Economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a medicare advantage population
Economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a medicare advantage population
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DOI：
10.18553/jmcp.2008.14.2.176
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发表时间：
2008-03-01
影响因子：
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通讯作者：
Akazawa, Manabu
中科院分区：
文献类型：
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作者：
Blanchette, Christopher M.;Gutierrez, Benjamin;Akazawa, Manabu
背景：慢性阻塞性肺疾病（COPD）是一种高度流行的疾病，患者消耗大量资源。在社区医疗保险受益人中，12%的人报告他们在2002年患有慢性阻塞性肺病。对于临床医生来说，区分COPD和哮喘可能很困难，但在COPD和哮喘患者中，大约20%的患者同时患有这两种疾病。合并哮喘和慢性阻塞性肺病的经济影响可能很大，但尚未得到研究。目的：评估医疗保险优势人群中COPD患者哮喘的成本负担。方法：我们审查了一个大型健康计划的数据库，其中包含来自30多个不同计划的信息，覆盖了大约2500万成员。我们确定了年龄在40岁或以上的医疗保险受益人，他们的医疗和药房福利和医疗索赔符合国际疾病分类，第九次修订，临床修改（ICD-9-CM）的慢性阻塞性肺病或哮喘诊断代码，鉴定期为1年（日历年2004年）。我们根据2004年医疗索赔（任何诊断领域）的诊断将患者分配到2个队列；COPD组至少有1例COPD医疗索赔，COPD +哮喘组至少有1例COPD和哮喘医疗索赔。患者的索引日期是2004年期间首次有COPD或哮喘诊断代码的医疗索赔的日期。为了确认诊断，每位患者需要在指标日期前12个月至指标日期后12个月的24个月内至少有1项COPD索赔（COPD队列）或至少1项COPD索赔和至少1项哮喘索赔（COPD +哮喘队列）。我们排除了以下患者：(1)在索引日期前后的12个月内没有连续入组；(2)任何类型的药物没有至少1个药房索赔（以验证药房福利）。结果测量包括急诊室（ER）和医院服务的使用，以及费用（减去会员费用分担后的净提供者支付），分类为全因、非呼吸和呼吸相关。使用服务地点代码确定急诊室使用情况和住院时间。至少需要连续2天的服务日期（住院时间[LOS]至少1天）才能表明住院治疗。需要至少1天的住院观察，以区分住院服务与住院服务地点索赔报告的其他服务（例如程序或检查）。多变量分析调整了年龄、性别、普查地区和Charlson合并症指数（CCI）。使用普通最小二乘回归预测呼吸相关的总医疗保健成本，使用logistic回归预测至少1个急性事件的发生，定义为使用急诊室或住院医院。所有的双向相互作用都被考虑，只有那些有显著结果的才被包括在模型中。所有报告的P值均为双侧，显著性水平为0.05。结果：2004年，数据库中的68,532人参加了医疗保险优势计划。在应用其他纳入标准后，我们排除了大约11%没有任何类型药房索赔的患者。共有8086名患者（11.8%）至少有1项COPD诊断代码的医疗索赔和至少1项COPD或哮喘的其他医疗索赔，并且连续登记至少24个月。COPD +哮喘队列有1843例（22.8%），COPD队列有6243例（77.2%）。与无哮喘的COPD患者相比，COPD +哮喘患者年龄略轻，且女性比例较高。两个队列在地理分布上存在差异，COPD +哮喘队列的疾病严重程度较高，CCI平均评分为2.6（标准差[SD]， 2.1）， COPD队列为2.3 [2.3],P < 0.001)。与呼吸相关的药房费用占呼吸相关医疗保健总费用的比例相对较小：COPD队列约为5.7%，COPD +哮喘队列约为8.8%。在COPD队列中，呼吸相关费用占全因医疗保健总费用的22.0%，在COPD +哮喘队列中占28.7%。COPD +哮喘组的平均（[SD]，中位数）未调整呼吸相关医疗费用为7,240美元（[15,057美元]，1,957美元），COPD组为5,158美元（[11,881美元]，808美元）。在调整了相关变量后，COPD +哮喘队列患者比COPD队列患者更有可能发生至少1次急性事件（例如，急诊室就诊和住院）（调整优势比为1.6；95% CI为1.4-1.7），并且调整后的呼吸相关医疗保健费用为1,931美元（37.1%），为7,135美元，而COPD队列为5,204美元（P < 0.001）。结论：患有慢性阻塞性肺病和哮喘的医疗保险受益人比没有哮喘的慢性阻塞性肺病患者承担更高的医疗保健费用和使用更多的医疗保健服务。
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease whose sufferers consume a large amount of resources. Among community-dwelling Medicare beneficiaries, 12% reported that they had COPD in 2002. For clinicians, differentiating COPD from asthma may be difficult, but among patients with COPD and asthma, approximately 20% have both conditions. The economic impact of concomitant asthma and COPD is potentially large but has not been studied.OBJECTIVE: To assess the cost burden of asthma in patients with COPD in a Medicare Advantage population.METHODS: We reviewed the database of a large health plan that contained information from more than 30 distinct plans covering approximately 25 million members. We identified Medicare beneficiaries aged 40 years or older with medical and pharmacy benefits and medical claims with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for COPD or asthma over a 1-year identification period (calendar year 2004). We assigned patients to 2 cohorts based on diagnoses on medical claims (any diagnosis field) during 2004; the COPD cohort had at least 1 medical claim for COPD, and the COPD + asthma cohort had at least 1 claim for COPD and at least 1 claim for asthma. A patient's index date was the first date during 2004 in which there was a medical claim with a diagnosis code for COPD or asthma. To confirm diagnosis, each patient was required to have at least 1 additional claim for COPD (COPD cohort) or at least 1 claim for COPD and at least 1 claim for asthma (COPD + asthma cohort) during the 24-month period from 12 months before through 12 months after the index date. We excluded patients who (1) were not continuously enrolled during the 12 months before and after the index date and (2) did not have at least 1 pharmacy claim for a drug of any type (to verify pharmacy benefits). Outcome measures included the use of emergency room (ER) and hospital services, and cost (net provider payment after subtraction of member cost share), categorized as all-cause, non-respiratory, and respiratory-related. ER use and inpatient hospital stays were identified using place-of-service codes. A minimum of 2 consecutive dates of service (length of stay [LOS] of at least 1 day) was required to indicate an inpatient hospitalization. An LOS of at least 1 day was required to distinguish inpatient services from other services (e.g., procedures or tests) reported on claims with an inpatient place of service. Multivariate analyses adjusted for age, gender, census region, and Charlson Comorbidity Index (CCI). Ordinary least squares regression was used to predict respiratory-related total health care costs and logistic regression was used to predict the occurrence of at least 1 acute event, defined as use of either an ER or an inpatient hospital. All 2-way interactions were considered, and only those with significant results were included in the models. All reported P values were 2-sided with a 0.05 significance level.RESULTS: During 2004, 68,532 individuals within the database were enrolled in a Medicare Advantage plan. After application of the other inclusion criteria, we excluded approximately 11 % of the patients who did not have 1 pharmacy claim of any type. There were 8,086 patients (11.8%) who had at least 1 medical claim with diagnosis codes for COPD and at least 1 other medical claim for either COPD or asthma and were continuously enrolled for at least 24 months. The COPD + asthma cohort numbered 1,843 patients (22.8%), and the COPD cohort numbered 6,243 patients (77.2%). Compared with COPD patients without asthma, patients with COPD + asthma were slightly younger, and a higher proportion was female. There were differences between the 2 cohorts in geographic distribution, and the COPD + asthma cohort had a higher disease severity with a mean CCI score of 2.6 (standard deviation [SD], 2.1) compared with the COPD cohort (2.3 [2.3], P < 0.001). Respiratory-related pharmacy costs were a relatively small part of total respiratory-related health care costs: approximately 5.7% for the COPD cohort and 8.8% for the COPD + asthma cohort. Respiratory-related costs accounted for 22.0% of total all-cause health care costs for the COPD cohort and 28.7% for the COPD + asthma cohort. Mean ([SD], median) unadjusted respiratory-related health care costs were $7,240 ([$15,057], $1,957) for the COPD + asthma cohort and $5,158 ([$11,881], $808) in the COPD cohort. After adjusting for covariates, patients in the COPD + asthma cohort were more likely to have at least 1 acute event (e.g., ER visits and hospitalizations) than patients in the COPD cohort (adjusted odds ratio, 1.6; 95% CI, 1.4-1.7) and had $1,931 (37.1%) greater adjusted respiratory-related health care costs-$7,135 versus $5,204 for the COPD cohort (P < 0.001).CONCLUSION: Medicare beneficiaries with COPD and asthma incur higher health care costs and use more health care services than those with COPD without asthma.