The Impact of Care Specialty on Survival-Adjusted Medical Costs of COPD Patients After a Hospitalization: a longitudinal analysis

  • Wenjia Chen
  • Don D. Sin
  • J. Mark FitzGerald
  • Mohsen Sadatsafavi
  • for the Canadian Respiratory Research Network
Original Research

ABSTRACT

Background

Little is known about the impact of care provider’s specialty on the medical costs of COPD patients over time.

Objective

To compare the long-term medical costs between newly hospitalized COPD patients whose post-discharge care was initiated by a pulmonary specialist versus by a general practitioner.

Design

Retrospective matched cohort study.

Participants

We identified patients with an incident COPD-related hospitalization from the administrative health database (January 1, 1996, to December 31, 2012) of British Columbia, Canada.

Main measures

Patients were categorized as receiving specialist care or primary care within the first 90 days after discharge from an incident COPD-related hospitalization. Using propensity scores, we matched each patient who initially received specialist care to a patient who received primary care based on demographics, COPD severity, comorbidity, and admission time. A survival-adjusted, multi-part generalized linear model was used to estimate direct medical costs (in 2015 Canadian dollars, [$], including inpatient, outpatient, pharmacy, and community care costs) as overall and as COPD-specific and comorbidity-related costs over the following 5 years.

Key results

The sample included 7710 patients under each group. The initial specialist-care recipients had a modestly higher 5-year survival than the generalist-care recipients (0.564 [95% CI 0.535, 0.634] vs 0.555 [95% CI 0.525, 0.625]; P < .001). Meanwhile, the former incurred $2809 higher all-cause medical costs over 5 years compared to the latter (95% CI $2343, $2913; P < .001), mainly driven by higher medication costs (difference $1782 [95% CI $1658, $1830]; P < .001) particularly related to COPD medications ($1170 [95% CI $1043, $1225]; P < .001). Specialist care recipients also incurred higher costs of COPD-related hospitalization ($1144 [95% CI $650, $1221]; P < .001).

Conclusions

Compared to generalist care, specialist care following COPD hospitalization is slightly more expensive, mainly driven by medication costs especially COPD-specific medications. Future studies should compare differences in health-related quality of life and COPD functional status.

KEY WORDS

COPD specialty of care healthcare costs longitudinal analysis 

Notes

Acknowledgements

WC had full access to all of the data in the study and takes responsibility for the content of the manuscript, including the integrity of the data and the accuracy of the data analysis. WC, JMF, DS, and MS conceived and designed the study. WC analyzed the data and wrote the first draft of the manuscript. WC, JMF, DS, and MS contributed to the interpretation of the data and clinical inputs. All authors were involved in the revision of the manuscript for important intellectual content and approved the final version to be published.

Compliance with ethical standards

Conflict of interest

The authors declare no conflict of interests.

Supplementary material

11606_2018_4406_MOESM1_ESM.docx (71 kb)
ESM 1 (DOCX 70.5 KB)

References

  1. 1.
    Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary. Am J Respir Crit Care Med 2017.  https://doi.org/10.1164/rccm.201701-0218PP.
  2. 2.
    Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD: Role of comorbidities. Eur Respir J 2006;28(6):1245–1257.  https://doi.org/10.1183/09031936.00133805.CrossRefPubMedGoogle Scholar
  3. 3.
    The Human and Economic Burden of COPD - A Leading Cause of Hospital Admission in Canada | Canadian Respiratory Guidelines. http://www.respiratoryguidelines.ca/the-human-and-economic-burden-of-copd-a-leading-cause-of-hospital-admission-in-canada. Accessed 2 Feb 2018.
  4. 4.
    Wier LM, Elixhauser A, Pfuntner A, Au DH. Overview of Hospitalizations among Patients with COPD, 2008: Statistical Brief #106. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. http://www.ncbi.nlm.nih.gov/books/NBK53969/. Accessed 2 Feb 2018.
  5. 5.
    World Health Organization. Burden of COPD. WHO. http://www.who.int/respiratory/copd/burden/en/. Accessed 2 Feb 2018.
  6. 6.
    Mittmann N, Kuramoto L, Seung SJ, Haddon JM, Bradley-Kennedy C, Fitzgerald JM. The cost of moderate and severe COPD exacerbations to the Canadian healthcare system. Respir Med 2008;102(3):413–421.  https://doi.org/10.1016/j.rmed.2007.10.010.CrossRefPubMedGoogle Scholar
  7. 7.
    Ford ES, Murphy LB, Khavjou O, Giles WH, Holt JB, Croft JB. TOtal and state-specific medical and absenteeism costs of copd among adults aged ≥ 18 years in the united states for 2010 and projections through 2020. Chest 2015;147(1):31–45.  https://doi.org/10.1378/chest.14-0972.CrossRefPubMedGoogle Scholar
  8. 8.
    Chapman KR, Bourbeau J, Rance L. The burden of COPD in Canada: results from the Confronting COPD survey. Respir Med 2003;97 Suppl C:S23–31.CrossRefPubMedGoogle Scholar
  9. 9.
    Edwards ST, Mafi JN, Landon BE. Trends and Quality of Care in Outpatient Visits to Generalist and Specialist Physicians Delivering Primary Care in the United States, 1997–2010. J Gen Intern Med 2014;29(6):947–955.  https://doi.org/10.1007/s11606-014-2808-y.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Pothirat C, Liwsrisakun C, Bumroongkit C, Deesomchok A, Theerakittikul T, Limsukon A. Comparative study on health care utilization and hospital outcomes of severe acute exacerbation of chronic obstructive pulmonary disease managed by pulmonologists vs internists. Int J Chron Obstruct Pulmon Dis 2015;10:759–766.  https://doi.org/10.2147/COPD.S81267.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Diaz-Fuentes G, Lakshmi V, Blum S, Sy S, Escalera E. Chronic Obstructive Pulmonary Disease: Comparison of Care by Specialists and Generalists in an Inner-City Hospital. Internet J Pulm Med. 2004;5(1). http://ispub.com/IJPM/5/1/12172. Accessed 2 Feb 2018.
  12. 12.
    Bourbeau J, Sebaldt RJ, Day A, et al. Practice patterns in the management of chronic obstructive pulmonary disease in primary practice: The CAGE study. Can Respir J J Can Thorac Soc 2008;15(1):13–19.Google Scholar
  13. 13.
    Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet Lond Engl 1997;349(9063):1436–1442.  https://doi.org/10.1016/S0140-6736(96)07495-8.CrossRefGoogle Scholar
  14. 14.
    Basu A, Manning WG. Estimating lifetime or episode-of-illness costs under censoring. Health Econ 2010;19(9):1010–1028.  https://doi.org/10.1002/hec.1640.CrossRefPubMedGoogle Scholar
  15. 15.
    Government of Canada SC. Population by sex and age group, by province and territory (Number, both sexes). http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo31a-eng.htm. Published September 26, 2014. Accessed 2 Feb 2018.
  16. 16.
    British Columbia Ministry of Health [creator]. Consolidation File (MSP Registration & Premium Billing). Population Data BC[publisher]. Data Extract. MOH. 2014. Available at: http://www.popdata.bc.ca/data. Accessed 2 Feb 2018.
  17. 17.
    BC Vital Statistics Agency [creator]. Vital Statistics Deaths. Population Data BC [publisher]. Data Extract. BC Vital Statistics Agency. 2014. Available at: http://www.popdata.bc.ca/data. Accessed Feb 2 2018.
  18. 18.
    CIHI [creator]. Discharge Abstract Database (Hospital Separations). Population Data BC [publisher]. Data Extract. MOH. 2014. Available at: http://www.popdata.bc.ca/data. Accessed 2 Feb 2018.
  19. 19.
    M British Columbia Ministry of Health [creator]. Medical Services Plan (MSP) Payment Information File. Population Data BC [publisher]. Data Extract. MOH. 2014. Available at: http://www.popdata.bc.ca/data. Accessed 2 Feb 2018.
  20. 20.
    British Columbia Ministry of Health [creator]. PharmaNet. BC Ministry of Health [publisher]. Data Extract. Data Stewardship Committee. 2013. Available at: http://www.popdata.bc.ca/data. Accessed 2 Feb 2018.
  21. 21.
    British Columbia Ministry of Health[creator]. Home and Community Care. BC Ministry of Health [publisher].Data Extract. MOH. 2014. Available from: http://www.popdata.bc.ca/data. Accessed 2 Feb 2018.
  22. 22.
    (CIHI) CI for HI. CIHI Data Quality Study of the DAD 2009–2010 Discharge Abstract Database. https://secure.cihi.ca/estore/productFamily.htm?pf=PFC1762&lang=en&media=0. Published April 27, 2012. Accessed 2 Feb 2018.
  23. 23.
    Gershon AS, Wang C, Guan J, Vasilevska-Ristovska J, Cicutto L, To T. Identifying individuals with physcian diagnosed COPD in health administrative databases. COPD 2009;6(5):388–394.CrossRefPubMedGoogle Scholar
  24. 24.
    Hernán MA, Alonso A, Logan R, et al. Observational studies analyzed like randomized experiments: an application to postmenopausal hormone therapy and coronary heart disease. Epidemiol Camb Mass 2008;19(6):766–779.  https://doi.org/10.1097/EDE.0b013e3181875e61.CrossRefGoogle Scholar
  25. 25.
    Sadatsafavi M, FitzGerald M, Marra C, Lynd L. Costs and health outcomes associated with primary vs secondary care after an asthma-related hospitalization: a population-based study. Chest 2013;144(2):428–435.  https://doi.org/10.1378/chest.12-2773.CrossRefPubMedGoogle Scholar
  26. 26.
    Mapel DW, Dutro MP, Marton JP, Woodruff K, Make B. Identifying and characterizing COPD patients in US managed care. A retrospective, cross-sectional analysis of administrative claims data. BMC Health Serv Res 2011;11:43.  https://doi.org/10.1186/1472-6963-11-43.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383.CrossRefPubMedGoogle Scholar
  28. 28.
    Poole B, Robinson S, MacKinnon M. Resource Intensity Weights and Canadian hospital costs: some preliminary data. Healthc Manag Forum Can Coll Health Serv Exec Forum Gest Soins Santé Collège Can Dir Serv Santé 1998;11(1):22–26.Google Scholar
  29. 29.
    Chen W, Lynd LD, FitzGerald JM, et al. Excess medical costs in patients with asthma and the role of comorbidity. Eur Respir J 2016;48(6):1584–1592.  https://doi.org/10.1183/13993003.01141-2016.CrossRefPubMedGoogle Scholar
  30. 30.
    Chen W, Lynd LD, FitzGerald JM, Sadatsafavi M. Influences of Socioeconomic Status on Costs of Asthma Under Universal Health Coverage. Med Care 2016;54(8):789–795.  https://doi.org/10.1097/MLR.0000000000000563.CrossRefPubMedGoogle Scholar
  31. 31.
    McKendry R, Reid RJ, McGrail KM, et al. Emergency Rooms in British Columbia: A Pilot Project to Validate Current Data and Describe Users. Vancouver (BC): Centre for Health Services and Policy Research; 2002.Google Scholar
  32. 32.
    Cohen J. CHAPTER 2 - The t Test for Means. In: Cohen J, ed. Statistical Power Analysis for the Behavioral Sciences (Revised Edition). Academic Press; 1977:19–74. http://www.sciencedirect.com/science/article/pii/B9780121790608500074. Accessed 2 Feb 2018.
  33. 33.
    Austin PC, Urbach DR. Using G-computation to estimate the effect of regionalization of surgical services on the absolute reduction in the occurrence of adverse patient outcomes. Med Care 2013;51(9):797–805.  https://doi.org/10.1097/MLR.0b013e31829a4fb4.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013;187(4):347–365.  https://doi.org/10.1164/rccm.201204-0596PP.CrossRefPubMedGoogle Scholar
  35. 35.
    Health M of. Special Authority - Province of British Columbia. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority#Druglist. Accessed 2 Feb 2018.
  36. 36.
    Calverley PMA, Anderson JA, Celli B, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007;356(8):775–789.  https://doi.org/10.1056/NEJMoa063070.CrossRefPubMedGoogle Scholar
  37. 37.
    Mathioudakis AG, Kanavidis P, Chatzimavridou-Grigoriadou V, et al. Tiotropium HandiHaler improves the survival of patients with COPD: a systematic review and meta-analysis. J Aerosol Med Pulm Drug Deliv 2014;27(1):43–50.  https://doi.org/10.1089/jamp.2012.1012.CrossRefPubMedGoogle Scholar
  38. 38.
    Singh S, Loke YK, Enright PL, Furberg CD. Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. BMJ 2011;342:d3215.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    National Clinical Guideline Centre (UK). Ch 7. Managing Stable COPD. In: Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care. Royal College of Physicians (UK); 2010. https://www.ncbi.nlm.nih.gov/books/NBK65045/. Accessed 2 Feb 2018.
  40. 40.
    Health M of. Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management - Province of British Columbia. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/copd. Accessed 2 Feb 2018.
  41. 41.
    Services M of TI and C. Health Boundaries - Province of British Columbia. https://www2.gov.bc.ca/gov/content/data/geographic-data-services/land-use/administrative-boundaries/health-boundaries. Accessed 2 Feb 2018.
  42. 42.
    Waiting Your Turn: Wait Times for Health Care in Canada, 2016 Report. Fraser Institute. http://bit.ly/2gHMwL2?__unam=b07cbf6-15f4a7f006e-72453276-6&_ga=GA1.2.158609998.1508783358. Published November 23, 2016. Accessed 2 Feb 2018.
  43. 43.
    Macaulay D, Sun SX, Sorg RA, et al. Development and validation of a claims-based prediction model for COPD severity. Respir Med 2013;107(10):1568–1577.  https://doi.org/10.1016/j.rmed.2013.05.012.CrossRefPubMedGoogle Scholar
  44. 44.
    Gershon AS, Campitelli MA, Croxford R, et al. Combination long-acting β-agonists and inhaled corticosteroids compared with long-acting β-agonists alone in older adults with chronic obstructive pulmonary disease. JAMA 2014;312(11):1114–1121.  https://doi.org/10.1001/jama.2014.11432.CrossRefPubMedGoogle Scholar
  45. 45.
    Gupta SK. Intention-to-treat concept: A review. Perspect Clin Res 2011;2(3):109–112.  https://doi.org/10.4103/2229-3485.83221.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Daniel RM., Cousens SN., De Stavola BL., Kenward MG, Sterne JAC. Methods for dealing with time-dependent confounding. Stat Med 2013;32(9):1584–1618.  https://doi.org/10.1002/sim.5686.CrossRefPubMedGoogle Scholar
  47. 47.
    Prieto-Centurion V, Rolle AJ, Au DH, et al. Multicenter Study Comparing Case Definitions Used to Identify Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2014;190(9):989–995.  https://doi.org/10.1164/rccm.201406-1166OC.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Wenjia Chen
    • 1
  • Don D. Sin
    • 2
    • 3
  • J. Mark FitzGerald
    • 3
    • 4
    • 5
  • Mohsen Sadatsafavi
    • 1
    • 4
  • for the Canadian Respiratory Research Network
  1. 1.Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverCanada
  2. 2.Division of Respiratory Medicine, Department of Medicine, The UBC Centre for Heart Lung Innovation, St. Paul’s HospitalUniversity of British ColumbiaVancouverCanada
  3. 3.Institute for Heart and Lung Health, Division of Respiratory Medicine, Faculty of MedicineUniversity of British ColumbiaVancouverCanada
  4. 4.Centre for Clinical Epidemiology and EvaluationUniversity of British ColumbiaVancouverCanada
  5. 5.UBC Division of Respiratory Medicine, Department of Medicine, The Lung CentreGordon and Leslie Diamond Health Care CentreVancouverCanada

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