Estimating the economic burden of status epilepticus to the health care system

PURPOSE

Status epilepticus (SE) is a major neurological condition associated with significant morbidity and mortality. No studies to evaluate the cost burden of SE have been performed to date. This study estimates the direct cost related to an inpatient admission for SE in an urban academic medical center.

METHODS

Cases of SE were defined based on a standard 30 min or greater seizure duration. The inpatient claims data were analyzed for 192 patients admitted with SE from 1 July 1993 through 30 June 1994. Patient demographic and clinical characteristics associated with increased cost were identified using multiple regression. The direct costs for SE were compared with other common DRGs.

RESULTS

The median reimbursement for a patient with SE was dollar 8417. The average length of stay for all SE patients was 12.9 days. Age groups (17-45 and 46-64) and etiology (acute CNS) were the only patient factors significantly associated with increased cost. SE patients had 30-60% higher reimbursements than patients admitted for other acute health problems including acute myocardial infarction or congestive heart failure.

CONCLUSIONS

The direct inpatient costs for SE are high compared with the direct costs of admissions for other major conditions such as acute myocardial infarction or congestive heart failure. Data from this study were used to estimate a dollar 4 billion annual direct cost for inpatient admissions for SE. Given the incidence and the high costs, further more detailed evaluation of these costs may be useful in assessing the adequacy of reimbursement for this subset of patients with epilepsy.

Causes of death in elderly prostate cancer patients and in a comparison nonprostate cancer cohort

BACKGROUND

Prostate cancer tends to affect older men and to progress relatively slowly. Since the prevalence of comorbidity increases with advancing age, competing causes of death are important contributors to death rates among prostate cancer patients. Accurate determination of the underlying causes of death in older men dying with prostate cancer may thus also be more difficult.

METHODS

We compared the distribution of underlying causes of death in decedents from a population-based cohort of elderly prostate cancer patients to that from a population-based comparison cohort of elderly men without prostate cancer. Among decedents from the prostate cancer patient cohort, we examined associations of patient demographics, disease stage, and initial treatment, with assignment of a prostate cancer underlying cause of death (versus any other cause) by use of multivariable logistic regression. In the subgroup of prostate cancer patient decedents having underlying causes of death other than prostate cancer, the underlying cause distribution was compared with that in nonprostate cancer cohort decedents.

RESULTS

Prostate cancer was the underlying cause for 39% (95% confidence interval [CI] = 36.3-41.9) of the decedents in the prostate cancer cohort. Causes of death among prostate cancer patients not dying of prostate cancer were similar to those among the nonprostate cancer cohort decedents. However, in those who were aggressively treated, the adjusted odds of other cancer causes of death were 51% higher (odds ratio [OR] = 1.51; 95% CI = 1.08-2.10) than that in nonprostate cancer patient decedents, while in those treated with watchful waiting the adjusted odds were 34% lower (OR = 0.66; 95% CI = 0.47-0.93).

CONCLUSIONS

Initial treatment may influence the underlying cause of death reported in vital statistics for prostate cancer patients.

A sociodemographic and economic comparison of breast reconstruction, mastectomy, and conservative surgery

BACKGROUND

There are a variety of surgical choices for women with early-stage breast cancer, including breast-conserving surgery, mastectomy, or mastectomy plus reconstructive surgery. This report examines some of the factors that affect these choices and the costs of the various treatment options.

METHODS

Data from the Virginia Cancer Registry were linked to insurance claims from the Trigon Blue Cross and Blue Shield Company for women with local and regional staged breast cancer from 1989 to 1991 in Virginia. Multivariate analyses and cost studies were performed.

RESULTS

There were 592 women who underwent breast-conserving surgery (BCS, 26%), mastectomy (58%), or mastectomy plus reconstruction (16%). Increasing age reduced the use of reconstruction. The choice of reconstruction was not affected by tumor size, nodal status, or race. Sixty percent of women had immediate breast reconstruction at the time of mastectomy; the majority had the implant procedure. The cost of BCS ($21,582) was higher than that of mastectomy ($16,122, P < .01). The costs for BCS and mastectomy were significantly lower than for mastectomy plus reconstruction ($31,047, P < .05). The 2-year cost for immediate reconstruction was $8200 less than for delayed procedures and was similar to the cost of BCS.

CONCLUSIONS

Age was the driving force in reconstruction decisions. Clinical factors such as tumor size and nodal status were more important for the choice between BCS and mastectomy. There are significant cost differences between the various procedures. For a similar cosmetic outcome, BCS is less expensive than breast reconstruction. When reconstruction is required, a simultaneous procedure is less expensive.

A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort

BACKGROUND

The objective of this study was to examine and compare lifetime treatment patterns and hospitalization of incident nonsmall cell lung carcinoma (NSCLC) between pre-Medicare eligible (age < 65 years) and supplemental Medigap (age > or = 65 years) enrollees in a commercially insured cohort using insurance claims.

METHODS

Claims from Virginia Blue Cross and Blue Shield beneficiaries with NSCLC submitted between 1989-1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, disease stage, and type of tumor. Initial treatment categories were stratified using Physicians' Current Procedural Terminology codes.

RESULTS

There were 1706 incident NSCLC patients; 349 were age < or = 64 years ("younger") and 1212 were age > or = 65 years ("elderly"). Having commercial insurance was not associated with any survival advantage compared with national averages at 2 years. In comparison with elderly patients, younger patients more often were treated with surgery for local disease (80.2% vs. 54.8%) and surgery alone or in combination with radiation for regional disease (51.9% vs. 32.0%). Radiation was used more often in elderly patients compared with younger patients with local disease (30.5% vs. 14.0%) but less often in patients with distant disease (76.2% vs. 54.9%). Compared with elderly patients, younger patients presenting with distant disease received more chemotherapy (18.8% vs. 5.1%; P <0.001); late palliative use of chemotherapy or radiation occurred in only 4-8% of younger patients. Compared with elderly patients, younger patients with regional or distant disease spent more days in the hospital (compared with national averages at 2 years: regional disease, 30.0 vs. 23.9 days; distant disease, 33.0 vs. 21.4 days; P <0.0001).

CONCLUSIONS

The results of this study show that more comprehensive health insurance is not associated with better outcomes in patients with NSCLC. Age specific trends for greater use of surgery, radiation, and total hospitalization in younger patients is consistent with other reports. Commercial health care claims supplemented by clinical staging from cancer registries can address long term practice patterns in patients with cancer.

Costs of care associated with non-small-cell lung cancer in a commercially insured cohort

PURPOSE

To examine the cost of incident cases of non-small-cell lung cancer (NSCLC) in a commercially insured cohort.

METHODS

Claims from Virginia Blue Cross and Blue Shield (BCBS) beneficiaries with lung cancer from 1989 to 1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, stage, and type of cancer at diagnosis. Costs for all medical care included insurance payment, copayments, and deductibles for 2 years after diagnosis or until death.

RESULTS

Three hundred forty-nine incident NSCLC patients were evaluated. The mean 2-year cost for each patient after diagnosis or until death was $47,941 (95% confidence interval, $43,758 to $52,124). Total average costs and hospital days were significantly lower for local disease ($37,514, 21.2 days), but were similar for regional ($52,797, 30.0 days) and distant ($49,382, 33.0 days) disease. Hospital days accounted for 48% and hospital-based claims for 70% of costs. Initial treatments, which included radiation, unadjusted for stage, had the lowest survival rates and the highest costs, and were associated with the most hospital days. Initial stage, race, gender, and age were not predictors of total 2-year costs. The independent predictors of total 2-year costs were type of treatment: any radiation therapy, any surgery, or any chemotherapy (all, P < .001). Inpatient hospital days was only a modest predictor of costs after adjusting for type of treatment. Patients who survived less than 1 year spent 30.5 days in hospital and had an average cost of $47,280.

CONCLUSION

The direct health care costs of younger NSCLC patients care are substantial. These results should serve as a benchmark for future comparisons as the United States market shifts to managed care.

Variation in the use of breast-conserving therapy for Medicare beneficiaries in Virginia: clinical, geographic, and hospital characteristics

BACKGROUND

Treatment for early-stage breast cancer has evolved significantly in recent years. Breast-conserving therapy (BCT) has been shown to offer equivalent survival compared to traditional mastectomy. However, there is marked variation in the performance of BCT which may not reflect clinical appropriateness or patient preference. Little is known about the factors related to variation in BCT performance in older women with early-stage breast cancer.

METHODS

Retrospective claims analysis of 1,512 Medicare patients using part-A data for the years 1992 to 1993, with additional explicit chart review. A clinical algorithm was developed to categorize patients according to their candidacy for BCT and compare this to their treatment. Demographic, clinical, and geographic variables were included in the model.

RESULTS

The overall BCT rate in Virginia was 20%, with marked variation among providers of all types. BCT rates ranged from 0% to 44% among hospitals caring for more than 12 cases per year. Twenty-six percent of patients considered good candidates for BCT by current guidelines received this option. Large urban hospitals had significantly higher rates of BCT than smaller hospitals, regardless of the presence of radiation oncology capability. Distance from radiation oncology facilities was a factor in low BCT rates of rural populations, but low BCT rates also were present even in facilities with access to radiation oncology services.

CONCLUSIONS

These data present a detailed analysis of the patterns of BCT for Virginia Medicare beneficiaries with early-stage breast cancer. Clinical contraindications to BCT for confirmed early-stage disease were uncommon. Despite similar patient profiles and hospital-reported range of cancer services, marked variation in BCT rates exists. A large number of patients chose traditional mastectomy over BCT due to fears of radiation, but few received radiation oncology consultation. BCT rates were highest in hospitals with radiation oncology facilities on grounds; hospitals with facilities nearby had rates similar to those without access to radiation facilities. Patient preferences are documented poorly. This study provides further evidence that many women are receiving BCT in patterns that may not reflect clinical appropriateness for BCT nor access to necessary facilities.

Comorbidity measurement in elderly female breast cancer patients with administrative and medical records data

The inter-rater reliability, cross-source (Medicare claims versus medical record) agreement, and ability to predict all-cause mortality of three aggregate comorbidity indices were evaluated in a group of 404 elderly, incident breast cancer cases identified from the Virginia Cancer Registry and linked to Medicare administrative data files. Comorbidity was based on both medical records and Medicare claims data using indices from Charlson et al (1987), Satariano and Ragland (1994), and Kaplan and Feinstein (1974). Inter-rater agreement was good for all indices (kappas > or = 0.80). Agreement between comorbidity indices measured by claims and medical records was considerably poorer (kappas between 0.30 and 0.40). However, claims-based and medical records-based comorbidity indices were similarly associated with mortality. For the Charlson index, the index best predicting survival, the adjusted relative risk for an increase from a lower to higher comorbidity category was 1.48 (95% confidence interval 1.23, 1.78) based on medical records compared to 1.53 (95% confidence interval 1.23, 1.93) based on Medicare claims. The claims-based Charlson index score still appeared to be associated with survival (relative risk = 1.30; 95% confidence interval = 1.00, 1.70) after controlling for the medical records-based score. This suggests that both comorbidity data sources add valuable prognostic information and, conversely, that the use of either source alone will result in some misclassification of comorbidity.

Appendectomy incidental to cholecystectomy among elderly Medicare beneficiaries

To assess the risks of adverse outcomes after appendectomy incidental to cholecystectomy among elderly Medicare beneficiaries, 8,936 persons undergoing cholecystectomy with incidental appendectomy and 44,461 persons undergoing cholecystectomy without incidental appendectomy were studied. Controlling for age, race, gender and co-morbidity status, the risk for wound infection in persons with incidental appendectomy was 83 percent higher than in persons without incidental appendectomy (95 percent confidence interval, 1.53 to 2.18). The risks for having other adverse outcomes, including other infections, extensive intrahospital complications and mortality rate at 30 days, were also higher for the former group, although these differences were not statistically significant. In addition, the demographic characteristics and health status of persons undergoing cholecystectomy with incidental appendectomy with persons undergoing cholecystectomy only were compared. Males, persons of younger ages, of white race or with no co-morbid conditions, were significantly more likely to undergo cholecystectomy with incidental appendectomy. Variables to control for differences in the demographic characteristics and health status between persons receiving and not receiving incidental appendectomy were included in the regression models for adverse outcomes. However, these models may not completely control for differences between the two groups. As a result, the actual relationship between incidental appendectomy and adverse outcomes may be underestimated. The preventive effect of incidental appendectomy on morbidity and mortality rates from future instances of appendicitis was assessed by determining the remaining lifetime risk for acute appendicitis. For persons 65 to 69 years of age, 115 incidental appendectomies would be required to prevent one future instance of appendicitis and 4,472 incidental appendectomies would be needed to prevent a single future death from acute appendicitis. Because incidental appendectomy increases the risk for wound infection among persons undergoing cholecystectomy and because the lifetime risk for acute appendicitis is relatively low for persons of this age group, surgeons should carefully consider the risks and benefits of incidental appendectomy in the elderly.

Optimal levels of arginine in maintenance intravenous hyperalimentation

The optimal levels of arginine (Arg) for growth and immunity were studied in mildly depleted, noninjured rats maintained on intravenous hyperalimentation. Three groups of S-D rats (eight/group, weighing 275-300 g) underwent catheter insertion, 1 day of fasting, and then 7 days of intravenous hyperalimentation consisting of 20% dextrose, adequate minerals and vitamins, and three amino acid regimens: (1) FreAmine II (1.55 g Arg/liter); (2) FreAmine III (4.05 g Arg/liter); (3) experimental (7.5 g Arg/liter). The increase in arginine levels was achieved by lowering the glycine levels. There were no differences among the groups in terms of body weight gain (6.9 vs 8.3 vs 10.0 g) or in cumulative N balance (574 vs 660 vs 642 mg). Liver, spleen, and adrenal weights did not differ. Thymus weight was greater in groups B and C: (A) 345 +/- 27 mg vs (B) 445 +/- 34 mg, p less than 0.05, vs (C) 438 +/- 26 mg, p less than 0.05) as were the total number of lymphocytes/thymus (X 10(-9) (A) 0.93 +/- 0.12 vs (B) 1.37 +/- 0.18, p less than 0.05, vs (C) 1.46 +/- 0.15, p less than 0.05). Mitogen-induced thymocyte blastogenesis (cpm) was greatest in group C in response to phytohemagglutinin: (A) 9.558 +/- 3,799 vs (B) 20,088 +/- 5,890, NS, vs (C) 37,234 +/- 6,209, p less than 0.01 vs A and p less than 0.05 vs B) and Concanavalin A: (A) 71,035 +/- 15,228 vs (B) 111,734 +/- 15,021, NS, vs (C) 172,967 +/- 19,861, p less than 0.01 vs A and p less than 0.05 vs B). In the intravenous hyperalimentation-maintained noninjured rat ARG concentrations more than 1.55 g/liter do not enhance N retention or growth. Larger doses of ARG have strong thymic immunostimulatory effects without any toxicity or growth reduction.

Cyclosporine A impairs wound healing in rats

Cellular immune responses may play an important role in the early inflammatory and cellular phases of wound healing. Cyclosporine A (CSA), a new immunosuppressive agent, impairs cellular immunity and T-cell-dependent humoral immunity. Therefore, the effect of CSA-induced immunosuppression in a rat wound-healing model was studied. Sprague-Dawley rats underwent a standardized skin incision and subcutaneous implantation of sterile polyvinyl alcohol sponges. CSA was dissolved in olive oil and given by gavage to one group of animals at a total dose of 125 mg/kg/10 days. The control group received an equivalent volume of olive oil. Ten-day-old wounds were weaker in CSA-treated animals, both in the fresh state (282 +/- 19 g vs 380 +/- 27 g, P less than 0.01), and after formalin fixation (1111 +/- 74 g vs 1419 +/- 57 g, P less than 0.01). In addition, CSA-treated rats accumulated significantly less hydroxyproline in the wound sponge granuloma, an index of reparative collagen deposition. The impairment in wound healing occurred without differences in body weight gain or organ weights. There was a profound immunosuppression in the animals receiving CSA as determined by thymic lymphocyte blastogenesis in response to Con A and PHA. These findings suggest that immunosuppression in otherwise healthy animals impairs wound healing.

Fluid and mononuclear cells from healing wounds inhibit thymocyte immune responsiveness

It has been shown previously that fluid obtained from 7-day-old wounds noncytotoxically inhibits normal thymic lymphocyte blastogenesis and that mononuclear cells (MNC) from the same wounds lack mitogenic responsiveness. The present series of experiments studies whether wound MNC are the source of the wound inhibitory factor(s) and the effect of adult thymectomy (ATDX) on their generation. Adult male Sprague-Dawley rats (300-350 g), intact or ATDX (performed at 8-10 weeks of age), underwent dorsal wounding (7 cm) and subcutaneous implantation of sterile Ivalon sponges. Seven days later sponges were harvested, wound fluid was obtained, and the cell pellet was purified to 90% MNC. Normal rat thymocyte blastogenesis (stimulation index) to Con A and PHA evaluated in a microculture system (10 separate experiments) was 169.9 +/- 10.0 and 30.1 +/- 3.7. Addition of 10% wound fluid markedly inhibited thymocyte mitogenesis--6.3 +/- 1.0 and 2.7 +/- 0.6, respectively (P less than 0.001). Heat-inactivated wound fluid (56 degrees C, 30 min) had similar inhibitory activity--3.4 +/- 0.9 and 2.7 +/- 0.6 (P less than 0.001). Normal thymic blastogenesis could also be inhibited by the addition of 5 X 10(4) wound MNC to the microculture system--4.4 +/- 1.1 and 1.9 +/- 0.3 (P less than 0.001). Wound fluid from ATDX rats had much less inhibitory activity (77.1 +/- 22.4 and 7.2 +/- 2.1, P less than 0.01) vs control wound fluid. In addition wound MNC from ADTX animals were also less immune suppressive (30.7 +/- 4.9 and 13.5 +/- 3.7, P less than 0.001) than control MNC. Forty-eight-hour supernatants of wound MNC from intact rats, added in 25% concentration to normal thymocyte cultures, demonstrated inhibition similar to that of the wound fluid from the same animals: 4.4 +/- 0.7 and 3.9 +/- 0.6, while ATDX MNC supernatants had minimal inhibitory activity (110.1 +/- 18.2 and 25.7 +/- 6.5, P less than 0.005). No cytotoxicity could be demonstrated in any of these experiments by trypan blue exclusion. It is concluded that 7-day-old wound fluid noncytotoxically inhibits thymocyte blastogenesis; this effect is also demonstrated by wound MNC and their supernatants, suggesting immune "suppressor" lymphocytes are present in wounds; ATDX, which abrogates suppressor cell induction, leads to marked diminution of wound inhibitory activity. The data suggest that important immune events occur at the wound site; their relation to normal wound healing remains to be elucidated.