Trends and drivers of pharmaceutical expenditures from systemic anti-cancer therapy

Expenditures on medicine for systemic anti-cancer therapy (SACT) have seen large increases in recent years. The characterization of patients with high SACT costs is crucial to identify cost-driving factors, but little is known about the distribution of expenditures at the patient-level. We priced 260,834 registrations of SACT for 12,589 patients from 2008 to 2019 by combining them with product-level billings of EUR 142.1 million. Based on this, we defined high-cost patients as the 2.5% most expensive by accumulated SACT expenditures. We found that high-cost patients accounted for 28.8% of the total SACT expenditures and were observed across all major cancer groups except for pancreatic cancer. The risk of becoming a high-cost patient was increased for younger age groups, i.e., 18-44 and 45-64 years, for patients with BMI ≥ 25, and for patients with multiple cancer diagnoses, while no alteration of risk was observed due to comorbidities or sex. Changes in the characteristics of high-cost patients during the study period were found with an increased risk of becoming high-cost in later years for elderly patients and patients with lung cancer and a decreased risk for breast cancer patients.

Data mining-based clinical profiles of substance use-related emergency department utilizers

OBJECTIVE

Substance-use is a prevalent presentation to the emergency department (ED); however, the clinical characterization of patients who are treated and discharged without admission for further treatment is under-investigated. The study aims to define and characterize the clinical profiles of this patient population.

METHODS

Patients' presentations were examined by clinical data mining (chart review) of ED records of substance use-related events of individuals discharged without admission for further treatment. Records (N = 199) from three major hospitals in New York City from March and June 2017 were randomly sampled with primary diagnosis of alcohol, opioid-related and other psychoactive substance-use presentations. Qualitative thematic coding of clinical presentation with inter-rater reliability was performed. Quantitative distinctive validity tested independence through Pearson's chi-squared and analysis of variance using Fisher's F-test.

RESULTS

Six distinct clinical profiles were identified, including, High Utilizers (chronically intoxicated with comorbid health conditions) (36.7%), Single Episode (20.1%), Service Request (14.1%), Altered Mental Status (13.6%), Overdose (9.0%), and Withdrawal (7.5%). The profiles differed (p < 0.05) in age, housing status, payor, mode of arrival, referral source, index visit time, prescribed treatment, triage acuity level, psychiatric history, and medical history. Differences (p < 0.05) between groups across clinical profiles in age and pain level at triage were observed.

CONCLUSIONS

The identified clinical profiles represent the broad spectrum and complex nature of substance use-related ED utilization, highlighting critical factors of psychosocial and mental-health comorbidities. These findings provide a preliminary foundation to support person-centered interventions to decrease substance use-related ED utilization and to increase engagement/linkage of patients to addiction treatment.

[Hiperfrequency in mental health hospital emergencies: case-control study.]

OBJECTIVE

To ensure the efficiency of the operation of the Emergency Department, specific mental health studies are needed. The purpose of the study was to identify and quantify the sociodemographic, clinical and organizational factors associated with the hyperfrequency of hospital Mental Health emergency departments in the three central areas of Asturias.

METHODS

A retrospective case-control study was carried out. A total of 110 hyperfrequenters were recorded in 2017, based on a definition of five or more visits to the emergency department. The control group was composed of 170 subjects who attended on one occasion. In addition to descriptive analysis, Chi-square and ANOVA tests were used to identify differences between the two groups. A multivariate study was also carried out using binomial logistic regression.

RESULTS

Hyperfrequent users were more likely to be young adult (30-44 years old), single, living with their family of origin, and with no jobs. The most prevalent diagnoses for these users were "Personality and Behavior Disorder" (F60-69) and "Schizophrenia, Schizotypal Disorders and Delusional Disorders" (F20-29). The most frequent reason for consultation was "anxiety/depression/somatization symptoms". The destination of the most frequent emergency was "Continue follow-up at scheduled appointments" and most consultations were made in the morning and on weekdays.

CONCLUSIONS

Hyperfrequent users continue to demand attention despite being assigned one or more devices. Knowing their needs would help to improve healthcare and use resources more efficiently and effectively.

The Role of Using HEART Score to Risk Stratify Chest Pain Among Emergency Department High Utilizers

The HEART score is used to effectively risk stratify undifferentiated chest pain patients in the Emergency Department (ED). It is unclear whether such risk stratification can be applied among ED high utilizers. We aim to determine the efficacy and safety of using the HEART score to predict 30-day short-term major adverse cardiac events (MACE) in ED high utilizers. We conducted a retrospective, observational study in which ED high utilizers were defined as patients who had four or more ED visits within the past 12 months. ED high utilizers presenting at the study ED with chest pain were enrolled. Patients in which the HEART score was utilized were placed in the HEART group and patients with no HEART scores documented were placed to the usual care group. Hospital admissions and cardiac stress tests performed during the index hospitalizations, and 30-day MACE rates were analyzed and compared between the HEART and usual care groups. From January 1, 2017 to December 31, 2019, a total of 8,315 patient visits from ED high utilizers were enrolled. In the HEART group, 49% of ED visits were admitted with 20% receiving stress tests. A 30-day MACE outcome occurred among 1.4% of visits. In the usual care group, 44% of ED visits were admitted, with only 9% receiving index stress tests and a 1.5% of 30-day MACE occurrence (p=0.727). The study showed that similar short-term MACE outcomes occurred between patients using HEART scores and usual care to risk stratify chest pain among ED high utilizers.

Expenditure variations analysis using residuals for identifying high health care utilizers in a state Medicaid program

Background

High utilizers receive great attention in health care research because they have a largely disproportionate spending. Existing analyses usually identify high utilizers with an empirical threshold on the number of health care visits or associated expenditures. However, such count-and-cost based criteria might not be best for identifying impactable high utilizers.

Methods

We propose an approach to identify impactable high utilizers using residuals from regression-based health care utilization risk adjustment models to analyze the variations in health care expenditures. We develop linear and tree-based models to best adjust per-member per-month health care cost by clinical and socioeconomic risk factors using a large administrative claims dataset from a state public insurance program.

Results

The risk adjustment models identify a group of patients with high residuals whose demographics and categorization of comorbidities are similar to other patients but who have a significant amount of unexplained health care utilization. Deeper analysis of the essential hypertension cohort and chronic kidney disease cohort shows these variations in expenditures could be within individual ICD-9-CM codes and from different mixtures of ICD-9-CM codes. Additionally, correlation analysis with 3M™ Potentially Preventable Events (PPE) software shows that a portion of this utilization may be preventable. In addition, the high utilizers persist from year to year.

Conclusions

After risk adjustment, patients with higher than expected expenditures (high residuals) are associated with more potentially preventable events. These residuals are temporally consistent and hence may be useful in identifying and intervening impactable high utilizers.

Impact of an individual plan of care for frequent and high utilizers in a large healthcare system

INTRODUCTION

"Frequent or High Utilizers" are significant stressors to Emergency Departments (EDs) and Inpatient Units across the United States (US). These patients incur higher healthcare costs with ED visits and inpatient admissions. Our aims were to determine whether implementation of individualized care plans (ICPs) could 1) reduce costs, 2) reduce inpatient length of stay (LOS), and 3) reduce ED encounters throughout a large healthcare system.

METHODS

13 EDs were included including academic, community, Free-standing and pediatric EDs. Data was collected from January 1, 2014 through December 31, 2017. ICPs were created for high ED utilizers, as recommended by staff input through multidisciplinary care committees at each site. The ICP consisted of 1) specific symptom-related information with approaches in management, 2) recent assessment from specialists, 3) social work summary, and 4) psychiatry summary. A Best Practice Alert was placed in the electronic medical record that could be seen at all hospitals within the system. ICP's were updated annually.

RESULTS

626 ICPs were written; 452 initial ICPs and 174 updates. The 452 ICP patients accounted for 23,705 encounters during the four-year period; on average, an ICP patient visited the ED 52 times (14.75 encounters/year). Overall indirect and direct costs decreased 42% over first 6 months, inpatient LOS improved from 1.9 to 0.97 days/month, and ED encounters decreased from 1.96 to 1.14. All cost and LOS data significantly improved at 24 months post-ICP inception.

CONCLUSION

Implementation of individualized care plan can reduce cost, inpatient LOS, and ED encounters for high utilizers.

Recurrent use of inpatient withdrawal management services: Characteristics, service use, and cost among Medicaid clients

Reducing repeat use of costly inpatient services, such as inpatient withdrawal management, among Medicaid members is a target of healthcare reform. However, characteristics of frequent users of inpatient withdrawal management are understudied. We described the characteristics, service utilization, and costs of New York Medicaid clients who use withdrawal management services by analyzing data from Medicaid records from 2008. We examined follow-up care for individuals with different levels of repeat withdrawal management. We found 32,196 Medicaid withdrawal management patients with a total of 67,073 episodes and we divided patients into low (1 episode, n = 19,602), medium (2-3 episodes, n = 8619) and high (≥4 episodes, n = 3978) use categories. High users had almost 8 times the withdrawal management cost of low users. Similarly, they had 5 times more emergency department visits than low users. High users had high levels of homelessness (75%), 20% had HIV/AIDS, and 40% had Hepatitis. High withdrawal management users were less likely than low users to receive any follow-up treatment services. Medicaid clients with high utilization of inpatient withdrawal management are a small but costly population with poor follow-up rates to subsequent treatment services. They are a socially disenfranchised group that may benefit from targeted services to address their complex clinical needs.

Factors associated with emergency department useamong veteran psychiatric patients

Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n = 226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.

Difficult Patients in the Emergency Department: Personality Disorders and Beyond

Physician-patient encounters in clinical settings, especially in the emergency department, can be of varying degrees of difficulty. Medically complicated, challenging cases can be paradoxically rewarding, whereas psychologically driven difficulty is frustrating and counterproductive for patient care. This article presents 3 different complementary perspectives on difficult patients: clinical presentations, manifestations of personality traits and disorders in clinical settings, and how physician feelings may affect care. Management strategies are discussed.

Overutilization of ambulatory medical care in the elderly German population?--An empirical study based on national insurance claims data and a review of foreign studies

BACKGROUND

By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healthcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008.

METHODS

The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases.

RESULTS

Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent.

CONCLUSION

We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.