STUDY DESIGN: Sequential cross-sectional study of nationally representative data.

METHODS: We examined data from the National Health Interview Survey (NHIS) from 1997 to 2004 linked to 2 years of subsequent Medical Expenditure Panel Survey (MEPS) data. Psychological distress was measured in the NHIS using the K6, a 6-item scale of the Kessler Psychological Distress Scale, which we classified as no/low, mild-moderate, or severe. We examined subsequent annualized total, outpatient, and office-based expenditures, and outpatient and office-based visits from MEPS.

RESULTS: Psychological distress remained stable from 1997 to 2004. There were upward trends in overall healthcare expenditures (P <.001) and outpatient expenditures (P <.001), but not outpatient visits. Overall healthcare expenditures, outpatient expenditures, and outpatient visits significantly increased as psychological distress increased from no/low to mild-moderate to severe. The interaction between psychological distress strata and year was not significant for expenditures or for visits.

CONCLUSIONS: The upward trend in total and outpatient healthcare expenditures in the United States appears unrelated to psychological distress, although healthcare expenditures are consistently higher among those with greater psychological distress. Future work will explore the impact of treatment on costs and stability of the nation's mental health over time.

Limited preview of Chapter 12 available via Google Books.

METHODS: A survey elicited utility measures for health states under risk-insensitive and risk-sensitive conditions (time tradeoff and standard gamble methods, respectively). Risk attitude was modeled assuming constant proportional risk posture, thus the utility function used was a power function. A multivariable linear regression model was used to examine the relationship between risk attitude and sociodemographic factors.

RESULTS: Of the 62 study subjects, the mean age was 47.6 years, 47% were female, and 33% were African American. Overall, 37% of respondents were decidedly risk averse, 37% moderately risk averse, 15% moderately risk seeking, and 11% decidedly risk seeking. Significant predictors of increasing risk aversion in multivariate modeling were white race (P < 0.01) and lower education (P < 0.05). Women also tended to be more risk averse (P = 0.07).

CONCLUSIONS: This study found significant differences in risk attitude across race and educational status, with a smaller difference across gender. Further research is needed to validate these findings and clarify their contribution to racial and gender variations in health care utilization and their future role in decision and cost-effectiveness analyses.

METHODS: We conducted a systematic search of the English-language medical literature for original CUAs published from 1976 through 2001, using Medline and other databases. Each study was audited independently by two trained readers, who recorded the methodological and reporting practices used.

RESULTS: Our review identified 533 original CUAs. Comparing articles published in 1998 to 2001 (n = 305) with those published in 1976 to 1997 (n = 228), studies improved in almost all categories, including: clearly presenting the study perspective (73% vs. 52%, P < 0.001); discounting both costs and quality-adjusted life-years (82% vs. 73%, P = 0.0115); and reporting incremental cost-utility ratios (69% vs. 46%, P < 0.001). The proportion of studies disclosing funding sources did not change (65% vs. 65%, P = 0.939). Adherence to recommended practices was greater in more experienced journals, and roughly equal in industry versus non-industry-funded analyses. The data suggest an impact in methodological practices used in US-based CUAs in accordance with recommendations of the USPCEHM.

CONCLUSIONS: Adherence to methodological and reporting practices in published CUAs is improving, although many studies still omit basic elements. Medical journals, particularly those with little experience publishing cost-effectiveness analyses, should adopt and enforce standard protocols for conducting and reporting CUAs.

OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47% compared with 38%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

METHOD: The authors selected articles regarding cost-utility analysis of depression management from the Harvard Center for Risk Analysis Cost-Effectiveness Registry. Characteristics of the publications, including study methods and analysis, were examined. Cost-utility ratios for interventions were arranged in a league table.

RESULTS: Of the 539 cost-utility analyses in the registry, nine (1.7%) were of depression management. Methods for determining utilities and the source of the data varied. Markov models or cohort simulations were the most common analytic techniques. Pharmacologic interventions generally had lower costs per quality-adjusted life year than nonpharmacologic interventions. Psychotherapy alone, care management alone, and psychotherapy plus care management all had lower costs per quality-adjusted life year than usual care. Depression screening and treatment appeared to fall within the cost-utility ranges accepted for common nonpsychiatric medical conditions.

CONCLUSIONS: There is a paucity of literature on cost-utility analysis of depression management. High-quality cost-utility analysis should be considered for further research in depression management.

OBJECTIVES: To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use. DESIGN: Observational cohort study.

SETTING: Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes.

PATIENTS: Individuals (N= 38887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey.

INTERVENTIONS AND MEASUREMENTS: Pharmacy dispensing of ACE/ARB.

RESULTS: Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P =.0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found.

CONCLUSIONS: In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.

Summary: It has become trite to observe that increases in health care costs have become unsustainable. How best for policy to address these increases, however, depends in part on the degree to which they represent increases in the real quantity of medical services as opposed to increased unit prices of existing services. And an even more fundamental question is the degree to which the increased spending actually has purchased improved health. Accounting for Health and Health Care addresses both these issues. The government agencies responsible for measuring unit prices for medical services have taken steps in recent years that have greatly improved the accuracy of those measures. Nonetheless, this book has several recommendations aimed at further improving the price indices.

Allison B. Rosen is a member of the National Research Council's Panel to Advance a Research Program on the Design of National Health Accounts.

METHODS: Data from 2 large health plans were used to compare cost sharing in disease management programs with cost sharing outside of disease management programs.

RESULTS: The copayments charged to participants in disease management programs usually do not differ substantially from those charged to other beneficiaries.

CONCLUSIONS: Cost sharing and disease management result in conflicting approaches to benefit design. Increasing copayments may lead to underuse of recommended services, thereby decreasing the clinical effectiveness and increasing the overall costs of disease management programs. Policymakers and private purchasers should consider the use of targeted benefit designs when implementing disease management programs or redesigning cost-sharing provisions. Current information systems and health services research are sufficiently advanced to permit these benefit designs.

METHODS: Detailed clinical data on 3605 Medicare patients undergoing CABG in 28 Alabama and Iowa hospitals were analyzed by stepwise linear regression to identify significant clinical predictors of PLOS. Analysis of variance was used to compare hospitals' PLOS while controlling for significant patient risk factors.

RESULTS: The mean age was 72.1 years, 34.7% were female, and the in-hospital mortality rate was 5.6%. The median and mean PLOS were 8 and 11.1 days, respectively. Significant predictors of longer PLOS included increasing age, female sex, history of chronic obstructive pulmonary disease, cerebrovascular disease, or mitral valve disease, elevated admission blood urea nitrogen, and preoperative placement of an intraaortic balloon pump. Hospitals varied significantly (P =.0001) in their unadjusted PLOS. These hospital-level variations persisted despite adjustment for both preoperative patient characteristics (P =.0001) and postoperative complications and death (P =.0001).

CONCLUSIONS: This study found significant between-hospital variations in PLOS that were not explained by patient factors. This finding suggests the potential for increased efficiency in the care of patients undergoing CABG at many institutions. Further research is needed to determine the practice patterns contributing to variations in length of stay after bypass surgery.

OBJECTIVE: To estimate the cost-effectiveness to Medicare of first-dollar coverage (no cost sharing) of ACE inhibitors for beneficiaries with diabetes.

DESIGN: Markov model with costs and benefits discounted at 3%.

DATA SOURCES: Published literature and Medicare claims data.

TARGET POPULATION: 65-year-old Medicare beneficiary with diabetes.

TIME HORIZON: Lifetime.

PERSPECTIVE: Medicare and societal.

INTERVENTIONS: We evaluated Medicare first-dollar coverage of ACE inhibitors compared with current practice (no coverage) and the new Medicare drug benefit.

OUTCOME MEASURES: Costs (2003 U.S. dollars), quality-adjusted life-years (QALYs), life-years, and incremental cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS: Compared with current practice, first-dollar coverage of ACE inhibitors saved both lives and money (0.23 QALYs gained and 1606 USD saved per Medicare beneficiary). Compared with the new Medicare drug benefit, first-dollar coverage remained a dominant strategy (0.15 QALYs gained, 922 USD saved).

RESULTS OF SENSITIVITY ANALYSIS: Results were most sensitive to our estimate of increase in ACE inhibitor use; however, if ACE inhibitor use increased by only 7.2% (from 40% to 47.2%), first-dollar coverage would remain life-saving at no net cost to Medicare. In analyses conducted from the societal perspective, benefits were similar and cost savings were larger.

LIMITATIONS: Results depend on accuracy of the underlying data and assumptions. The effect of more generous drug coverage on medication adherence is uncertain.

CONCLUSIONS: Medicare first-dollar coverage of ACE inhibitors for beneficiaries with diabetes appears to extend life and reduce Medicare program costs. A reduction in program costs may result in more money to spend on other health care needs of the elderly.

METHODS: Systematic review of the English-language medical literature from 1998 through 2001. The authors searched MEDLINE for original CEAs reported in costs per quality-adjusted life years(i.e., cost-utility analyses). Two independent readers abstracted data elements and met to resolve discrepancies.

RESULTS: Among the 303 abstracts reviewed, a clear description of the intervention was present in 94%, comparator in 71%, target population in 85%, and study perspective in 28%. All 4 data elements were reported in 20% of abstracts, 3 elements in 49%, 2 in 22%, and 0 or 1 in 9%. In journals with CEA-specific abstract reporting requirements, structured abstract requirements, or impact factors>or=10, significantly more data were included in abstracts than in journals without these features (P<0.01 for all comparisons).

CONCLUSIONS: Abstracts of published CEAs frequently omit data elements critical to proper study interpretation. An explicit core set of reporting standards is needed, based on the standards by the US Public Health Service's Panel on Cost-Effectiveness for reporting of CEAs, but specific to the accompanying abstracts.

OBJECTIVE: To examine trends in hip fracture incidence and resulting mortality over 20 years in the US Medicare population.

DESIGN, SETTING, AND PATIENTS: Observational study using data from a 20% sample of Medicare claims from 1985-2005. In patients 65 years or older, we identified 786,717 hip fractures for analysis. Medication data were obtained from 109,805 respondents to the Medicare Current Beneficiary Survey between 1992 and 2005.

MAIN OUTCOME MEASURES: Age- and sex-specific incidence of hip fracture and age- and risk-adjusted mortality rates.

RESULTS: Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100,000 (95% confidence interval [CI], 921.7-992.9) for women and 414.4 per 100,000 (95% CI, 401.6-427.3) for men. The age-adjusted incidence of hip fracture increased from 1986 to 1995 and then steadily declined from 1995 to 2005. In women, incidence increased 9.0%, from 964.2 per 100,000 (95% CI, 958.3-970.1) in 1986 to 1050.9 (95% CI, 1045.2-1056.7) in 1995, with a subsequent decline of 24.5% to 793.5 (95% CI, 788.7-798.3) in 2005. In men, the increase in incidence from 1986 to 1995 was 16.4%, from 392.4 (95% CI, 387.8-397.0) to 456.6 (95% CI, 452.0-461.3), and the subsequent decrease to 2005 was 19.2%, to 369.0 (95% CI, 365.1-372.8). Age- and risk-adjusted mortality in women declined by 11.9%, 14.9%, and 8.8% for 30-, 180-, and 360-day mortality, respectively. For men, age- and risk-adjusted mortality decreased by 21.8%, 25.4%, and 20.0% for 30-, 180-, and 360-day mortality, respectively. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis. The incidence decrease is coincident with increased use of bisphosphonates.

CONCLUSION: In the United States, hip fracture rates and subsequent mortality among persons 65 years and older are declining, and comorbidities among patients with hip fractures have increased.

METHODS: For each year from 2005 through 2020, we forecasted life expectancy and quality-adjusted life expectancy for a representative 18-year-old, assuming a continuation of past trends in smoking (based on data from the National Health Interview Survey for 1978 through 1979, 1990 through 1991, 1999 through 2001, and 2004 through 2006) and past trends in body-mass index (BMI) (based on data from the National Health and Nutrition Examination Survey for 1971 through 1975, 1988 through 1994, 1999 through 2002, and 2003 through 2006). The 2003 Medical Expenditure Panel Survey was used to examine the effects of smoking and BMI on health-related quality of life.

RESULTS: The negative effects of increasing BMI overwhelmed the positive effects of declines in smoking in multiple scenarios. In the base case, increases in the remaining life expectancy of a typical 18-year-old are held back by 0.71 years or 0.91 quality-adjusted years between 2005 and 2020. If all U.S. adults became nonsmokers of normal weight by 2020, we forecast that the life expectancy of an 18-year-old would increase by 3.76 life-years or 5.16 quality-adjusted years.

CONCLUSIONS: If past obesity trends continue unchecked, the negative effects on the health of the U.S. population will increasingly outweigh the positive effects gained from declining smoking rates. Failure to address continued increases in obesity could result in an erosion of the pattern of steady gains in health observed since early in the 20th century.

METHODS: This study used 539 CUAs from a registry. It includes data elements comprising year of publication, the research center in which the study was performed, the clinical area covered by the CUA, and the specific journal. Finally, each paper was assigned to a journal type that could be one of the three categories: health services research, general medicine, or clinical specialty.

RESULTS: When the average number of publications is plotted against time, the plot reveals an S-shaped curve. It appears that, whereas CUAs initially were published more frequently in general medical or health services research journals, there was a clear increase in the diffusion of CUA into subspecialty journals over time. The concentration ratio for research centers as measured by the Herfindhal-Hirschman Index decreased over time.

CONCLUSIONS: The spread of CUA through the medical literature follows patterns identified for the diffusion of other new technologies and processes. Future research should focus on what impact this spread has had on the practice of medicine and formulation of health policy.

METHODS: We searched the English-language medical literature for original CUAs reporting outcomes as cost per quality-adjusted life-year (QALY). Two trained readers independently audited each article, abstracting data on the health state descriptions, corresponding utility weights, methods of elicitation, and sources of the estimates. The utility elicitation methods from 1998 to 2001 were compared with the methods used to obtain utilities before 1998.

RESULTS: We identified 306 CUAs published after 1998, reporting 1210 separate health-related utility estimates, bringing the total in our catalog to 2159 weights. Most frequently, health states pertained to the circulatory system and oncology. Methods varied substantially: 36% of authors used direct elicitation (standard gamble, time trade-off or rating scale), 23% used generic health status instruments (EQ-5D, Health Utilities Index, etc.), and 25% estimated weights based on clinical judgment. Community preferences were used in 27% of the values. Compared with pre-1998, utilities published from 1998 to 2001 were more likely to be elicited using a generic instrument, more likely elicited from community samples, and less likely derived from expert opinion, with no formally employed methodology.

CONCLUSIONS: Increasingly, analysts conducting CUAs are using generic, preference-weighted instruments, and relying on community-based preferences. Our catalog of utility weights provides a useful reference tool for producers and consumers of CUAs, but also highlights the continued need for improvement in methods and transparency.

BACKGROUND: Cardiovascular "report cards" often compare risk-adjusted surgical outcomes; however, it is unclear to what extent the risk-adjustment process itself may affect these metrics.

METHODS: As part of the Cooperative Cardiovascular Project's Pilot Revascularization Study, we compared the predictive accuracy of four bypass clinical risk models among 3,654 Medicare patients undergoing surgery at 28 hospitals in Alabama and Iowa. We also compared the agreement in hospital-level risk-adjusted bypass outcome performance ratings depending on which of the four risk models was applied.

RESULTS: Although the four risk models had similar discriminatory abilities (C-index, 0.71 to 0.74), certain models tended to overpredict mortality in higher-risk patients. There was high correlation between a hospital's risk-adjusted mortality rates regardless of which of the four models was used (correlation between risk-adjusted rating, 0.93 to 0.97). In contrast, there was limited agreement in which hospitals were identified as "performance outliers" depending on which risk-adjustment model was used and how outlier status was defined.

CONCLUSIONS: A hospital's risk-adjusted bypass surgery mortality rating, relative to its peers, was consistent regardless of the risk-adjustment model applied, supporting their use as a means of provider performance feedback. Designation of performance outliers, however, can vary significantly depending on the benchmark and methods used for this determination.

DATA AND METHODS: We compared rankings of the most common diseases covered by the CUAs to rankings of U.S. disease burden. We also examined the extent to which CUAs covered key Healthy People 2010 priorities.

RESULTS: CUAs have focused mostly on pharmaceuticals (40%) and surgical procedures (16%). When compared to leading causes of DALYs, the data show overrepresentation of CUAs in cerebrovascular disease, diabetes, breast cancer, and HIV/AIDS, and underrepresentation in depression and bipolar disorder, injuries, and substance abuse disorders. Few CUAs have targeted Healthy People 2010 areas, such as physical activity.

CONCLUSIONS: Published CUAs are associated with burden measures, but have not covered certain important health problems. These discrepancies do not alone indicate that society has been targeting resources for research inefficiently, but they do suggest the need to formalize the question of where each CUA research dollar might do the most good.