Disparities in Major Joint Replacement Surgery among Adults with Medicare Supplement Insurance

The objective of this study was to determine if disparities in hip and knee replacement surgery exist among osteoarthritis patients with AARP-branded Medicare supplement plan (ie, Medigap) coverage provided by UnitedHealthcare. Patients were selected into the study if they had 1 or more medical claims with a diagnosis of osteoarthritis from July 1, 2006 to June 30, 2007. Logistic regression analyses tested for age-, sex-, race-, or income-related differences in the likelihood of receiving a hip or knee replacement surgery. The regression models controlled for socioeconomics, health status, type of supplement plan, and residential location. Of the 2.2 million Medigap insureds eligible for this study, 529,652 (24%) had osteoarthritis. Of these, 32,527 (6.1%) received a hip or knee replacement. Males were 6% (P-<-0.001) more likely than females to have a replacement surgery. Patients living in minority or lower income neighborhoods were less likely to receive a hip or knee replacement. Supplement plan type was not a strong predictor of the likelihood of hip or knee replacement. Disparities were much greater by comorbid condition and residential location. Disparities in hip and knee replacement surgery existed by age, sex, race, and income levels. Larger disparities were found by residential location and comorbid condition. Interventions are being considered to address these disparities. (Population Health Management 2011;14:231-238)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90479/1/pop-2E2010-2E0042.pd

Identifying microbial drivers in biological phenotypes with a Bayesian Network Regression model

1. In Bayesian Network Regression models, networks are considered the predictors of continuous responses. These models have been successfully used in brain research to identify regions in the brain that are associated with specific human traits, yet their potential to elucidate microbial drivers in biological phenotypes for microbiome research remains unknown. In particular, microbial networks are challenging due to their high-dimension and high sparsity compared to brain networks. Furthermore, unlike in brain connectome research, in microbiome research, it is usually expected that the presence of microbes have an effect on the response (main effects), not just the interactions. 2. Here, we develop the first thorough investigation of whether Bayesian Network Regression models are suitable for microbial datasets on a variety of synthetic and real data under diverse biological scenarios. We test whether the Bayesian Network Regression model that accounts only for interaction effects (edges in the network) is able to identify key drivers (microbes) in phenotypic variability. 3. We show that this model is indeed able to identify influential nodes and edges in the microbial networks that drive changes in the phenotype for most biological settings, but we also identify scenarios where this method performs poorly which allows us to provide practical advice for domain scientists aiming to apply these tools to their datasets. 4. BNR models provide a framework for microbiome researchers to identify connections between microbes and measured phenotypes. We allow the use of this statistical model by providing an easy-to-use implementation which is publicly available Julia package at https://github.com/solislemuslab/BayesianNetworkRegression.jl.Comment: 62 pages, 49 figure

Frequency of Participation in an Employee Fitness Program and Health Care Expenditures

Regular physical activity is strongly linked to prevention of costly chronic health conditions. However, there has been limited examination of the impact that level of participation in physical activity promotion programs has on health care costs. This study examined a fitness reimbursement program (FRP) offered to small employers. FRP participants received $20 reimbursement every month they visited their fitness center ≥12 days. Visits were recorded electronically. Participants were assigned to 4 mutually exclusive cohorts by mean monthly fitness center visits: low (<4 visits); low-moderate (≥4 and <8 visits), high-moderate (≥8 and <12 visits), and high (≥12 visits, which qualified for reimbursement). Cohorts were matched by inverse propensity score weighting on demographic, health status, health care supply, and socioeconomic characteristics. Between-cohort differences in propensity score-weighted health care costs, starting from FRP program sign-up, were examined with a generalized linear model. Analyses were conducted with and without high-cost outliers during the pre- and post-FRP period. A total of 8723 participants (mean follow-up: 11.1 months) were identified during October 2010-June 2013. With high-cost outliers removed (n?=?226), a pattern of lower per-member-per-month health care costs was observed with increasing participation: compared with the low cohort, monthly savings were:$6.14 (2.6%) for low-moderate (P?=?0.60), $16.40 (6.9$20.01 (8.4%) for high (P?=?0.08). With high-cost outliers included, significant monthly cost savings were observed for the moderate-high ($43.52, P?Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140192/1/pop.2015.0102.pd

Predictors of improvement in subjective sleep quality reported by older adults following group-based cognitive behavior therapy for sleep maintenance and early morning awakening insomnia

ObjectiveCognitive behavior therapy is an effective nonpharmacologic treatment for insomnia. However, individualized administration is costly and often results in substantial variability in treatment response across individual patients, particularly so for older adults. Group-based administration has demonstrated impressive potential for a brief and inexpensive answer to the effective treatment of insomnia in the older population. It is important to identify potential predictors of response to such a treatment format to guide clinicians when selecting the most suitable treatment for their patients. The aim of our study was to identify factors that predict subjective sleep quality of older adults following group-based administration of cognitive behavior therapy for insomnia (CBT-I).MethodsEighty-six adults (41 men; mean age, 64.10 y; standard deviation [SD], 6.80) with sleep maintenance or early morning awakening insomnia were selected from a community-based sample to participate in a 4-week group-based treatment program of CBT-I. Participants were required to complete 7-day sleep diaries and a comprehensive battery of questionnaires related to sleep quality and daytime functioning. Hierarchical multiple regression analyses were used to identify factors predicting subjective sleep quality immediately following treatment and at 3-month follow-up. Sleep diaries reported average nightly sleep efficiency (SE), which was used as the outcome measure of sleep quality.Results and conclusionsParticipants with the greatest SE following treatment while controlling for pretreatment SE were relatively younger and had more confidence in their ability to sleep at pretreatment. These characteristics may be useful to guide clinicians when considering the use of a group-based CBT-I for sleep maintenance or early morning awakening insomnia in older adults.Nicole Lovato, Leon Lack, Helen Wright, David J. Kennawa

Longitudinal patterns of antidepressant prescribing in primary care in the UK: comparison with treatment guidelines

The objective of this study was to determine whether patients beginning therapy on the most common tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) differed in their likelihood of having antidepressant treatment that was consistent with recommended treatment guidelines in the UK. An analytical file constructed from a large general practitioner medical records database (DIN-LINK) from the UK for the years 1992-97 was constructed. A total of 16 204 patients with a new episode of antidepressant therapy who initiated therapy on one of the most often prescribed TCAs (amitriptyline, dothiepin, imipramine and lofepramine) or SSRIs (fluoxetine, paroxetine and sertraline) were analysed. A dichotomous measure was defined to indicate whether subjects were prescribed at least 120 days of antidepressant therapy at an adequate average daily dose within the first 6 months after initiation of therapy. Only 6.0% of patients initiating therapy on aTCA and 32.9% of patients initiating therapy on a SSRI were prescribed antidepressant treatment that was consistent with treatment guidelines. After controlling for observable characteristics, patients who initiated therapy on a SSRI were much more likely (odds ratio=7.473, p<0.001) to have a prescribed average daily dose and duration consistent with recommended treatment guidelines within the first 6 months of initiating therapy than were patients who initiated therapy on a TCA. These findings suggest that initial antidepressant selection is an important determinant of whether the subsequent course of treatment is consistent with current national guidelines for the treatment of depression in the UK.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68732/2/10.1177_026988119901300204.pd

Cost Burden of Illness for Hepatitis C Patients with Employer-Sponsored Health Insurance

The disease burden of hepatitis C virus (HCV) is expected to more than double in the next two decades. Currently, there is very little information about the costs of HCV treatment for employers who pay for treatment and health plans that cover HCV patients. This study reports the medical costs of HCV for workers with health insurance. A retrospective claims data design was used for this study. A sample of HCV patients with health insurance was drawn from the inpatient, outpatient, and enrollment files of the MEDSTAT Group's MarketScan family of databases for 1993-1998. Patients were grouped into cohorts and studied for up to 2 years before and after HCV diagnosis. Sample size varies according to length of follow-up, peaking at 3,077 patients enrolled for at least 6 months. In the first year following HCV diagnosis, average payments for HCV patients ($10,925) were almost six times as high as payments for all patients in the MarketScan database ($1,186). Doctors are encouraged to test high-risk patients to find HCV patients earlier in the course of their disease and to better manage their care in order to avoid unnecessary illness and expenses for this disease.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63140/1/109350702320229195.pd

A More Generalizable Method to Evaluate Changes in Health Care Costs with Changes in Health Risks Among Employers of All Sizes

The objective of this study was to estimate the association between changes in health care expenditures relative to changes in health risk status for employers of all sizes. Repeat health risk assessments (HRAs) were obtained from 50,005 employees and spouses with 2 years of health plan enrollment, and from 37,559 employees and spouses with 3 years of enrollment in employer-sponsored medical coverage. Changes in health care expenditures were measured from the year before completion of the first HRA to the years before and after the completion of the second HRA. Propensity score weighting was used to adjust for those who did not repeat the HRA so results could be extrapolated to the larger population. Propensity score weighted multiple regression analyses were used to estimate the relationship between changes in health care expenditures with changes in risk status for 9 risk categories. Significantly higher health care expenditures were associated with those who moved from low risk to medium or high risk, compared to those who remained low risk. Expenditure reductions estimated for those who improved their health status from high risk to medium or low risk were not statistically significant. This study is unique because of its large sample size, its use of data from a wide range of employer sizes, and its efforts to extend generalizability to those who did not complete both HRAs. These results demonstrate that the potential for short-term health care savings may be greater for programs that help maintain low risk than for programs focused on risk reduction. (Population Health Management 2014;17:297?305)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140183/1/pop.2013.0103.pd

Return on investment of public health interventions : a systematic review

BACKGROUND: Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions. METHODS: We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries. RESULTS: We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5. CONCLUSIONS: This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy

What Are the Total Costs of Surgical Treatment for Uterine Fibroids?

Abstract Objective: To investigate the direct and indirect costs of uterine fibroid (UF) surgery. Methods: Data were obtained from the MarketScan Commercial Claims and Encounters databases for 1999–2004. Our sample included 22,860 women with insurance coverage who were treated surgically for UF and 14,214 women who were treated nonsurgically for UF. Medical care costs and missed workdays were divided into baseline (1 year prior to surgery) and postoperative (1 year after surgery) periods. For a subsample of women, we calculated average annual costs 3 years before and after their surgery. Results: Of patients electing surgery, 85.9% underwent hysterectomy, 7.6% myomectomy, 4.9% endometrial ablation, and 1.6% uterine artery embolization (UAE). Women undergoing UAE incurred the highest medical care costs in the operative year ($16,430 unadjusted,$20,634 adjusted for confounders), followed by hysterectomy ($15,180 unadjusted,$17,390 adjusted), myomectomy ($14,726 unadjusted,$18,674 adjusted), and endometrial ablation ($12,096 unadjusted,$13,019 adjusted). Women treated nonsurgically incurred costs of $7,460 unadjusted and$8,257 adjusted during the year after they were diagnosed with UF. Three years after surgery, patients treated with hysterectomy had the lowest annual costs. Missed workdays in the year after surgery were high, resulting in significant losses to employers in the magnitude of $6,670–$25,229, depending on treatment, values assigned to missed workdays, and whether the analyses adjusted for confounders. Conclusions: UF surgical treatment costs were high. Absenteeism and disability were important components of the cost burden of UF treatment for women, their employers, and the healthcare system.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63391/1/jwh.2008.0456.pd

Effectiveness of Writing Groups in Nursing Homes

We examine the effect of participation in an 8-week writing group in six nursing homes. Pretest and posttest assessments of cognitive and affective functional status were administered to 62 participants and 54 control subjects. We asked writing-group participants about previous writing experience and perceived ability to convey feelings, ideas, life experiences, and memories to others. Weekly assessments were conducted on eight group process measures. Findings suggest that participation in writing groups may reduce depression, particularly among residents with higher cognitive ability and greater depression. Significantly more participants than control subjects report an ability to relate feelings and ideas to other residents and staff. Improvement in group process measures is greatest for cognitively impaired participants and those with high physical function scores. There is considerable improve ment in residents for whom writing-group participation frequently is considered inappropriate: those without writing experience, the depressed, and the cognitively impaired.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67030/2/10.1177_073346488900800308.pd