•The SEEK model cost $305.58 per incident of child maltreatment prevented.•SEEK saves an estimated $2,151,878 in health care costs for 29,610 children.•Implementing the SEEK model appears to be cost ...saving.•Costs are less than the short-term medical and mental health costs of child abuse.
Funding for prevention interventions is often quite limited. Cost-related assessments are important to best allocate prevention funds.
To determine the (1) overall cost for implementing the Safe Environment for Every Kid (SEEK) model, (2) cost of implementation per child, and (3) cost per case of maltreatment averted.
Cost-effective analysis of a randomized controlled trial.
102 pediatric providers at 18 pediatric primary care practices. 924 families with children < 6 years receiving care by those providers.
Practices and their providers were randomized to either SEEK training and implementation or usual care. Families in SEEK and control practices were recruited for evaluation. Rates of psychological and physical abuse were calculated by parent self-report 12 months following recruitment. Model costs were calculated including salaries for team members, provider time for training and booster sessions, and development and distribution of materials.
Implementing SEEK in all 18 practices would have cost approximately $265,892 over 2.5 years; $3.59 per child per year; or $305.58 ($229.18-$381.97) to prevent one incident. Based on a very conservative cost estimate of $2779 per maltreatment incident, SEEK would save an estimated $2,151,878 in health care costs for 29,610 children.
The SEEK model is cost saving. Cost per case of psychological and physical abuse averted were significantly lower than the short-term costs of medical and mental health care for maltreated children. SEEK model expansion has the potential to significantly decrease medical, mental health, and other related costs associated with maltreatment.
Marked variation in hospital costs and payments is a target for health care reform efforts. Limited data exist to explain variability in prices for head and neck surgical procedures.
To characterize ...variations in hospital price markup for head and neck cancer surgery, and examine associations with market concentration and hospital for-profit status.
In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 150 275 patients who underwent head and neck cancer surgery for a malignant upper aerodigestive tract neoplasm from 2001 to 2011. The markup ratio (charges to costs) was modeled as a continuous and categorical variable. Hospital market concentration was evaluated using a variable-radius Herfindahl-Hirschman Index from the 2000, 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from May 2019 to July 2019.
Multivariable regression was used to evaluate associations between hospital and patient variables and hospital markup.
There were 150 275 patients (mean SD age, 61.8 12.6 years; 104 974 70.0% male) from 2001 to 2011 for whom hospital market information was available. Hospital markup ratios ranged from 0.8 to 8.7, with a mean markup ratio of 2.8 (95% CI, 2.7-2.9). Hospitals in the lowest markup ratio quartile had a mean markup ratio of 1.8 (95% CI, 1.8-1.9), while hospitals in the top markup ratio quartile (extreme markup) had a mean markup ratio of 4.1 (95% CI, 4.0-4.2). Extreme markup hospitals were more often large (77.5% vs 66.6%), private for-profit hospitals (19.0% vs 1.3%), and were less likely to be high-volume hospitals (21.0% vs 9.4%) or in competitive markets (64.4% vs 82.0%). Postoperative complications occurred more often in extreme markup hospitals (22.7% vs 17.1%). On multivariate analysis, a significantly higher markup was associated with private, for-profit hospitals (47.9%; 95% CI, 33.3%-64.2%), hospitals in the West (25.5%; 95% CI, 12.6%-39.8%), Hispanic race (9.8%; 95% CI, 4.4%-15.5%), prior radiation therapy (5.3%; 95% CI, 1.3%-9.4%), comorbidity (3.5%; 95% CI, 1.7%-5.4%), and complications (2.8%; 95% CI, 0.3%-5.4%). Hospital market concentration modified the association between hospital for-profit status and markup, with higher markups in for-profit hospitals in moderately concentrated and concentrated (less competitive) markets.
In this cross-sectional study, there was wide variation in hospital markup for head and neck cancer surgery, with a 4-fold increase in charges relative to costs in 25% of hospitals. Variations in surgical price were primarily associated with hospital profit status. These data suggest that greater transparency is needed to address disparities in hospital pricing.
To compare patient and Medicare savings from the use of optical coherence tomography (OCT) in guiding therapy for neovascular age-related macular degeneration (nvAMD) to the research investments made ...in developing OCT by the National Institutes of Health (NIH) and the National Science Foundation (NSF).
Observational cohort study.
Main outcome measures were spending by Medicare as tracked by Current Procedural Terminology codes on intravitreal injections (67028), retinal OCT imaging (92134), and anti–vascular endothelial growth factor (anti-VEGF) treatment–specific J-codes (J0178, J2778, J9035, J3490, and J3590). These claims were identified from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services among fee-for-service (FFS) Medicare beneficiaries from 2012 to 2015; 2008 claims were acquired from the 100% FFS Part B Medicare Claims File. OCT research costs were determined by searching for grants awarded by NIH and NSF from inception to 2015. All costs and savings were discounted by 3% annually and adjusted for inflation to 2015 dollars.
From 2008 to 2015, the United States government and nvAMD patients have accrued an estimated savings of $9.0 billion and $2.2 billion, respectively, from the use of OCT to guide personalized anti-VEGF treatment. The $9.0 billion represents a 21-fold return on government investment into developing the technology through NIH and NSF grants.
Although an overall cost-benefit ratio of government-sponsored research is difficult to estimate because the benefit may be diffuse and delayed, the investment in OCT over 2 decades has been recouped many times over in just a few years through better personalized therapy.
Magnetic resonance imaging (MRI) is avoided in most patients with implanted cardiac devices because of safety concerns.
To define the safety of a protocol for MRI at the commonly used magnetic ...strength of 1.5 T in patients with implanted cardiac devices.
Prospective nonrandomized trial. (ClinicalTrials.gov registration number: NCT01130896) SETTING: One center in the United States (94% of examinations) and one in Israel.
438 patients with devices (54% with pacemakers and 46% with defibrillators) who underwent 555 MRI studies.
Pacing mode was changed to asynchronous for pacemaker-dependent patients and to demand for others. Tachyarrhythmia functions were disabled. Blood pressure, electrocardiography, oximetry, and symptoms were monitored by a nurse with experience in cardiac life support and device programming who had immediate backup from an electrophysiologist.
Activation or inhibition of pacing, symptoms, and device variables.
In 3 patients (0.7% 95% CI, 0% to 1.5%), the device reverted to a transient back-up programming mode without long-term effects. Right ventricular (RV) sensing (median change, 0 mV interquartile range {IQR}, -0.7 to 0 V) and atrial and right and left ventricular lead impedances (median change, -2 Ω IQR, -13 to 0 Ω, -4 Ω IQR, -16 to 0 Ω, and -11 Ω IQR, -40 to 0 Ω, respectively) were reduced immediately after MRI. At long-term follow-up (61% of patients), decreased RV sensing (median, 0 mV, IQR, -1.1 to 0.3 mV), decreased RV lead impedance (median, -3 Ω, IQR, -29 to 15 Ω), increased RV capture threshold (median, 0 V, IQR, 0 to 0.2 Ω), and decreased battery voltage (median, -0.01 V, IQR, -0.04 to 0 V) were noted. The observed changes did not require device revision or reprogramming.
Not all available cardiac devices have been tested. Long-term in-person or telephone follow-up was unavailable in 43 patients (10%), and some data were missing. Those with missing long-term capture threshold data had higher baseline right atrial and right ventricular capture thresholds and were more likely to have undergone thoracic imaging. Defibrillation threshold testing and random assignment to a control group were not performed.
With appropriate precautions, MRI can be done safely in patients with selected cardiac devices. Because changes in device variables and programming may occur, electrophysiologic monitoring during MRI is essential.
Understanding eye care use over time is essential to estimate continued unmet health care needs and help guide future public health priorities.
To update trends in using eye care and affording ...eyeglasses in the United States.
This analysis of data from the US National Health Interview Survey included adults 18 years and older from 9 annual cross-sectional population-based samples ranging in size from 21 781 to 36 697 participants from 2008 to 2016. Data were analyzed from August 2017 to February 2018.
Visual impairment, defined as self-reported difficulty seeing despite wearing eyeglasses.
Outcome measures included visits to an eye care professional and inability to afford eyeglasses when needed in the past year. Survey logistic regression, adjusted for age, sex, race/ethnicity, visual impairment status, education, employment, general health, poverty-income ratio, and vision insurance, was used to examine associations between survey year and eye care outcomes.
Analyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21 781 to 36 697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, or Asian in 2016. There was a significant trend for eye care use and difficulty affording eyeglasses from 2008 to 2016. In fully adjusted models, Americans were less likely to use eye care in 2014 compared with 2008 (odds ratio OR, 0.90; 99.9% CI, 0.82-0.98; P < .001). Compared with 2008, Americans were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001). After adjusting for all covariates, including survey year, those with visual impairment compared with those without were more likely to use eye care (OR, 1.54; 99.9% CI, 1.45-1.65; P < .001) but had greater difficulty affording eyeglasses (OR, 3.86; 99.9% CI, 0.58-0.72; P < .001). Women were also more likely to use eye care (OR, 1.42; 99.9% CI, 1.37-1.48; P < .001) and report difficulty affording eyeglasses (OR, 1.68; 99.9% CI, 1.56-1.81; P < .001) compared with men. Compared with non-Hispanic white individuals, black, Asian, and Hispanic individuals were less likely to use eye care, and Asian and black individuals were less likely to have difficulty affording eyeglasses.
These data indicate decreased difficulty affording eyeglasses among Americans from 2014 to 2016, possibly related to economic recovery and health care reform. However, the findings suggest women and racial/ethnic minorities are more likely to have lower use of eye care or inability to afford eyeglasses.
A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures.
To characterize the volume-outcome association specifically ...for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes.
In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable.
Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis.
Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900).
Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.
The Medicare cost savings from the use of bevacizumab in the United States for the treatment of exudative age-related macular degeneration (AMD) were estimated by replacing the use of bevacizumab ...with ranibizumab and aflibercept.
Retrospective trend study.
Main outcome measures were spending by Medicare as tracked by Current Procedural Terminology (CPT) codes for intravitreal injections (67028) and treatment-specific J-codes (J0178, J2778, J9035, J3490, and J3590) for inhibitors of vascular endothelial growth factor. These claims were identified from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services among fee-for-service (FFS) Medicare beneficiaries from 2012 to 2015. The 2008 claims were acquired from the 100% fee-for-service (FFS) Part B Medicare Claims File.
The use of bevacizumab from 2008 to 2015 resulted in an estimated savings of $17.3 billion, which corresponded to a $13.8 billion savings to Medicare and a $3.5 billion savings to patients. This amount underestimated the actual cost savings to Medicare providers, since approximately 30% of Medicare-eligible recipients received care within Medicare Advantage plans and were not included in this analysis.
The cost savings from the use of bevacizumab from 2008 to 2015 for Medicare fee-for-service patients undergoing treatment for exudative AMD was estimated at $17.3 billion. Additional savings over the $17.3 billion would have accrued from the use of bevacizumab if diagnostic categories such as diabetic macular edema and retinal vein occlusion were included in this study.
Background
Alcohol use disorders (AUD) have long been considered to be some of the most disabling mental disorders; however, empirical data on the burden of disease associated with AUD have been ...sparse. The objective of this article is to quantify the burden of disease (in disability‐adjusted life years DALYs lost), deaths, years of life lost due to premature mortality (YLL), and years of life lost due to disability (YLD) associated with AUD for the United States in 2005.
Methods
Statistical modeling was based on epidemiological indicators derived from the National Epidemiologic Survey on Alcohol and Related Conditions. Formal consistency analyses were applied. Risk relations were taken from recent meta‐analyses and the disability weights from the burden of disease study of the National Institutes of Health. Monte Carlo simulations were used to derive confidence intervals. All analyses were performed by sex and age. Sensitivity analyses were undertaken on key indicators.
Results
In the United States in 2005, 65,000 deaths, 1,152,000 YLL, 2,443,000 YLD, and 3,595,000 DALYs were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD.
Conclusions
Using data from a large representative survey (checked for consistency) and by combining these data with the best available evidence, we found that AUD were associated with a larger burden of disease than previously estimated. To reduce this disease burden, implementation of prevention interventions and expansion of treatment are necessary.
Purpose: To estimate the annual loss of productivity from blindness and moderate to severe visual impairment (MSVI) using simple models (analogous to how a rapid assessment model relates to a ...comprehensive model) based on minimum wage (MW) and gross national income (GNI) per capita (US$, 2011).
Methods: Cost of blindness (COB) was calculated for the age group ≥50 years in nine sample countries by assuming the loss of current MW and loss of GNI per capita. It was assumed that all individuals work until 65 years old and that half of visual impairment prevalent in the ≥50 years age group is prevalent in the 50-64 years age group. For cost of MSVI (COMSVI), individual wage and GNI loss of 30% was assumed. Results were compared with the values of the uncorrected refractive error (URE) model of productivity loss.
Results: COB (MW method) ranged from $0.1 billion in Honduras to $2.5 billion in the United States, and COMSVI ranged from $0.1 billion in Honduras to $5.3 billion in the US. COB (GNI method) ranged from $0.1 million in Honduras to $7.8 billion in the US, and COMSVI ranged from $0.1 billion in Honduras to $16.5 billion in the US. Most GNI method values were near equivalent to those of the URE model.
Conclusion: Although most people with blindness and MSVI live in developing countries, the highest productivity losses are in high income countries. The global economy could improve if eye care were made more accessible and more affordable to all.
People with neuromuscular disease frequently have difficulty clearing pulmonary secretions, which leads to pneumonia and respiratory failure. High-frequency chest wall oscillation (HFCWO) is one ...intervention used to facilitate secretion clearance.
The objective of this study was to determine if HFCWO therapy leads to improved outcomes as measured by lower healthcare use for patients who have a chronic neuromuscular disease.
We performed a cohort study comparing healthcare claims before and after initiation of HFCWO. Data were obtained from two large databases of commercial insurance claims. Study subjects were commercial insurance members with an International Classification of Diseases, Ninth Revision, code for a neuromuscular disease and a claim for HFCWO between 2007 and 2011. The study included both children and adults.
There were 426 patients in this study. Their mean age was 29.9 ± 22 years. Total medical costs per member per month decreased by $1,949 (18.6%) after initiation of HFCWO (P = 0.002). Inpatient admission costs decreased by $2,392 (41.7%) (P = 0.001), and pneumonia costs decreased by $514 (18.1%) (P = 0.015). To account for the possibilities of misclassification based on diagnosis and bias due to loss to follow-up, we compared outcomes between those lost to follow-up and those not, and we found similar results.
Total medical costs, hospitalizations, and pneumonia claims were less after than before initiation of HFCWO in a broad group of patients with neuromuscular disease. Subject to the limitations that administrative data did not capture how HFCWO was used and that HFCWO may be a marker of generally better care, our findings lend support to the routine use of this intervention in the care of patients with neuromuscular diseases.
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