65; Hispanic patients: hazard ratio, 1.12; 95% CI, 0.99-1.28). To investigate the association of several variables with CSS, data were stratified for multivariate analysis using forward Cox regression. This identified socioeconomic status, cancer stage, and receipt of treatment as predictive factors for the survival differences. Black non-Hispanic patients were most likely to present at a later stage (odds ratio, 1.62; 95% CI, 1.38-1.90) and to receive less treatment (odds ratio, 0.67; 95% CI, 0.55-0.81). Unmarried status, high poverty areas, increased emergency department visits, and receipt of healthcare at non-NCI/nonteaching hospitals also significantly impacted stage and treatment.

CONCLUSIONS

Black non-Hispanic patients have a worse HNC prognosis than patients in all other racial/ethnic groups, including Hispanic patients. Modifiable risk factors include access to nonemergent care and prevention measures, such as tobacco cessation; presence of social support; communication barriers; and access to tertiary centers for appropriate treatment of their cancers.

The Economic Impacts of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in an Australian Cohort

Objectives: This study aims to estimate direct and indirect health economic costs associated with government and out-of-pocket (OOP) expenditure based on health care service utilization and lost income of participants and carers, as reported by Australian Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patient survey participants. Design: A cost of illness study was conducted to estimate Australian cost data for individuals with a ME/CFS diagnosis as determined by the Canadian Consensus Criteria (CCC), International Consensus Criteria (ICC), and the 1994 CDC Criteria (Fukuda). Setting and participants: Survey participants identified from a research registry database provided self-report of expenditure associated with ME/CFS related healthcare across a 1-month timeframe between 2017 and 2019. Main outcome measures: ME/CFS related direct annual government health care costs, OOP health expenditure costs, indirect costs associated with lost income and health care service use patterns. Results: The mean annual cost of health care related expenditure and associated income loss among survey participants meeting diagnostic criteria for ME/CFS was estimated at $14.5 billion. For direct OOP and Government health care expenditure, high average costs were related to medical practitioner attendance, diagnostics, natural medicines, and device expenditure, with an average attendance of 10.6 referred attendances per annum and 12.1 GP visits per annum related specifically to managing ME/CFS. Conclusions: The economic impacts of ME/CFS in Australia are significant. Improved understanding of the illness pathology, diagnosis, and management, may reduce costs, improve patient prognosis and decrease the burden of ME/CFS in Australia.

Psychotropic polypharmacy and its association with health-related quality of life among cancer survivors in the USA: a population-level analysis

PURPOSE

Cancer survivors that use multiple psychotropic medications are at an increased risk of psychotropic polypharmacy. We examined the association between psychotropic polypharmacy and health-related quality of life (HRQoL) among cancer survivors living in the USA.

METHODS

We used the Medical Expenditure Panel Survey (MEPS) data for 2010, 2012, and 2014 to identify adult cancer survivors. Psychotropic polypharmacy was defined as use of at least two classes of psychotropic prescription medications. The physical component summary (PCS) and the mental component summary (MCS) were obtained from the 12-item Short Form Health Survey version 2 to measure HRQoL. Adjusted ordinary least square regressions were performed to evaluate the association between psychotropic polypharmacy and HRQoL.

RESULTS

Among 31 million US cancer survivors (weighted from a sample of 2609), 16.3% reported psychotropic polypharmacy. Lung cancer survivors had the highest prevalence of psychotropic polypharmacy (22.5%), followed by survivors of breast cancer (17.8%), colorectal, and other gastrointestinal cancers (16.0%). The unadjusted PCS and MCS scores for those with psychotropic polypharmacy were significantly lower than those without psychotropic polypharmacy, overall, and for each cancer type. In multivariable regressions, cancer survivors with psychotropic polypharmacy had significantly lower PCS scores (β =  - 3.63, p < 0.0001) and MCS scores (β =  - 2.28, p = 0.0138) compared to those without psychotropic polypharmacy.

CONCLUSION

Cancer survivors requiring multiple psychotropic medications have poorer quality of life.

Economic and Humanistic Burden of Cervical Cancer in the United States: Results from a Nationally Representative Survey

Objective: To measure the economic and humanistic burden of cervical cancer in the United States.

Materials and Methods: This was a retrospective analysis of Medical Expenditure Panel Survey data (2006–2015). Cervical cancer cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification code “180” or clinical classification software code “26”. The control group included women without any cancer diagnosis. Study outcomes included health care resource use (institutional inpatient and outpatient, emergency room, and physician office visits), costs, limitations in activities of daily living, and quality of life (general health status, 12-Item Short Form Health Survey [SF-12] physical and mental component summary [MCS], EuroQol-5D and Short-Form Six-Dimension health utility, and Patient Health Questionnaire-2 depression severity). Generalized linear models, controlling for sociodemographic and clinical covariates, were conducted to compare outcomes between cases and controls.

Results: The analytic cohort included 275,246 cervical cancer cases and 146,061,609 noncancer controls. Cases were significantly older (mean age [years]: 42.03 vs. 36.98) and had a higher Charlson comorbidity burden (mean score: 1.06 vs. 0.46) versus controls. Multivariate analyses suggested that compared to controls, cancer cases had significantly higher costs: institutional outpatient ($1,610 vs. $502), physician visit ($2,422 vs. $1,321), and total health care ($10,031 vs. $4,913). Cases were 1.99 (odds ratio [OR]: 1.991; 95% confidence interval [CI]: 1.23–3.22) and 2.56 (OR: 2.562; 95% CI: 1.78–3.68) times as likely to report activity limitations and poor general health versus controls. Cervical cancer patients had significantly lower SF-12 physical and MCS score, health utility, and higher depression severity.

Conclusions: Cervical cancer is associated with significant economic burden, activity limitations, and quality of life impairment among ambulatory women in the United States.

Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients

Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients' sociodemographic factors, clinical factors, and beliefs; physicians' beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003-05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total population than lower-spending areas did. Availability of services and physicians' beliefs, but not patients' beliefs, were important in explaining geographic variations in end-of-life spending. Enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care.

Provider Costs of Treating Colorectal Cancer in Government Hospital of Malaysia

Background

The incidence of colorectal cancer (CRC) is rapidly rising in several Asian countries, including Malaysia, but there is little data on health care provider costs in this region. The aim of this study was to estimate the cost of CRC management from the perspective of the health care provider, based on standard operating procedures.

Methods

A combination of top-down approach and activity-based costing was applied. The standard operating procedure (SOP) for CRC was developed for each stage according to national data and guidelines at the University of Malaya Medical Centre (UMMC). The unit cost was calculated and incorporated into the treatment pathway in order to obtain the total cost of managing a single CRC patient according to the stage of illness. The cost data were represented by means and standard deviation and the results were demonstrated by tabulation. All cost data are presented in Malaysian Ringgit (RM). The cost difference between early stage (Stage I) and late stage (Stage II–IV) was analysed using independent t-test.

Results

The cost per patient increased with stage of CRC, from RM13,672 (USD4,410.30) for stage I, to RM27,972 (USD9,023.20) for Stage IV. The early stage had statistically significant lower cost compared to late stage t(2) = −4.729, P = 0.042. The highest fraction of the cost was related to surgery for Stage I, but was superseded by oncology day care treatment for Stages II–IV. CRC is a costly illness. From a provider perspective, the highest cost was found in Stages III and IV. The early stages conserved more resources than did the advanced stages of cancer.

Conclusion

Early diagnosis and management of CRC, therefore, not only affects oncologic prognosis, but has implications for health care costs. This adds further justification to develop and implement CRC screening programmes in Malaysia.

Assessing the Financial Burden Associated With Treatment Options for Resectable Pancreatic Cancer

OBJECTIVE

The aim of this study is to assess the financial burden associated with treatment options for resectable pancreatic cancer.

BACKGROUND

As the volume of cancer care increases in the United States, there is growing interest among both clinicians and policy-makers to reduce its financial impact on the healthcare system. However, costs relative to the survival benefit for differing treatment modalities used in practice have not been described.

METHODS

Patients undergoing resection for pancreatic cancer were identified in the Truven Health MarketScan database. Associations between chemoradiation therapies and survival were performed using parameterized multivariable accelerated failure time models. Median payments over time were calculated for surgery, chemoradiation, and subsequent hospitalizations.

RESULTS

A total of 2408 patients were included. Median survival among all patients was 21.1 months [95% confidence interval (CI): 19.8-22.5 months], whereas median follow-up time was 25.1 months (95% CI: 23.5-26.5 months). After controlling for comorbidity, receipt of neoadjuvant therapy, and nodal involvement, a longer survival was associated with undergoing combination gemcitabine and nab-paclitaxel [time ratio (TR) = 1.26, 95% CI: 1.02-1.57, P = 0.035) or capecitabine and radiation (TR = 1.25, 95% CI: 1.04-1.51, P = 0.018). However, median cumulative payments for gemcitabine with nab-paclitaxel were highest overall [median $74,051, interquartile range (IQR): $38,929-$133,603).

CONCLUSIONS

Total payments for an episode of care relative to improvement in survival vary significantly by treatment modality. These data can be used to inform management decisions about pursuing further care for pancreatic cancer. Future investigations should seek to refine estimates of the cost-effectiveness of different treatments.

Health care use during cancer survivorship: Review of 5 years of evidence

Improvements in treatment strategies have resulted in increasing survival rates among patients diagnosed with cancer but also result in a growing population of individuals who have greater health care needs. These needs will persist from diagnosis throughout the continuing phase of care, or the survivorship phase. To better define models of survivorship care, there must be a strong evidence base in survivor health care use patterns. The objective of this review, which covers studies from 2012 to January 2018, was to evaluate the available evidence on patterns of health care visits among survivors of adult cancers and to understand what is known about the rate of health care visits, the physician specialties associated with these visits, and/or the types health care settings (eg, outpatient, emergency room). The findings underscore the importance of primary care, with the majority of studies reporting that >90% of survivors visited a primary care provider in the prior year. Visits to oncologists and/or other physician specialties were positively associated with receiving cancer screenings and obtaining quality care for noncancer-related conditions. High care density/low care fragmentation between physician specialties had lower costs and a lower likelihood of redundant health care utilization. The follow-up in almost all studies was 3 years, providing short-term evidence; however, as the survivorship period lengthens with improved treatments, longer follow-up will be required. The long-term patterns with which survivors of cancer engage the health care system are critical to designing long-term follow-up care plans that are effective in addressing the complex morbidity that survivors experience.

National cost study versus hospital cost accounting for organ recovery cost assessment in a French hospital group

Background

Methods

Results

Conclusions

Death or Debt? National Estimates of Financial Toxicity in Persons with Newly-Diagnosed Cancer

PURPOSE

The purpose of this study was to evaluate the impact of cancer upon a patient's net worth and debt in the US.

METHODS

This longitudinal study used the Health and Retirement Study from 1998-2014. Persons ≥50years with newly-diagnosed malignancies were included, excluding minor skin cancers. Multivariable generalized linear models assessed changes in net worth and debt (consumer, mortgage, home equity) at 2 and 4 years after diagnosis (year₊₂, year₊₄), controlling for demographic and clinically-related variables, cancer-specific attributes, economic factors, and mortality. A 2-year period before cancer diagnosis served as a historical control.

RESULTS

Across 9.5 million estimated new diagnoses of cancer from 2000-2012, individuals averaged 68.6±9.4 years with slight majorities being married (54.7%), not retired (51.1%), and Medicare beneficiaries (56.6%). At year₊₂, 42.4% depleted their entire life's assets, with higher adjusted odds associated with worsening cancer, requirement of continued treatment, demographic and socioeconomic factors (ie, female, Medicaid, uninsured, retired, increasing age, income, and household size), and clinical characteristics (ie, current smoker, worse self-reported health, hypertension, diabetes, lung disease) (P<.05); average losses were $92,098. At year₊₄, financial insolvency extended to 38.2%, with several consistent socioeconomic, cancer-related, and clinical characteristics remaining significant predictors of complete asset depletion.

CONCLUSIONS

This nationally-representative investigation of an initially-estimated 9.5 million newly-diagnosed persons with cancer who were ≥50 years of age found a substantial proportion incurring financial toxicity. As large financial burdens have been found to adversely affect access to care and outcomes among cancer patients, the active development of approaches to mitigate these effects among already vulnerable groups remains of key importance.

Health services costs for cancer care in Australia: Estimates from the 45 and Up Study

Background

Cancer care represents a substantial and rapidly rising healthcare cost in Australia. Our aim was to provide accurate population-based estimates of the health services cost of cancer care using large-scale linked patient-level data.

Methods

We analysed data for incident cancers diagnosed 2006–2010 and followed to 2014 among 266,793 eligible participants in the 45 and Up Study. Health system costs included Medicare and pharmaceutical claims, inpatient hospital episodes and emergency department presentations. Costs for cancer cases and matched cancer-free controls were compared, to estimate monthly/annual excess costs of cancer care by cancer type, before and after diagnosis and by phase of care (initial, continuing, terminal). Total costs incurred in 2013 were also estimated for all people diagnosed in Australia 2009–2013.

Results

7624 participants diagnosed with cancer were matched with up to three controls. The mean excess cost of care per case was AUD$1,622 for the year before diagnosis, $33,944 for the first year post-diagnosis and $8,796 for the second year post-diagnosis, with considerable variation by cancer type. Mean annual cost after the initial treatment phase was $4,474/case and the mean cost for the last year of life was $49,733/case. In 2013 the cost for cancers among people in Australia diagnosed during 2009–2013 was ~$6.3billion (0.4% of Gross Domestic Product; $272 per capita), with the largest costs for colorectal cancer ($1.1billion), breast cancer ($0.8billion), lung cancer ($0.6billion) and prostate cancer ($0.5billion).

Conclusions

The cost of cancer care is substantial and varies by cancer type and time since diagnosis. These findings emphasise the economic importance of effective primary and secondary cancer prevention strategies.

Economic Burden of Chronic Conditions Among Survivors of Cancer in the United States

Purpose The prevalence of cancer survivorship and chronic health conditions is increasing. Limited information exists on the economic burden of chronic conditions among survivors of cancer. This study examines the prevalence and economic effect of chronic conditions among survivors of cancer. Methods Using the 2008 to 2013 Medical Expenditure Panel Survey, we present nationally representative estimates of the prevalence of chronic conditions (heart disease, high blood pressure, stroke, emphysema, high cholesterol, diabetes, arthritis, and asthma) and multiple chronic conditions (MCCs) and the incremental annual health care use, medical expenditures, and lost productivity for survivors of cancer attributed to individual chronic conditions and MCCs. Incremental use, expenditures, and lost productivity were evaluated with multivariable regression. Results Survivors of cancer were more likely to have chronic conditions and MCCs compared with adults without a history of cancer. The presence of chronic conditions among survivors of cancer was associated with substantially higher annual medical expenditures, especially for heart disease ($4,595; 95% CI, $3,262 to $5,927) and stroke ($3,843; 95% CI, $1,983 to $5,704). The presence of four or more chronic conditions was associated with increased annual expenditures of $10,280 (95% CI, $7,435 to $13,125) per survivor of cancer. Annual lost productivity was higher among survivors of cancer with other chronic conditions, especially stroke ($4,325; 95% CI, $2,687 to $5,964), and arthritis ($3,534; 95% CI, $2,475 to $4,593). Having four or more chronic conditions was associated with increased annual lost productivity of $9,099 (95% CI, $7,224 to $10,973) per survivor of cancer. The economic impact of chronic conditions was similar among survivors of cancer and individuals without a history of cancer. Conclusion These results highlight the importance of ensuring access to lifelong personalized screening, surveillance, and chronic disease management to help manage chronic conditions, reduce disruptions in employment, and reduce medical expenditures among survivors of cancer.

Antineoplastic Treatment of Advanced-Stage Non-Small-Cell Lung Cancer: Treatment, Survival, and Spending (2000 to 2011)

Purpose Multiple agents for advanced non-small-cell lung cancer (NSCLC) have been approved in the past decade, but little is known about their use and associated spending and survival. Methods We used SEER-Medicare data for elderly patients with a new diagnosis of advanced-stage NSCLC and were treated with antineoplastic agents between 2000 and 2011 (N = 22,163). We estimated the adjusted percentage of patients who received each agent, days while on treatment, survival, and spending in the 12 months after diagnosis. Results During the 12-year study period, a marked shift in treatment occurred along with a rapid adoption of pemetrexed (39.2%), erlotinib (20.3%), and bevacizumab (18.9%) and a decline in paclitaxel (38.7%), gemcitabine (17.0%), and vinorelbine (5.7%; all P < .05). The average total days on therapy increased by 5 days (from 103 to 108 days). Patients who received bevacizumab, erlotinib, or pemetrexed had the longest treatment durations on average (approximately 146 days v 75 days for those who did not receive these agents). Approximately 44% of patients received antineoplastic agents in the last 30 days of life throughout the study period. Acute inpatient spending declined (from $29,376 to $23,731), whereas outpatient spending increased 23% (from $37,931 to $46,642). Median survival gains of 1.5 months were observed. Conclusion Considerable shifts in the treatment of advanced-stage NSCLC occurred along with modest gains in survival and total Medicare spending. More precise outcome information is needed to inform value-based treatment decisions for advanced-stage NSCLC.

The impact of chronic conditions on the economic burden of cancer survivorship: a systematic review

INTRODUCTION

This systematic review examines the excess cost of chronic conditions on the economic burden of cancer survivorship among adults in the US. Areas covered: Twelve published studies were identified. Although studies varied substantially in populations, comorbidities examined, methods, and types of cost reported, costs for cancer survivors with comorbidities generally increased with greater numbers of comorbidities or an increase in comorbidity index score. Survivors with comorbidities incurred significantly more in total medical costs, out-of-pocket costs, and costs by service type compared to cancer survivors without additional comorbidities. Expert commentary: Cancer survivors with comorbidities bear significant excess out-of-pocket costs and their care is also more expensive to the healthcare system. On-going evaluation of different payment models, care coordination, and disease management programs for cancer survivors with comorbidities will be important in monitoring impact on healthcare costs.

Productivity Costs Associated With Breast Cancer Among Survivors Aged 18-44 Years

INTRODUCTION

No study has quantified productivity losses associated with breast cancer in younger women aged 18-44 years. This study estimated productivity costs, including work and home productivity losses, among younger women who reported ever receiving a breast cancer diagnosis.

METHODS

A two-part regression model and 2000-2010 National Health Interview Survey data were used to estimate the number of work and home productivity days missed because of breast cancer, adjusted for socioeconomic characteristics and comorbidities. Estimates for younger women were compared with those for women aged 45-64 years. Data were analyzed in 2013-2014.

RESULTS

Per capita, younger women with breast cancer had annual losses of $2,293 (95% CI=$1,069, $3,518) from missed work and $442 (95% CI=$161, $723) from missed home productivity. Total annual breast cancer-associated productivity costs for younger women were $344 million (95% CI=$154 million, $535 million). Older women with breast cancer had lower per capita work loss productivity costs of $1,407 (95% CI=$899, $1,915) but higher total work loss productivity costs estimated at $1,072 million (95% CI=$685 million, $1,460 million) than younger women.

CONCLUSIONS

Younger women with a history of breast cancer face a disproportionate share of work and home productivity losses. Although older women have lower per capita costs, total productivity costs were higher for older women because the number of older women with breast cancer is higher. The results underscore the importance of continued efforts by the public health community to promote and support the unique needs of younger breast cancer survivors.

Medical Care Costs of Breast Cancer in Privately Insured Women Aged 18-44 Years

INTRODUCTION

Breast cancer in women aged 18-44 years accounts for approximately 27,000 newly diagnosed cases and 3,000 deaths annually. When tumors are diagnosed, they are usually aggressive, resulting in expensive treatment costs. The purpose of this study is to estimate the prevalent medical costs attributable to breast cancer treatment among privately insured younger women.

METHODS

Data from the 2006 MarketScan database representing claims for privately insured younger women were used. Costs for younger breast cancer patients were compared with a matched sample of younger women without breast cancer, overall and for an active treatment subsample. Analyses were conducted in 2013 with medical care costs expressed in 2012 U.S. dollars.

RESULTS

Younger women with breast cancer incurred an estimated $19,435 (SE=$415) in additional direct medical care costs per person per year compared with younger women without breast cancer. Outpatient expenditures comprised 94% of the total estimated costs ($18,344 [SE=$396]). Inpatient costs were $43 (SE=$10) higher and prescription drug costs were $1,048 (SE=$64) higher for younger women with breast cancer than in younger women without breast cancer. For women in active treatment, the burden was more than twice as high ($52,542 [SE=$977]).

CONCLUSIONS

These estimates suggest that breast cancer is a costly illness to treat among younger, privately insured women. This underscores the potential financial vulnerability of women in this age group and the importance of health insurance during this time in life.

Treatment Costs of Breast Cancer Among Younger Women Aged 19-44 Years Enrolled in Medicaid

INTRODUCTION

A few studies have examined the costs of breast cancer treatment in a Medicaid population at the state level. However, no study has estimated medical costs for breast cancer treatment at the national level for women aged 19-44 years enrolled in Medicaid.

METHODS

A sample of 5,542 younger women aged 19-44 years enrolled in fee-for-service Medicaid with diagnosis codes for breast cancer in 2007 were compared with 4.3 million women aged 19-44 years enrolled in fee-for-service Medicaid without breast cancer. Nonlinear regression methods estimated prevalent treatment costs for younger women with breast cancer compared with those without breast cancer. Individual medical costs were estimated by race/ethnicity and by type of services. Analyses were conducted in 2013 and all medical treatment costs were adjusted to 2012 U.S. dollars.

RESULTS

The estimated monthly direct medical costs for breast cancer treatment among younger women enrolled in Medicaid was $5,711 (95% CI=$5,039, $6,383) per woman. The estimated monthly cost for outpatient services was $4,058 (95% CI=$3,575, $4,541), for inpatient services was $1,003 (95% CI=$708, $1,298), and for prescription drugs was $539 (95% CI=$431, $647). By race/ethnicity, non-Hispanic white women had the highest monthly total medical costs, followed by Hispanic women and non-Hispanic women of other race.

CONCLUSIONS

Cost estimates demonstrate the substantial medical costs associated with breast cancer treatment for younger Medicaid beneficiaries. As the Medicaid program continues to evolve, the treatment cost estimates could serve as important inputs in decision making regarding planning for treatment of invasive breast cancer in this population.

Dartmouth Atlas Area-Level Estimates of End-of-Life Expenditures: How Well Do They Reflect Expenditures for Prospectively Identified Advanced Lung Cancer Patients?

OBJECTIVE

Assess validity of the retrospective Dartmouth hospital referral region (HRR) end-of-life spending measures by comparing with health care expenditures from diagnosis to death for prospectively identified advanced lung cancer patients.

DATA/SETTING/DESIGN

We calculated health care spending from diagnosis (2003-2005) to death or through 2011 for 885 patients aged ≥65 years with advanced lung cancer using Medicare claims. We assessed the association between Dartmouth HRR-level spending in the last 2 years of life and patient-level spending using linear regression with random HRR effects, adjusting for patient characteristics.

FINDINGS

For each $1 increase in the Dartmouth metric, spending for our cohort increased by $0.74 (p < .001). The Dartmouth spending variable explained 93.4 percent of the HRR-level variance in observed spending.

CONCLUSIONS

HRR-level spending estimates for deceased patient cohorts reflect area-level care intensity for prospectively identified advanced lung cancer patients.

Estimating the health and economic burden of cancer among those diagnosed as adolescents and young adults

Adolescent and young adult cancer survivors-those who were ages 15-39 at their first cancer diagnosis-have important health limitations. These survivors are at risk for higher health care expenditures and lost productivity, compared to adults without a history of cancer. Using Medical Expenditure Panel Survey data, we present nationally representative estimates of the economic burden among people who were diagnosed with cancer in adolescence or young adulthood. Our findings demonstrate that surviving cancer at this age is associated with a substantial economic burden. Compared to adults without a history of cancer, adolescent and young adult cancer survivors had excess annual medical expenditures of $3,170 per person and excess annual productivity losses of $2,250 per person. Multifaceted prevention strategies, including education and sustained intervention programs to ensure access to lifelong risk-based follow-up care, may be effective ways to improve the economic outcomes associated with cancer survivorship in this population.

Academic-Community Partnership to Develop a Patient-Centered Breast Cancer Risk Reduction Program for Latina Primary Care Patients

This collaborative study sought to address Latina breast cancer (BC) disparities by increasing health literacy (HL) in a community health center situated on the US-Mexico border region of San Diego County. An academic-community partnership conducted formative research to develop a culturally tailored promotora-based intervention with 109 individuals. The Spanish language program, entitled Nuestra Cocina: Mesa Buena, Vida Sana (Our Kitchen: Good Table, Healthy Life), included six sessions targeting HL, women's health, BC risk reduction, and patient-provider communication; sessions include cooking demonstrations of recipes with cancer-risk-reducing ingredients. A pilot study with 47 community health center Latina patients was conducted to examine the program's acceptability, feasibility, and ability to impact knowledge and skills. Pre- and post-analyses demonstrated that participants improved their self-reported cancer screening, BC knowledge, daily fruit and vegetable intake, and ability to read a nutrition label (p < 0.05). Results of the pilot study demonstrate the importance of utilizing patient-centered culturally appropriate noninvasive means to educate and empower Latina patients.

Costs of colorectal cancer in different states of the disease

OBJECTIVES

This cross-sectional study estimates the resource use and costs among prevalent colorectal cancer (CRC) patients in different states of the disease.

METHODS

Altogether 508 Finnish CRC patients (aged 26-96; colon cancer 56%; female 47%) answered a questionnaire enquiring about informal care, work capacity, and demographic factors. Furthermore, data on direct medical resource use and productivity costs were obtained from registries. Patients were divided into five mutually exclusive groups based on the disease state and the time from diagnosis: primary treatments (the first six months after the diagnosis), rehabilitation, remission, metastatic disease, and palliative care. The costs were calculated for a six-month period. Multivariate modeling was performed to find the cost drivers.

RESULTS

The costs were highest during the primary treatment state and the advanced disease states. The total costs for the cross-sectional six-month period were €22 200 in the primary treatment state, €2106 in the rehabilitation state, €2812 in the remission state, €20 540 in the metastatic state, and €21 146 in the palliative state. Most of the costs were direct medical costs. The informal care cost was highest per patient in the palliative care state, amounting to 33% of the total costs. The productivity costs varied between disease states, constituting 19-40% of the total costs, and were highest in the primary treatment state.

CONCLUSIONS

The first six months after the diagnosis of CRC are resource intensive, but compared with the metastatic disease state, which lasts on average for 2-3 years, the costs are rather modest. Informal care constitutes a remarkable share of the total costs, especially in the palliative state. These results form a basis for the evaluation of the cost effectiveness of new treatments when allocating resources in CRC treatment.

Economic studies in colorectal cancer: challenges in measuring and comparing costs

Estimates of the costs associated with cancer care are essential both for assessing burden of disease at the population level and for conducting economic evaluations of interventions to prevent, detect, or treat cancer. Comparisons of cancer costs between health systems and across countries can improve understanding of the economic consequences of different health-care policies and programs. We conducted a structured review of the published literature on colorectal cancer (CRC) costs, including direct medical, direct nonmedical (ie, patient and caregiver time, travel), and productivity losses. We used MEDLINE to identify English language articles published between 2000 and 2010 and found 55 studies. The majority were conducted in the United States (52.7%), followed by France (12.7%), Canada (10.9%), the United Kingdom (9.1%), and other countries (9.1%). Almost 90% of studies estimated direct medical costs, but few studies estimated patient or caregiver time costs or productivity losses associated with CRC. Within a country, we found significant heterogeneity across the studies in populations examined, health-care delivery settings, methods for identifying incident and prevalent patients, types of medical services included, and analyses. Consequently, findings from studies with seemingly the same objective (eg, costs of chemotherapy in year following CRC diagnosis) are difficult to compare. Across countries, aggregate and patient-level estimates vary in so many respects that they are almost impossible to compare. Our findings suggest that valid cost comparisons should be based on studies with explicit standardization of populations, services, measures of costs, and methods with the goal of comparability within or between health systems or countries. Expected increases in CRC prevalence and costs in the future highlight the importance of such studies for informing health-care policy and program planning.

Evaluating direct medical expenditures estimation methods of adults using the medical expenditure panel survey: an example focusing on head and neck cancer

OBJECTIVE

To inform policymakers of the importance of evaluating various methods for estimating the direct medical expenditures for a low-incidence condition, head and neck cancer (HNC).

METHODS

Four methods of estimation have been identified: 1) summing all health care expenditures, 2) estimating disease-specific expenditures consistent with an attribution approach, 3) estimating disease-specific expenditures by matching, and 4) estimating disease-specific expenditures by using a regression-based approach. A literature review of studies (2005-2012) that used the Medical Expenditure Panel Survey (MEPS) was undertaken to establish the most popular expenditure estimation methods. These methods were then applied to a sample of 120 respondents with HNC, derived from pooled data (2003-2008).

RESULTS

The literature review shows that varying expenditure estimation methods have been used with MEPS but no study compared and contrasted all four methods. Our estimates are reflective of the national treated prevalence of HNC. The upper-bound estimate of annual direct medical expenditures of adult respondents with HNC between 2003 and 2008 was $3.18 billion (in 2008 dollars). Comparable estimates arising from methods focusing on disease-specific and incremental expenditures were all lower in magnitude. Attribution yielded annual expenditures of $1.41 billion, matching method of $1.56 billion, and regression method of $1.09 billion.

CONCLUSIONS

This research demonstrates that variation exists across and within expenditure estimation methods applied to MEPS data. Despite concerns regarding aspects of reliability and consistency, reporting a combination of the four methods offers a degree of transparency and validity to estimating the likely range of annual direct medical expenditures of a condition.

A data mining approach for grouping and analyzing trajectories of care using claim data: the example of breast cancer

Background

With the increasing burden of chronic diseases, analyzing and understanding trajectories of care is essential for efficient planning and fair allocation of resources. We propose an approach based on mining claim data to support the exploration of trajectories of care.

Methods

A clustering of trajectories of care for breast cancer was performed with Formal Concept Analysis. We exported Data from the French national casemix system, covering all inpatient admissions in the country. Patients admitted for breast cancer surgery in 2009 were selected and their trajectory of care was recomposed with all hospitalizations occuring within one year after surgery. The main diagnoses of hospitalizations were used to produce morbidity profiles. Cumulative hospital costs were computed for each profile.

Results

57,552 patients were automatically grouped into 19 classes. The resulting profiles were clinically meaningful and economically relevant. The mean cost per trajectory was 9,600€. Severe conditions were generally associated with higher costs. The lowest costs (6,957€) were observed for patients with in situ carcinoma of the breast, the highest for patients hospitalized for palliative care (26,139€).

Conclusions

Formal Concept Analysis can be applied on claim data to produce an automatic classification of care trajectories. This flexible approach takes advantages of routinely collected data and can be used to setup cost-of-illness studies.

Economic burden of cancer survivorship among adults in the United States

PURPOSE

To present nationally representative estimates of the impact of cancer survivorship on medical expenditures and lost productivity among adults in the United States.

METHODS

Using the 2008 to 2010 Medical Expenditure Panel Survey, we identified 4,960 cancer survivors and 64,431 individuals without a history of cancer age ≥ 18 years. Direct medical costs were measured using annual health care expenditures and examined by source of payment and service type. Indirect morbidity costs were estimated from lost productivity as a result of employment disability, missed work days, and lost household productivity. We evaluated the economic burden of cancer survivorship by estimating excess costs among cancer survivors, stratified by time since diagnosis (recently diagnosed [≤ 1 year] and previously diagnosed [> 1 year]), compared with individuals without a history of cancer using multivariable regression models stratified by age (18 to 64 and ≥ 65 years), controlling for age, sex, race/ethnicity, education, and comorbidities.

RESULTS

In 2008 to 2010, the annual excess economic burden of cancer survivorship among recently diagnosed cancer survivors was $16,213 per survivor age 18 to 64 years and $16,441 per survivor age ≥ 65 years. Among previously diagnosed cancer survivors, the annual excess burden was $4,427 per survivor age 18 to 64 years and $4,519 per survivor age ≥ 65 years. Excess medical expenditures composed the largest share of the economic burden among cancer survivors, particularly among those recently diagnosed.

CONCLUSION

The economic impact of cancer survivorship is considerable and is also high years after a cancer diagnosis. Efforts to reduce the economic burden caused by cancer will be increasingly important given the growing population of cancer survivors.

Spending more, doing more, or both? An alternative method for quantifying utilization during hospitalizations

BACKGROUND

Because relative value unit (RVU)-based costs vary across hospitals, it is difficult to use them to compare hospital utilization.

OBJECTIVE

To compare estimates of hospital utilization using RVU-based costs and standardized costs.

DESIGN

Retrospective cohort.

SETTING AND PATIENTS

Years 2009 to 2010 heart failure hospitalizations in a large, detailed hospital billing database that contains an itemized log of costs incurred during hospitalization.

INTERVENTION

We assigned every item in the database with a standardized cost that was consistent for that item across all hospitals.

MEASUREMENTS

Standardized costs of hospitalization versus RVU-based costs of hospitalization.

RESULTS

We identified 234 hospitals with 165,647 heart failure hospitalizations. We observed variation in the RVU-based cost for a uniform "basket of goods" (10th percentile cost $1,552; 90th percentile cost of $3,967). The interquartile ratio (Q75/Q25) of the RVU-based costs of a hospitalization was 1.35 but fell to 1.26 after costs were standardized, suggesting that the use of standardized costs can reduce the "noise" due to differences in overhead and other fixed costs. Forty-six (20%) hospitals had reported costs of hospitalizations exceeding standardized costs (indicating that reported costs inflated apparent utilization); 42 hospitals (17%) had reported costs that were less than standardized costs (indicating that reported costs underestimated utilization).

CONCLUSIONS

Standardized costs are a novel method for comparing utilization across hospitals and reduce variation observed with RVU-based costs. They have the potential to help hospitals understand how they use resources compared to their peers and will facilitate research comparing the effectiveness of higher and lower utilization.

Cost of illness in colorectal cancer: an international review

OBJECTIVES

Given the current-and increasing-pressure to limit expenditure on health care provision in many countries, a better understanding of the cost burden of colorectal cancer is needed. Cost-of-illness studies and reviews thereof can be a useful tool for analysing and critically evaluating the cost-related development of colorectal cancer, and they highlight important cost drivers.

METHODS

A systematic review was conducted from 2002 to 2012 to identify cost-of-illness studies related to colorectal cancer, searching the Medline, PubMed, Science Direct, Cochrane Library and the York CRD databases.

RESULTS

Among the 10 studies (from France, the US, Ireland and Taiwan) included in the review, 6 studies reported prevalence-based estimates and 4 studies focussed on incidence-based data. In the studies included in the review, long-term costs for colorectal cancer of up to $50,175 per patient (2008 values) were estimated. Most of the studies in the review showed that the initial and terminal phases of colorectal cancer care are the most expensive, with continuing treatment being the least costly phase. One study also highlighted that stage I CRC disease was the least costly and stage III the most costly of all 4 stages, due to the high cost impact of biological agents.

CONCLUSIONS

This review has highlighted a trend for rising costs associated with CRC, which is linked to the increasing use of targeted biological therapies. COI studies in colorectal cancer can identify specific components and areas of care that are especially costly, thereby focussing attention on more cost-effective approaches, which is especially relevant to the increased use of biological agents in the field of personalised medicine. COI studies are an important tool for further health economic evaluations of personalised medicine.

When does an episode of care for cancer begin?

BACKGROUND

Little is known about the medical care resources devoted to diagnosing and treating cancer-related symptoms before a definitive cancer diagnosis. Previous research using SEER-Medicare data to measure incremental costs and utilization associated with cancer started with the date of diagnosis. We hypothesized that health care use increases before diagnosis of a new primary cancer.

METHODS

We used a longitudinal case-control design to estimate incremental medical care utilization rates. Cases were 121,293 persons enrolled between January 2000 and December 2008 with ≥1 primary cancers. We selected 522,839 controls randomly from among all health plan members who had no tumor registry evidence of cancer before January 2009, and we frequency matched controls to cancer cases on a 5:1 ratio by age group, sex, and having health plan eligibility in the year of diagnosis of the index cancer case. Utilization data were extracted for all cases and controls for the period 2000 to 2008 from standardized distributed data warehouses. To determine when and the extent to which patterns of medical care use change preceding a cancer diagnosis, we compute hospitalization rates, hospital days, emergency department visits, same-day surgical procedures, ambulatory medical office visits, imaging procedures, laboratory tests, and ambulatory prescription dispensings per 1000 persons per month within integrated delivery systems.

RESULTS

One- to 3-fold increases in monthly utilization rates were observed during the 3 to 5 months before a cancer diagnosis, compared with matched noncancer control groups. This pattern was consistent for both aged and nonaged cancer patients. Aged cancer patients had higher utilization rates than nonaged cancer patients throughout the year before a cancer diagnosis.

CONCLUSIONS

The prediagnosis phase is a resource-intensive component of cancer care episodes and should be included in cost of cancer estimates. More research is needed to determine whether reliable prognostic markers can be identified as the start of a cancer episode before a pathology-based diagnosis.

Chemotherapy was not associated with cognitive decline in older adults with breast and colorectal cancer: findings from a prospective cohort study

OBJECTIVES

This study tested 2 hypotheses: (1) chemotherapy increases the rate of cognitive decline in breast and colorectal cancer patients beyond what is typical of normal aging and (2) chemotherapy results in systematic cognitive declines when compared with breast and colorectal cancer patients who did not receive chemotherapy.

SUBJECTS

Data came from personal interviews with a prospective cohort of patients with breast (n=141) or colorectal cancer (n=224) with incident disease drawn from the nationally representative Health and Retirement Study (1998-2006) with linked Medicare claims.

MEASURES

The 27-point modified Telephone Interview for Cognitive Status was used to assess cognitive functioning, focusing on memory and attention. We defined the smallest clinically significant change as 0.4 points per year.

RESULTS

We used Bayesian hierarchical linear models to test the hypotheses, adjusting for multiple possible confounders. Eighty-eight patients were treated with chemotherapy; 277 were not. The mean age at diagnosis was 75.5. Patients were followed for a median of 3.1 years after diagnosis, with a range of 0 to 8.3 years. We found no differences in the rates of cognitive decline before and after diagnosis for patients who received chemotherapy in adjusted models (P=0.86, one-sided 95% posterior intervals lower bound: 0.09 worse after chemotherapy), where patients served as their own controls. Moreover, the rate of cognitive decline after diagnosis did not differ between patients who had chemotherapy and those who did not (P=0.84, one-sided 95% posterior intervals lower bound: 0.11 worse for chemotherapy group in adjusted model).

CONCLUSIONS

There was no evidence of cognitive decline associated with chemotherapy in this sample of older adults with breast and colorectal cancer.

The Medical Expenditure Panel Survey (MEPS) experiences with cancer survivorship supplement

INTRODUCTION

The prevalence of cancer survivorship in the USA is expected to increase in the future because the US population is increasing in size and is aging and because survival following diagnosis is improving for many types of cancer. Medical care costs associated with cancer are also projected to increase dramatically. However, currently available data for estimating medical care costs and other important aspects of the burden of cancer, including time spent receiving medical care, productivity loss due to morbidity for patients and their families, and financial hardship, are limited, particularly in the population under the age of 65.

METHODS

We describe selected publicly available data sources for estimating the burden of cancer in the USA and a new collaborative effort to improve the quality of these data: the nationally representative Medical Expenditure Panel Survey (MEPS) Experiences with Cancer Survivorship Supplement.

CONCLUSIONS

Data from this effort can be used to address key gaps in cancer survivorship research related to medical care costs, employment patterns, financial hardship, and other aspects of the burden of illness for cancer survivors and their families.

IMPLICATIONS FOR CANCER SURVIVORS

Research using the MEPS Experiences with Cancer Survivorship Supplement can inform efforts by health care policy makers, healthcare systems, providers, and employers to improve the cancer survivorship experience in the USA.

Economic burden of cancer in the United States: estimates, projections, and future research

The economic burden of cancer in the United States is substantial and expected to increase significantly in the future because of expected growth and aging of the population and improvements in survival as well as trends in treatment patterns and costs of care following cancer diagnosis. In this article, we describe measures of the economic burden of cancer and present current estimates and projections of the national burden of cancer in the United States. We discuss ongoing efforts to characterize the economic burden of cancer in the United States and identify key areas for future work including developing and enhancing research resources, improving estimates and projections of economic burden, evaluating targeted therapies, and assessing the financial burden for patients and their families. This work will inform efforts by health care policy makers, health care systems, providers, and employers to improve the cancer survivorship experience in the United States.

Cost-of-illness studies: a guide to critical evaluation

Cost-of-illness (COI) studies aim to assess the economic burden of health problems on the population overall, and they are conducted for an ever widening range of health conditions and geographical settings. While they attract much interest from public health advocates and healthcare policy makers, inconsistencies in the way in which they are conducted and a lack of transparency in reporting have made interpretation difficult, and have ostensibly limited their usefulness. Yet there is surprisingly little in the literature to assist the non-expert in critically evaluating these studies. This article aims to provide non-expert readers with a straightforward guide to understanding and evaluating traditional COI studies. The intention is to equip a general audience with an understanding of the most important issues that influence the validity of a COI study, and the ability to recognize the most common limitations in such work.

Cost-related medication nonadherence and cost-saving strategies used by elderly Medicare cancer survivors

OBJECTIVES

This study was conducted to compare cost-related medication nonadherence among elderly Medicare enrollees with and without cancer and to describe the strategies cancer survivors used to offset the costs of medications.

METHODS

Using the 2005 Medicare Current Beneficiary Survey and Medicare claims, we compared self-reported cost-related medication nonadherence (CRN), spending less on basic needs to afford medicines, and cost reduction strategies among elderly beneficiaries with and without cancer. Descriptive statistics and logistic regression models were used to characterize and compare these populations.

RESULTS

In a nationally representative sample of 9,818 non-institutionalized elderly Medicare enrollees, 1,392 (14%) were classified as cancer survivors based on Medicare claims. Cancer survivors were older, more highly educated, more likely to be male and non-Hispanic, and more likely to have multiple comorbidities, poorer health status, and employer-paid medication coverage. While 10% of cancer survivors and 11% without cancer reported CRN, about 6% and 9% (p = 0.004) of those with and without cancer, respectively, reported spending less on basic needs to offset the costs of medications. Cancer survivors who reported CRN (n = 143) had lower income (62.2% versus 48.6%, p = 0.11) and were more likely to be African-American (13.0% versus 6.4%, p = 0.033) and have non-employer-based medication insurance (p = 0.002) compared to those who did not report CRN. In adjusted analyses, CRN among the two groups was similar, but with some subgroup differences noted by gender and cancer type. Use of cost reduction strategies was mostly similar among cancer survivors and those without cancer.

CONCLUSION

Cost-related medication nonadherence medication is common among elderly Medicare beneficiaries, but appears to be similar among those with and without cancer.

Medical cost trajectories and onsets of cancer and noncancer diseases in US elderly population

Time trajectories of medical costs-associated with onset of twelve aging-related cancer and chronic noncancer diseases were analyzed using the National Long-Term Care Survey data linked to Medicare Service Use files. A special procedure for selecting individuals with onset of each disease was developed and used for identification of the date at disease onset. Medical cost trajectories were found to be represented by a parametric model with four easily interpretable parameters reflecting: (i) prediagnosis cost (associated with initial comorbidity), (ii) cost of the disease onset, (iii) population recovery representing reduction of the medical expenses associated with a disease since diagnosis was made, and (iv) acquired comorbidity representing the difference between post- and pre diagnosis medical cost levels. These parameters were evaluated for the entire US population as well as for the subpopulation conditional on age, disability and comorbidity states, and survival (2.5 years after the date of onset). The developed approach results in a family of new forecasting models with covariates.

National estimates of out-of-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008

PURPOSE

To compare the prevalence of high out-of-pocket burdens among patients with cancer with other chronically ill and well patients, and to examine the sociodemographic characteristics associated with high burdens among patients with cancer.

METHODS

The sample included persons 18 to 64 years of age who received treatment for cancer, taken from a nationally representative sample of the US population from the 2001 to 2008 Medical Expenditure Panel Survey. We examined the proportion of persons living in families with high out-of-pocket burdens associated with medical spending, including insurance premiums, relative to income, defining high health care (total) burden as spending more than 20% of income on health care (and premiums).

RESULTS

The risk of high burdens is significantly greater for patients with cancer compared with other chronically ill and well patients. We find that 13.4% of patients with cancer had high total burdens, in contrast to 9.7% among those with other chronic conditions and 4.4% among those without chronic conditions. Among nonelderly persons with cancer, the following were associated with higher out-of-pocket burdens: private nongroup insurance, age 55 to 64 years, non-Hispanic black, never married or widowed, one child or no children, unemployed, lower income, lower education level, living in nonmetropolitan statistical areas, and having other chronic conditions.

CONCLUSION

High burdens may affect treatment choice and deter patients from getting care. Thus, although a detailed patient-physician discussion of costs of care may not be feasible, we believe that an awareness of out-of-pocket burdens among patients with cancer is useful for clinical oncologists.

Medical expenditures of adult cancer survivors aged <65 years in the United States

BACKGROUND

To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged <65 years. Most studies of expenditures for cancer survivors in this age group have been based on the Medical Expenditure Panel Survey (MEPS) and were limited to "affected survivors."

METHODS

MEPS expenditure data for 2001 to 2007 were linked to data identifying all survivors from the National Health Interview Survey (NHIS), which is the MEPS sampling frame. The sample was comprised of adults ages 25 to 64 years. Propensity-score matching was used to estimate the effects of cancer on average total and out-of-pocket expenditures for all services and separately for prescriptions. Probit models were used to estimate effects on the probability of exceeding different expenditure thresholds.

RESULTS

Mean annual expenditures on all services in 2007 were $16,910 ± $3911 for survivors who were newly diagnosed with cancer, $7992 ± $972 for survivors who had been diagnosed in previous years, and $3303 ± $103 for other adults. Fifty-three percent of survivors were not identified in MEPS but only by linking to NHIS. Expenditures for all survivors averaged approximately $9300 compared with $13,600 for "affected survivors." For previously diagnosed survivors, the increase in mean expenditures attributable to cancer was approximately $4000 to $5000 annually. On average, relatively little of the increase was paid out of pocket, but cancer nearly doubled the risk of high out-of-pocket expenditures.

CONCLUSIONS

Previous MEPS analyses overstated average expenditures for all survivors. Nevertheless, the current results indicated that the increase in expenditures attributable to cancer is substantial, even for longer term survivors, and that cancer increases the relative risk of high out-of-pocket expenditures.

International comparison of cost of falls in older adults living in the community: a systematic review

SUMMARY

Our objective was to determine international estimates of the economic burden of falls in older people living in the community. Our systematic review emphasized the need for a consensus on methodology for cost of falls studies to enable more accurate comparisons and subgroup-specific estimates among different countries.

INTRODUCTION

The purpose of this study was to determine international estimates of the economic burden of falls in older people living in the community.

METHODS

This is a systematic review of peer-reviewed journal articles reporting estimates for the cost of falls in people aged > or =60 years living in the community. We searched for papers published between 1945 and December 2008 in MEDLINE, PUBMED, EMBASE, CINAHL, Cochrane Collaboration, and NHS EED databases that identified cost of falls in older adults. We extracted the cost of falls in the reported currency and converted them to US dollars at 2008 prices, cost items measured, perspective, time horizon, and sensitivity analysis. We assessed the quality of the studies using a selection of questions from Drummond's checklist.

RESULTS

Seventeen studies met our inclusion criteria. Studies varied with respect to viewpoint of the analysis, definition of falls, identification of important and relevant cost items, and time horizon. Only two studies reported a sensitivity analysis and only four studies identified the viewpoint of their economic analysis. In the USA, non-fatal and fatal falls cost US $23.3 billion (2008 prices) annually and US $1.6 billion in the UK.

CONCLUSIONS

The economic cost of falls is likely greater than policy makers appreciate. The mean cost of falls was dependent on the denominator used and ranged from US $3,476 per faller to US $10,749 per injurious fall and US $26,483 per fall requiring hospitalization. A consensus on methodology for cost of falls studies would enable more accurate comparisons and subgroup-specific estimates among different countries.

Colorectal cancer: national and international perspective on the burden of disease and public health impact

Colorectal cancer is a significant cause of morbidity and mortality in the United States and throughout the world. The importance of this disease to gastroenterologists cannot be understated, given that screening and surveillance colonoscopy are dominant segments of clinical practice. The United States is the only country in the world where incidence and mortality rates from colorectal cancer are reported to be decreasing significantly, but health disparities in cancer screening, treatment, and survival persist. Health disparities are also evident worldwide, where the impact of this disease is staggering. In fact, rates of cancer are increasing in many parts of the world. Eliminating barriers to cancer screening and treatment could lead to substantial gains in quality and quantity of life and decrease the burden of colorectal cancer on public health. Programmatic and opportunistic screening programs have already had a measurable impact on disease burden, although the optimal screening strategy remains a matter of debate. Screening programs vary throughout the world, and further refinement will require a tailored approach because of differences in politics and fiscal reality among individual countries. Despite the strong impact of colorectal cancer on public health, there is cause for optimism and room for hope.

Inventory of data sources for estimating health care costs in the United States

OBJECTIVE

To develop an inventory of data sources for estimating health care costs in the United States and provide information to aid researchers in identifying appropriate data sources for their specific research questions.

METHODS

We identified data sources for estimating health care costs using 3 approaches: (1) a review of the 18 articles included in this supplement, (2) an evaluation of websites of federal government agencies, non profit foundations, and related societies that support health care research or provide health care services, and (3) a systematic review of the recently published literature. Descriptive information was abstracted from each data source, including sponsor, website, lowest level of data aggregation, type of data source, population included, cross-sectional or longitudinal data capture, source of diagnosis information, and cost of obtaining the data source. Details about the cost elements available in each data source were also abstracted.

RESULTS

We identified 88 data sources that can be used to estimate health care costs in the United States. Most data sources were sponsored by government agencies, national or nationally representative, and cross-sectional. About 40% were surveys, followed by administrative or linked administrative data, fee or cost schedules, discharges, and other types of data. Diagnosis information was available in most data sources through procedure or diagnosis codes, self-report, registry, or chart review. Cost elements included inpatient hospitalizations (42.0%), physician and other outpatient services (45.5%), outpatient pharmacy or laboratory (28.4%), out-of-pocket (22.7%), patient time and other direct nonmedical costs (35.2%), and wages (13.6%). About half were freely available for downloading or available for a nominal fee, and the cost of obtaining the remaining data sources varied by the scope of the project.

CONCLUSIONS

Available data sources vary in population included, type of data source, scope, and accessibility, and have different strengths and weaknesses for specific research questions.