Clara Dismuke - Academia.edu (original) (raw)

Papers by Clara Dismuke

Telemedicine and e-Health, 2013

Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, hi... more Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem. Materials and Methods: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the inperson condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. Results: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. Conclusions: The results of this study provide evidence that CVT is a costreducing mode of service delivery to Veterans with PTSD relative to in-person delivery.

Journal of general internal medicine, 2016

To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one... more To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one of four categories of comorbid depression: no depression, unrecognized depression, asymptomatic depression, or symptomatic depression. Data from the 2004-2011 Medical Expenditure Panel Survey (MEPS) was used to create nationally representative estimates. The dependent variable was total healthcare expenditures for the calendar year, including office-based, hospital outpatient, emergency room, inpatient hospital, prescription, dental, and home health care expenditures. The 2004-2011 direct medical costs were adjusted to a common 2014 dollar value. The primary independent variable was four mutually exclusive depression categories created from ICD-9-CM codes and the PHQ-2 depression screening tool. Healthcare expenditures were estimated using a two-part model and were adjusted for age, sex, race, marital status, education, health insurance, metropolitan statistical area status, region, inc...

Med Care, 2005

Growing reliance on service provision through systems and networks creates the need to better und... more Growing reliance on service provision through systems and networks creates the need to better understand the nature of the relationship between service collaboration and hospital performance and the conditions that affect this relationship. We examine 1) the effects of service provision through health systems and health networks on hospital cost performance and 2) the moderating effects of market conditions and service differentiation on the collaboration-cost relationship. We used moderated regression analysis to test the direct and moderating effects. Data on 1368 private hospitals came from the 1998 AHA Annual Survey, Medicare Cost Reports, and Solucient. Service collaboration was measured as the proportion of hospital services provided at the system level and at the network level. Market conditions were measured by the levels of managed care penetration and competition in the hospital's market. The proportion of hospital services provided at the system level had a negative relationship with hospital cost. The relationship was curvilinear for network use. Degree of managed care penetration moderated the relationship between network-based collaboration and hospital cost. The benefits of service collaboration through systems and networks, as measured by reduced cost, depend on degree of collaboration rather than mere membership. In loosely structured collaborations such as networks, costs reduce initially but increase later as the extent of collaboration increases. The effect of network-based collaboration is also tempered by managed care penetration. These effects are not seen in more tightly integrated forms such as systems.

Journal of Affective Disorders, 2016

This study used the Medical Expenditures Panel Survey (MEPS) to estimate the cost of diabetes, de... more This study used the Medical Expenditures Panel Survey (MEPS) to estimate the cost of diabetes, depression, and comorbid diabetes and depression over 8 years. An 8-year pooled dataset was created using the household and medical provider components of MEPS. Medical expenditures were adjusted to a common 2014 dollar value. Analyses used responses of 147,095 individuals ≥18 years of age for the years 2004-2011. The dependent variable in this study was total healthcare expenditure and the primary independent variables were diabetes and depression status. A two-part (probit/GLM) model was used to estimate the annual medical spending and marginal effects were calculated for incremental cost. In the pooled sample, after adjusting for socio-demographic factors, comorbidities and time trend covariates, the incremental cost of depression only was 2654(952654 (95% CI 2343-2966), diabetes was 2654(952692 (95% CI 2338-3046), and both was 6037(CI956037 (CI 95% 5243-6830) when compared to patients with none. Based on the unadjusted mean, annual average aggregate cost of depression only was estimated at 6037(CI95238.3 billion, diabetes only 150.1billionanddepressionanddiabetestogetherwas150.1 billion and depression and diabetes together was 150.1billionanddepressionanddiabetestogetherwas77.6 billion. Costs at both the individual and aggregate level are significant, with comorbid diagnoses resulting in higher incremental costs than the sum of the costs for each diagnosis alone. In addition, while the cost of depression increased over time, the cost of diabetes decreased over time, much due to decreased inpatient costs. This study highlights the tremendous cost savings possible through more aggressive screening, diagnosis, and treatment of depression.

Appl Econ, 2002

Portugal was the first country with a national health system to incorporate diagnosis related gro... more Portugal was the first country with a national health system to incorporate diagnosis related group (DRG) case-mix adjustment in formulating hospital budgets on a nation-wide basis. Most of the case-mix paymentąoutcomes literature comes from the USA where the quality of data is ...

The use of Diagnostic Related Groups (DRG) as a mechanism for hospital financing is a currently d... more The use of Diagnostic Related Groups (DRG) as a mechanism for hospital financing is a currently debated topic in Portugal. The DRG system was scheduled to be initiated by the Health Ministry of Portugal on January 1, 1990 as an instrument for the allocation of public hospital budgets funded by the National Health Service (NHS), and as a method of

Diabetes care, Jan 22, 2015

Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to... more Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in healthcare expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011. We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time. Relative to individuals without diabetes ($5,058 [95% CI 4,949−4,949-4,949−5,166]), individuals with diabetes ($12,180 [$11,775-$12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjusting for confounders, individuals with diabetes had 2,558(2,558 (2,558(2,266-$2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabe...

American Journal of Public Health, 2015

We examined the association between traumatic brain injury (TBI) severity and combat exposure by ... more We examined the association between traumatic brain injury (TBI) severity and combat exposure by race/ethnicity. We estimated logit models of the fully adjusted association of combat exposure with TBI severity in separate race/ethnicity models for a national cohort of 132 995 veterans with TBI between 2004 and 2010. Of veterans with TBI, 25.8% had served in a combat zone. Mild TBI increased from 11.5% to 40.3%, whereas moderate or severe TBI decreased from 88.5% to 59.7%. Moderate or severe TBI was higher in non-Hispanic Blacks (80.0%) and Hispanics (89.4%) than in non-Hispanic Whites (71.9%). In the fully adjusted all-race/ethnicity model, non-Hispanic Blacks (1.44; 95% confidence interval [CI] = 1.37, 1.52) and Hispanics (1.47; 95% CI = 1.26, 1.72) had higher odds of moderate or severe TBI than did non-Hispanic Whites. However, combat exposure was associated with higher odds of mild TBI in non-Hispanic Blacks (2.48; 95% CI = 2.22, 2.76) and Hispanics (3.42; 95% CI = 1.84, 6.35) than in non-Hispanic Whites (2.17; 95% CI = 2.09, 2.26). Research is needed to understand racial differences in the effect of combat exposure on mild TBI and on interventions to prevent TBI across severity levels.

Global Journal of Health Science, 2015

Primary: To examine Veterans Administration (VA) utilization and other potential mediators betwee... more Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI). A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI. United States (US) Veterans Administration (VA) Hospitals and Clinics. 14, 690 US veterans clinically diagnosed with TBI in 2006. Not Applicable. The study is a secondary data analysis. Mortality, Utilization. Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53). We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.

Journal of General Internal Medicine, 2015

Although the national cost of missed workdays associated with diabetes has been estimated previou... more Although the national cost of missed workdays associated with diabetes has been estimated previously, we use the most recent available national data and methodology to update the individual and national estimates for the U.S population. We identified 14,429 employed individuals ≥ 18 years of age in 2011 Medical Expenditure Panel Survey (MEPS) data. Diabetes and missed workdays were based on self-report, and cost was based on multiplying the daily wage rate for each individual by the number of missed days. Adjusted total national burden of missed workdays associated with diabetes was calculated using a novel two-part model to simultaneously estimate the association of diabetes with the number and cost of missed workdays. The unadjusted annual mean 2011 cost of missed workdays was 277(95277 (95 % CI 177.0-378.0) for individuals with diabetes relative to 277(95160 (95 % CI 130−130-130−189) for those without. The incremental cost of missed workdays associated with diabetes was 120(95120 (95 % CI 120(9530.7-$209.1). Based on the US population in 2011, the unadjusted national burden of missed workdays associated with diabetes was estimated to be 2.7billion,whilethefullyadjustedincrementalnationalburdenwasestimatedtobe2.7 billion, while the fully adjusted incremental national burden was estimated to be 2.7billion,whilethefullyadjustedincrementalnationalburdenwasestimatedtobe1.1 billion. We provide more precise estimates of the cost burden of diabetes due to missed workdays on the U.S population. The high incremental and total cost burden of missed workdays among Americans with diabetes suggests the need for interventions to improve diabetes care management among employed individuals.

Global Journal of Health Science, 2015

Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in t... more Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in the conflicts in Iraq and Afghanistan. TBI is a major burden for both the military and civilian population in the US and worldwide. It is a leading cause of death and disability in the US and a major health services resource burden.

Diabetes Research and Clinical Practice, 2015

Approximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimat... more Approximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimates of the association of CKD with medical care expenditures in individuals with diabetes. Our aim is to assess the association of CKD with total medical expenditures in US adults with diabetes using a national sample and novel cost estimation methodology. Data on 2,053 adults with diabetes in the 2011 Medical Expenditure Panel Survey (MEPS) was analyzed. Individuals with CKD were identified based on self-report. Adjusted mean health services expenditures per person in 2011 were estimated using a two-part model after adjusting for demographic and clinical covariates. Of the 2,053 individuals with diabetes, approximately 9.7% had self-reported CKD. Unadjusted mean expenditures for individuals with CKD were 20,726relativeto20,726 relative to 20,726relativeto9,689.49 for no CKD. Adjusted mean expenditures from the 2-part model for individuals with CKD were 8473higherrelativetoindividualswithoutCKD.AdditionalsignificantcovariateswereHispanic/otherrace,uninsured,urbandwellers,CVD,stroke,highcholesterol,arthritis,andasthma.TheestimatedunadjustedtotalexpendituresforindividualswithCKDwereestimatedtobeinexcessof8473 higher relative to individuals without CKD. Additional significant covariates were Hispanic/other race, uninsured, urban dwellers, CVD, stroke, high cholesterol, arthritis, and asthma. The estimated unadjusted total expenditures for individuals with CKD were estimated to be in excess of 8473higherrelativetoindividualswithoutCKD.AdditionalsignificantcovariateswereHispanic/otherrace,uninsured,urbandwellers,CVD,stroke,highcholesterol,arthritis,andasthma.TheestimatedunadjustedtotalexpendituresforindividualswithCKDwereestimatedtobeinexcessof43 billion in 2011. We showed that CKD is a significant contributor to the financial burden among individuals with diabetes, and that minorities and the uninsured with CKD may experience barriers in access to care. Our study also provides a baseline national estimate of CKD cost in Diabetes by which future studies can be used for comparison.

Health care management science, 1999

The use of Diagnosis Related Groups (DRG) as a mechanism for hospital financing is a currently de... more The use of Diagnosis Related Groups (DRG) as a mechanism for hospital financing is a currently debated topic in Portugal. The DRG system was scheduled to be initiated by the Health Ministry of Portugal on January 1, 1990 as an instrument for the allocation of public hospital budgets funded by the National Health Service (NHS), and as a method of payment for other third party payers (e.g., Public Employees (ADSE), private insurers, etc.). Based on experience from other countries such as the United States, it was expected that implementation of this system would result in more efficient hospital resource utilisation and a more equitable distribution of hospital budgets. However, in order to minimise the potentially adverse financial impact on hospitals, the Portuguese Health Ministry decided to gradually phase in the use of the DRG system for budget allocation by using blended hospital-specific and national DRG case-mix rates. Since implementation in 1990, the percentage of each hospi...

NeuroRehabilitation, 2010

Few studies have used national data to characterize the occurrence of aphasia in the U.S. The pur... more Few studies have used national data to characterize the occurrence of aphasia in the U.S. The purpose of this project was to use national hospital discharge data to examine the number and characteristics of patients discharged from U.S. hospitals with a diagnosis of aphasia. We examined data from the National Inpatient Sample (NIS) (1997-2006) using ICD-9 codes for aphasia to identify the number and demographic characteristics of patients with aphasia. Between 1997 and 2006 the number of individuals with aphasia was approximately 100,000 per year. During the 10-year period, the majority of individuals with aphasia were 65 years of age and older, female, had Medicare as a primary payer source and resided in the South. The occurrence of aphasia and demographic characteristics of individuals with aphasia has been generally consistent in the U.S. from 1997 to 2006. Future studies are needed to quantify direct and indirect costs of treating individuals with aphasia as well as other facto...

The American journal of managed care, 2008

To evaluate whether attending diabetes group visits (GVs) leads to lower medical care charges for... more To evaluate whether attending diabetes group visits (GVs) leads to lower medical care charges for inadequately insured patients with type 2 diabetes mellitus (DM). Randomized controlled clinical trial. Data were abstracted from financial records for 186 patients with uncontrolled type 2 DM randomized to receive care in GVs or usual care for 12 months. Mann-Whitney tests for differences of means for outpatient visits (primary and specialty care), emergency department (ED) visits, and inpatient stays were performed. Separate charge models were developed for primary and specialty outpatient visits. Because GV adherence is potentially dependent on unobserved patient characteristics, treatment effect models of outpatient charges and specialty care visits were estimated using maximum likelihood methods. Mann-Whitney test results indicated that GV patients had reduced ED and total charges but more outpatient charges than usual care patients. Ordinary least squares estimations confirmed tha...

Psychological Services, 2013

Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagn... more Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.

Poverty & Public Policy, 2011

Background: Poverty rates among individuals with disabilities are much higher than for the genera... more Background: Poverty rates among individuals with disabilities are much higher than for the general U.S. population. However, little is known about the likelihood of poverty among families of those with Spinal Cord Injury (SCI). Objectives: Examine the association of pre-injury and post-injury education with the likelihood of familial poverty by race/ethnicity for 1,405 adults between the ages of 18 and 64 who had a traumatic spinal cord injury at least one year prior to the study interview (2003). Methods: Based on reported household income in 2002, familial poverty status of individuals with a SCI was determined based on United States (U.S.) Federal Poverty Guidelines during the year of reported income. Based on a conceptual model of human capital loss and acquisition, a model of the likelihood of poverty was estimated separately for Non-Hispanic White and Black/Hispanic families. Results: 18.33% of Non-Hispanic White families and 42.35% of Black/Hispanic families with a member having SCI were found to be living below the poverty level. Bachelor's degree education attainment was the most important factor and was significantly associated with a lower likelihood of familial poverty for Non-Hispanic White (-0.10) and for Black/Hispanic families (-0.27). Conclusions: We have proposed that the Social Security Administration grant presumptive disability eligibility for SCI, guarantee continued medical benefits after employment and pilot an online college degree reimbursement plan to reduce poverty among families of individuals with SCI.

Spinal Cord, 2014

Secondary analysis of existing data. To estimate the association of diabetes with family income i... more Secondary analysis of existing data. To estimate the association of diabetes with family income in a pooled 15-year cohort of individuals with TSCI. A large specialty hospital in the southeastern United States. A total number of 1408 individuals identified with TSCI were surveyed regarding family income as well as clinical and demographic factors. Due to income being reported in censored intervals rather than individual dollar values, interval regression was used to estimate models of the association of family income with diabetes. Approximately 12% of individuals with TSCI reported being diagnosed with diabetes. The most frequent family income interval in our sample was <$10,000, lower than the poverty threshold. The family income interval with the highest rate of diabetes was 15,000−15,000-15,000−20,000. In an unadjusted model, diabetes was associated with a significant reduction of 8749andinafullyadjustedmodel,diabeteswassignificantlyassociatedwithareductionof8749 and in a fully adjusted model, diabetes was significantly associated with a reduction of 8749andinafullyadjustedmodel,diabeteswassignificantlyassociatedwithareductionof8560 in family income. Being a minority was also significantly associated with a reduction whereas educational attainment was associated with increased family income. TSCI severity was not significantly related to family income. Diabetes imposes an additional financial burden on individuals with TSCI an already vulnerable population with high health care costs. The burden is more pronounced in minorities with TSCI. Providers should be aware of the higher prevalence of diabetes among patients with TSCI and pursue a policy of testing early and vigilant management. Further studies are needed regarding special interventions for managing diabetes in the TSCI population.

PLoS ONE, 2014

Purpose: To assess the impact of mental health visits (MHV) on the cost of care for Veterans with... more Purpose: To assess the impact of mental health visits (MHV) on the cost of care for Veterans with diabetes and comorbid mental health conditions. Methods: A national cohort of 120,852 Veterans with diabetes and at least one mental health diagnosis (i.e., substance abuse, depression or psychoses) in 2002 was followed through 2006. Outcomes were pharmacy, inpatient and outpatient costs in 2012 dollars.

Telemedicine and e-Health, 2013

Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, hi... more Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem. Materials and Methods: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the inperson condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. Results: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. Conclusions: The results of this study provide evidence that CVT is a costreducing mode of service delivery to Veterans with PTSD relative to in-person delivery.

Journal of general internal medicine, 2016

To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one... more To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one of four categories of comorbid depression: no depression, unrecognized depression, asymptomatic depression, or symptomatic depression. Data from the 2004-2011 Medical Expenditure Panel Survey (MEPS) was used to create nationally representative estimates. The dependent variable was total healthcare expenditures for the calendar year, including office-based, hospital outpatient, emergency room, inpatient hospital, prescription, dental, and home health care expenditures. The 2004-2011 direct medical costs were adjusted to a common 2014 dollar value. The primary independent variable was four mutually exclusive depression categories created from ICD-9-CM codes and the PHQ-2 depression screening tool. Healthcare expenditures were estimated using a two-part model and were adjusted for age, sex, race, marital status, education, health insurance, metropolitan statistical area status, region, inc...

Med Care, 2005

Growing reliance on service provision through systems and networks creates the need to better und... more Growing reliance on service provision through systems and networks creates the need to better understand the nature of the relationship between service collaboration and hospital performance and the conditions that affect this relationship. We examine 1) the effects of service provision through health systems and health networks on hospital cost performance and 2) the moderating effects of market conditions and service differentiation on the collaboration-cost relationship. We used moderated regression analysis to test the direct and moderating effects. Data on 1368 private hospitals came from the 1998 AHA Annual Survey, Medicare Cost Reports, and Solucient. Service collaboration was measured as the proportion of hospital services provided at the system level and at the network level. Market conditions were measured by the levels of managed care penetration and competition in the hospital's market. The proportion of hospital services provided at the system level had a negative relationship with hospital cost. The relationship was curvilinear for network use. Degree of managed care penetration moderated the relationship between network-based collaboration and hospital cost. The benefits of service collaboration through systems and networks, as measured by reduced cost, depend on degree of collaboration rather than mere membership. In loosely structured collaborations such as networks, costs reduce initially but increase later as the extent of collaboration increases. The effect of network-based collaboration is also tempered by managed care penetration. These effects are not seen in more tightly integrated forms such as systems.

Journal of Affective Disorders, 2016

This study used the Medical Expenditures Panel Survey (MEPS) to estimate the cost of diabetes, de... more This study used the Medical Expenditures Panel Survey (MEPS) to estimate the cost of diabetes, depression, and comorbid diabetes and depression over 8 years. An 8-year pooled dataset was created using the household and medical provider components of MEPS. Medical expenditures were adjusted to a common 2014 dollar value. Analyses used responses of 147,095 individuals ≥18 years of age for the years 2004-2011. The dependent variable in this study was total healthcare expenditure and the primary independent variables were diabetes and depression status. A two-part (probit/GLM) model was used to estimate the annual medical spending and marginal effects were calculated for incremental cost. In the pooled sample, after adjusting for socio-demographic factors, comorbidities and time trend covariates, the incremental cost of depression only was 2654(952654 (95% CI 2343-2966), diabetes was 2654(952692 (95% CI 2338-3046), and both was 6037(CI956037 (CI 95% 5243-6830) when compared to patients with none. Based on the unadjusted mean, annual average aggregate cost of depression only was estimated at 6037(CI95238.3 billion, diabetes only 150.1billionanddepressionanddiabetestogetherwas150.1 billion and depression and diabetes together was 150.1billionanddepressionanddiabetestogetherwas77.6 billion. Costs at both the individual and aggregate level are significant, with comorbid diagnoses resulting in higher incremental costs than the sum of the costs for each diagnosis alone. In addition, while the cost of depression increased over time, the cost of diabetes decreased over time, much due to decreased inpatient costs. This study highlights the tremendous cost savings possible through more aggressive screening, diagnosis, and treatment of depression.

Appl Econ, 2002

Portugal was the first country with a national health system to incorporate diagnosis related gro... more Portugal was the first country with a national health system to incorporate diagnosis related group (DRG) case-mix adjustment in formulating hospital budgets on a nation-wide basis. Most of the case-mix paymentąoutcomes literature comes from the USA where the quality of data is ...

The use of Diagnostic Related Groups (DRG) as a mechanism for hospital financing is a currently d... more The use of Diagnostic Related Groups (DRG) as a mechanism for hospital financing is a currently debated topic in Portugal. The DRG system was scheduled to be initiated by the Health Ministry of Portugal on January 1, 1990 as an instrument for the allocation of public hospital budgets funded by the National Health Service (NHS), and as a method of

Diabetes care, Jan 22, 2015

Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to... more Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in healthcare expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011. We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time. Relative to individuals without diabetes ($5,058 [95% CI 4,949−4,949-4,949−5,166]), individuals with diabetes ($12,180 [$11,775-$12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjusting for confounders, individuals with diabetes had 2,558(2,558 (2,558(2,266-$2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabe...

American Journal of Public Health, 2015

We examined the association between traumatic brain injury (TBI) severity and combat exposure by ... more We examined the association between traumatic brain injury (TBI) severity and combat exposure by race/ethnicity. We estimated logit models of the fully adjusted association of combat exposure with TBI severity in separate race/ethnicity models for a national cohort of 132 995 veterans with TBI between 2004 and 2010. Of veterans with TBI, 25.8% had served in a combat zone. Mild TBI increased from 11.5% to 40.3%, whereas moderate or severe TBI decreased from 88.5% to 59.7%. Moderate or severe TBI was higher in non-Hispanic Blacks (80.0%) and Hispanics (89.4%) than in non-Hispanic Whites (71.9%). In the fully adjusted all-race/ethnicity model, non-Hispanic Blacks (1.44; 95% confidence interval [CI] = 1.37, 1.52) and Hispanics (1.47; 95% CI = 1.26, 1.72) had higher odds of moderate or severe TBI than did non-Hispanic Whites. However, combat exposure was associated with higher odds of mild TBI in non-Hispanic Blacks (2.48; 95% CI = 2.22, 2.76) and Hispanics (3.42; 95% CI = 1.84, 6.35) than in non-Hispanic Whites (2.17; 95% CI = 2.09, 2.26). Research is needed to understand racial differences in the effect of combat exposure on mild TBI and on interventions to prevent TBI across severity levels.

Global Journal of Health Science, 2015

Primary: To examine Veterans Administration (VA) utilization and other potential mediators betwee... more Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI). A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI. United States (US) Veterans Administration (VA) Hospitals and Clinics. 14, 690 US veterans clinically diagnosed with TBI in 2006. Not Applicable. The study is a secondary data analysis. Mortality, Utilization. Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53). We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.

Journal of General Internal Medicine, 2015

Although the national cost of missed workdays associated with diabetes has been estimated previou... more Although the national cost of missed workdays associated with diabetes has been estimated previously, we use the most recent available national data and methodology to update the individual and national estimates for the U.S population. We identified 14,429 employed individuals ≥ 18 years of age in 2011 Medical Expenditure Panel Survey (MEPS) data. Diabetes and missed workdays were based on self-report, and cost was based on multiplying the daily wage rate for each individual by the number of missed days. Adjusted total national burden of missed workdays associated with diabetes was calculated using a novel two-part model to simultaneously estimate the association of diabetes with the number and cost of missed workdays. The unadjusted annual mean 2011 cost of missed workdays was 277(95277 (95 % CI 177.0-378.0) for individuals with diabetes relative to 277(95160 (95 % CI 130−130-130−189) for those without. The incremental cost of missed workdays associated with diabetes was 120(95120 (95 % CI 120(9530.7-$209.1). Based on the US population in 2011, the unadjusted national burden of missed workdays associated with diabetes was estimated to be 2.7billion,whilethefullyadjustedincrementalnationalburdenwasestimatedtobe2.7 billion, while the fully adjusted incremental national burden was estimated to be 2.7billion,whilethefullyadjustedincrementalnationalburdenwasestimatedtobe1.1 billion. We provide more precise estimates of the cost burden of diabetes due to missed workdays on the U.S population. The high incremental and total cost burden of missed workdays among Americans with diabetes suggests the need for interventions to improve diabetes care management among employed individuals.

Global Journal of Health Science, 2015

Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in t... more Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in the conflicts in Iraq and Afghanistan. TBI is a major burden for both the military and civilian population in the US and worldwide. It is a leading cause of death and disability in the US and a major health services resource burden.

Diabetes Research and Clinical Practice, 2015

Approximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimat... more Approximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimates of the association of CKD with medical care expenditures in individuals with diabetes. Our aim is to assess the association of CKD with total medical expenditures in US adults with diabetes using a national sample and novel cost estimation methodology. Data on 2,053 adults with diabetes in the 2011 Medical Expenditure Panel Survey (MEPS) was analyzed. Individuals with CKD were identified based on self-report. Adjusted mean health services expenditures per person in 2011 were estimated using a two-part model after adjusting for demographic and clinical covariates. Of the 2,053 individuals with diabetes, approximately 9.7% had self-reported CKD. Unadjusted mean expenditures for individuals with CKD were 20,726relativeto20,726 relative to 20,726relativeto9,689.49 for no CKD. Adjusted mean expenditures from the 2-part model for individuals with CKD were 8473higherrelativetoindividualswithoutCKD.AdditionalsignificantcovariateswereHispanic/otherrace,uninsured,urbandwellers,CVD,stroke,highcholesterol,arthritis,andasthma.TheestimatedunadjustedtotalexpendituresforindividualswithCKDwereestimatedtobeinexcessof8473 higher relative to individuals without CKD. Additional significant covariates were Hispanic/other race, uninsured, urban dwellers, CVD, stroke, high cholesterol, arthritis, and asthma. The estimated unadjusted total expenditures for individuals with CKD were estimated to be in excess of 8473higherrelativetoindividualswithoutCKD.AdditionalsignificantcovariateswereHispanic/otherrace,uninsured,urbandwellers,CVD,stroke,highcholesterol,arthritis,andasthma.TheestimatedunadjustedtotalexpendituresforindividualswithCKDwereestimatedtobeinexcessof43 billion in 2011. We showed that CKD is a significant contributor to the financial burden among individuals with diabetes, and that minorities and the uninsured with CKD may experience barriers in access to care. Our study also provides a baseline national estimate of CKD cost in Diabetes by which future studies can be used for comparison.

Health care management science, 1999

The use of Diagnosis Related Groups (DRG) as a mechanism for hospital financing is a currently de... more The use of Diagnosis Related Groups (DRG) as a mechanism for hospital financing is a currently debated topic in Portugal. The DRG system was scheduled to be initiated by the Health Ministry of Portugal on January 1, 1990 as an instrument for the allocation of public hospital budgets funded by the National Health Service (NHS), and as a method of payment for other third party payers (e.g., Public Employees (ADSE), private insurers, etc.). Based on experience from other countries such as the United States, it was expected that implementation of this system would result in more efficient hospital resource utilisation and a more equitable distribution of hospital budgets. However, in order to minimise the potentially adverse financial impact on hospitals, the Portuguese Health Ministry decided to gradually phase in the use of the DRG system for budget allocation by using blended hospital-specific and national DRG case-mix rates. Since implementation in 1990, the percentage of each hospi...

NeuroRehabilitation, 2010

Few studies have used national data to characterize the occurrence of aphasia in the U.S. The pur... more Few studies have used national data to characterize the occurrence of aphasia in the U.S. The purpose of this project was to use national hospital discharge data to examine the number and characteristics of patients discharged from U.S. hospitals with a diagnosis of aphasia. We examined data from the National Inpatient Sample (NIS) (1997-2006) using ICD-9 codes for aphasia to identify the number and demographic characteristics of patients with aphasia. Between 1997 and 2006 the number of individuals with aphasia was approximately 100,000 per year. During the 10-year period, the majority of individuals with aphasia were 65 years of age and older, female, had Medicare as a primary payer source and resided in the South. The occurrence of aphasia and demographic characteristics of individuals with aphasia has been generally consistent in the U.S. from 1997 to 2006. Future studies are needed to quantify direct and indirect costs of treating individuals with aphasia as well as other facto...

The American journal of managed care, 2008

To evaluate whether attending diabetes group visits (GVs) leads to lower medical care charges for... more To evaluate whether attending diabetes group visits (GVs) leads to lower medical care charges for inadequately insured patients with type 2 diabetes mellitus (DM). Randomized controlled clinical trial. Data were abstracted from financial records for 186 patients with uncontrolled type 2 DM randomized to receive care in GVs or usual care for 12 months. Mann-Whitney tests for differences of means for outpatient visits (primary and specialty care), emergency department (ED) visits, and inpatient stays were performed. Separate charge models were developed for primary and specialty outpatient visits. Because GV adherence is potentially dependent on unobserved patient characteristics, treatment effect models of outpatient charges and specialty care visits were estimated using maximum likelihood methods. Mann-Whitney test results indicated that GV patients had reduced ED and total charges but more outpatient charges than usual care patients. Ordinary least squares estimations confirmed tha...

Psychological Services, 2013

Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagn... more Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.

Poverty & Public Policy, 2011

Background: Poverty rates among individuals with disabilities are much higher than for the genera... more Background: Poverty rates among individuals with disabilities are much higher than for the general U.S. population. However, little is known about the likelihood of poverty among families of those with Spinal Cord Injury (SCI). Objectives: Examine the association of pre-injury and post-injury education with the likelihood of familial poverty by race/ethnicity for 1,405 adults between the ages of 18 and 64 who had a traumatic spinal cord injury at least one year prior to the study interview (2003). Methods: Based on reported household income in 2002, familial poverty status of individuals with a SCI was determined based on United States (U.S.) Federal Poverty Guidelines during the year of reported income. Based on a conceptual model of human capital loss and acquisition, a model of the likelihood of poverty was estimated separately for Non-Hispanic White and Black/Hispanic families. Results: 18.33% of Non-Hispanic White families and 42.35% of Black/Hispanic families with a member having SCI were found to be living below the poverty level. Bachelor's degree education attainment was the most important factor and was significantly associated with a lower likelihood of familial poverty for Non-Hispanic White (-0.10) and for Black/Hispanic families (-0.27). Conclusions: We have proposed that the Social Security Administration grant presumptive disability eligibility for SCI, guarantee continued medical benefits after employment and pilot an online college degree reimbursement plan to reduce poverty among families of individuals with SCI.

Spinal Cord, 2014

Secondary analysis of existing data. To estimate the association of diabetes with family income i... more Secondary analysis of existing data. To estimate the association of diabetes with family income in a pooled 15-year cohort of individuals with TSCI. A large specialty hospital in the southeastern United States. A total number of 1408 individuals identified with TSCI were surveyed regarding family income as well as clinical and demographic factors. Due to income being reported in censored intervals rather than individual dollar values, interval regression was used to estimate models of the association of family income with diabetes. Approximately 12% of individuals with TSCI reported being diagnosed with diabetes. The most frequent family income interval in our sample was <$10,000, lower than the poverty threshold. The family income interval with the highest rate of diabetes was 15,000−15,000-15,000−20,000. In an unadjusted model, diabetes was associated with a significant reduction of 8749andinafullyadjustedmodel,diabeteswassignificantlyassociatedwithareductionof8749 and in a fully adjusted model, diabetes was significantly associated with a reduction of 8749andinafullyadjustedmodel,diabeteswassignificantlyassociatedwithareductionof8560 in family income. Being a minority was also significantly associated with a reduction whereas educational attainment was associated with increased family income. TSCI severity was not significantly related to family income. Diabetes imposes an additional financial burden on individuals with TSCI an already vulnerable population with high health care costs. The burden is more pronounced in minorities with TSCI. Providers should be aware of the higher prevalence of diabetes among patients with TSCI and pursue a policy of testing early and vigilant management. Further studies are needed regarding special interventions for managing diabetes in the TSCI population.

PLoS ONE, 2014

Purpose: To assess the impact of mental health visits (MHV) on the cost of care for Veterans with... more Purpose: To assess the impact of mental health visits (MHV) on the cost of care for Veterans with diabetes and comorbid mental health conditions. Methods: A national cohort of 120,852 Veterans with diabetes and at least one mental health diagnosis (i.e., substance abuse, depression or psychoses) in 2002 was followed through 2006. Outcomes were pharmacy, inpatient and outpatient costs in 2012 dollars.