Factors Influencing the Health Care Expenditures of

0 downloads 0 Views 162KB Size Report
99251, 99252, 99253, .... Chronic laryngitis. 0.063. 25. 12 to 39. \.001. Laryngeal malignancy. 1.054. 719 ... –107 to –88 ... .02. Multiple diagnoses. 1.791. 1826. 1763 to 1889. \.001. aNatural log coefficients for cost calculations in the equation ...
Original Research—Laryngology and Neurolaryngology

Factors Influencing the Health Care Expenditures of Patients with Laryngeal Disorders

Otolaryngology– Head and Neck Surgery 147(6) 1099–1107 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599812454838 http://otojournal.org

Seth M. Cohen, MD, MPH1, Jaewhan Kim, PhD2, Nelson Roy, PhD, CCC-SLP3, Carl Asche, MBA, PhD4, and Mark Courey, MD5

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Abstract Objective. To identify factors related to the health care spending of patients with laryngeal disorders. Study Design and Setting. Retrospective analysis of data from a large, nationally representative administrative US claims database. Subjects and Methods. Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008, and who were continuously enrolled for 12 months were included. Age, sex, comorbidity, geography, provider type, visit type, and type of laryngeal pathology were collected. To identify which factors were related to the direct costs, a generalized linear regression with gamma distribution was used. Results. Of almost 55 million individuals in the database, 309,300 patients with a laryngeal disorder and 12 months of follow-up data were identified (mean [SD] age, 47.3 [21.3] years; 63.5% female). Age, sex, geographic region, number of comorbid conditions, type of provider, visit type, and laryngeal pathology were significantly associated with the health care expenditures (all P values \.05). Costs increased with increasing age and were greater for male patients, higher in the South and Northeast compared with the West and North-central regions, greater in 2008 compared with 2004, higher for inpatient compared with outpatient care, higher with increasing number of comorbid conditions, and lower if a patient was treated by a primary care physician only. Among the various laryngeal pathologies, the greatest direct costs were for laryngeal cancer and patients with multiple diagnoses. Conclusion. This study identified multiple factors associated with the health care expenditures of patients with laryngeal disorders. Keywords dysphonia, laryngeal disease, voice disorders, costs, health economics, health care expenditure, larynx

Received January 18, 2012; revised June 5, 2012; accepted June 25, 2012.

H

ealth economics is a branch of economics concerned with issues related to the costs, efficiency, and effectiveness of the production and consumption of health care. Multiple types of financial information are evaluated to estimate disease-specific costs and the economic burden of specific illnesses.1 Evaluating the current societal financial burden of specific health conditions is an important aspect of managing health and cost outcomes.2 Such data provide the foundation for health care decision making and for comparative assessments of different evaluation and treatment strategies. Laryngeal disorders have important functional effects on the individual and greater public with economic consequences.3 With a lifetime prevalence of roughly 30%, voice disorders negatively affect patients’ quality of life (QOL) and occupational functioning with significant societal implications.4,5 Patients with neurologic voice disorders suffer impairments in general QOL comparable to patients with congestive heart failure, angina, and chronic obstructive pulmonary disease, and 7.2% of dysphonic individuals miss 1 or more work days annually.4-6 However, nationally representative data on the economic burden of laryngeal disorders have been limited. 1 Duke Voice Care Center, Division of Otolaryngology–Head & Neck Surgery, Duke University Medical Center, Durham, North Carolina, USA 2 Division of Public Health & Study Design and Biostatistics Center, University of Utah, Salt Lake City, Utah, USA 3 Department of Communication Sciences and Disorders, and Division of Otolaryngology–Head & Neck Surgery (Adjunct), University of Utah, Salt Lake City, Utah, USA 4 Center for Outcomes Research, Department of Medicine, University of Illinois College of Medicine, Peoria, Illinois, USA 5 Department of Otolaryngology–Head & Neck Surgery, University of California, San Francisco, California, USA

Corresponding Author: Seth M. Cohen, MD, MPH, Duke Voice Care Center, Division of Otolaryngology–Head & Neck Surgery, Duke University Medical Center, DUMC Box 3805, Durham, NC 27710, USA Email: [email protected]

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

1100

Otolaryngology–Head and Neck Surgery 147(6)

Table 1. International Classification of Diseases, Ninth Revision (ICD-9) Code Groupings Category

ICD-9-CM Codes

Vocal fold paralysis Bilateral vocal fold paralysis Vocal fold paresis Nonspecific dysphonia Acute laryngitis Benign laryngeal/vocal fold pathology Other larynx/vagus Chronic laryngitis Laryngeal cancer Laryngeal spasm Late effect cerebrovascular disease, other speech deficits

478.30, 478.32 478.34 478.31, 478.33 784.49, 784.42, 784.40, 784.41 464, 464.01, 464.20, 464.21 478.4, 478.5, 478.6, 478.71, 478.79, 212.1 478.70, 352.3 476.0, 476.1 161.0, 161.1, 161.2, 161.3, 161.8, 161.9 478.75 438.10, 438.19

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification.

Recently, the direct health care costs associated with the evaluation and management of laryngeal disorders in the general population was examined. With point prevalence rates of voice disorders of 6.6% to 7.5% and treatment-seeking rates of 5.9% to 22.1%, national direct cost estimates ranged from $ 0.7 to $4.9 billion.3,4,7 In addition, pharmacy claims accounted for 20.1% to 33.3%, procedure claims 50.4% to 69.9%, and medical encounter claims 16.3% to 8.6% of overall direct costs.3 However, the factors that influence these health care costs were not examined. Although prior studies reported that sex, age, comorbid conditions, and geographic region influence health care expenditures, a void exists in the literature regarding the impact of these factors on health care spending due to laryngeal disorders.8-10 Furthermore, these disorders represent a heterogeneous group of conditions that may be associated with varying degrees of economic burden. The purpose of this investigation is to examine how age, sex, comorbidity, geography, provider type, visit type, and type of laryngeal pathology influence the direct costs involved in the evaluation and treatment of patients with laryngeal disorders.

Methods The Duke University Medical Center Institutional Review Board approved the study. This was a retrospective analysis using data from a large, nationally representative administrative US claims database: the MarketScan Commercial Claims and Encounters data set and Medicare Supplemental and Coordination of Benefits data set for January 1, 2004, to December 31, 2008. The previously described MarketScan databases (Thomson Reuters Healthcare, Ann Arbor, Michigan) contain the annual health care claims of roughly 55 million individuals, including employees (\65 years of age), Medicare beneficiaries 65 years of age, and their dependents integrated from all care providers and connected to health care utilization and cost records at the patient level.11 Patients with laryngeal disorders who were continuously enrolled for at least 12 months after the day of first laryngeal diagnosis (ie, the index date) during January 1, 2004, to

December 31, 2008, were included. Patients must have had a primary or nonprimary diagnosis of at least one of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes (Table 1), referred to collectively as ‘‘dysphonia’’ diagnoses. Codes 438.10 and 438.19 both refer to late effects of cerebrovascular disease resulting in speech and language deficits (dysarthria and aphasia have separate ICD-9-CM codes). These codes were included because patients with brainstem stroke could potentially have disordered voices from nucleus ambiguus involvement. Patients with a single medical encounter with more than 1 dysphonia diagnosis and those with more than 1 dysphonia diagnosis on separate encounters were categorized as multiple diagnoses. Patients who saw more than 1 provider for a related diagnosis were counted as 1 patient, but all relevant costs incurred over the 12-month post–index period were tabulated and assigned to the relevant provider. Patients with less than 12 months of post–index date data were excluded. Age, sex, geographic location (all 50 states were divided into 4 census regions: Northeast, North-central, South, and West), employment status, type of medical encounter, physician specialty (otolaryngologist, primary care physician [PCP], and other specialist), pharmacy claims, and procedure claims were collected for each patient during the 12month post–index period as previously described.3,11,12 The type of medical encounter and procedures of interest were based on Evaluation and Management (E & M) Current Procedural Terminology (CPT) codes (Table 2). Because a medical claims database cannot unequivocally determine that a procedure was specifically performed for a dysphonia diagnosis, 2 approaches were used to determine whether a procedure claim was linked to a dysphonia diagnosis. The first cost estimate incorporated CPT codes that occurred on the same day as each medical encounter (new or return) for a dysphonia diagnosis, occurring over the 12month post–index period. The second cost estimate incorporated CPT codes that occurred within 4 weeks after each medical encounter (new or return) rendering a dysphonia diagnosis, occurring over the 12-month post–index period.3

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

Cohen et al

1101

Table 2. CPT Codes Used in Direct Cost Calculation Category

CPT Codes

Radiology

71010, 71050, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 70450, 70460, 70470, 70490, 70491, 70492, 71520, 71260, 71270, 70551, 70552, 70553, 70540, 70542, 70543 74210, 74220, 74230, 92610, 92611, 92612, 92613, 92614, 92615, 92616, 92617 92526 92506, 92507, 92508, 92520 31505, 31575 31579 31300, 31320, 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395, 31400, 31420, 31500, 31502, 31510, 31511, 31512, 31513, 31515, 31520, 31525, 31526, 31527, 31528, 31529, 31530, 31531, 31536, 31540, 31541, 31545, 31546, 31560, 31561, 31570, 31571, 31576, 31577, 31578, 31580, 31582, 31584, 31587, 31588, 31590, 31595, 31599, 64716, 64886 64613, 95874 95865 91010, 91011, 91012, 91020, 91030, 91034, 91035, 91037, 91038 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99354, 99355 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239 99251, 99252, 99253, 99254, 99255, 99356, 99357, 99217, 99218, 99219, 99220, 99238, 99239 99281, 99282, 99283, 99284, 99285, 99288 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 77263,77014, 77295 77290, 77334, 77338, 77300, 77413, 77427, 77336, 774214, 77470, 77301, 77280

Swallow study Swallow therapy Voice evaluation/therapy Laryngoscopy Stroboscopy Surgery

Chemodenervation Laryngeal electromyography Reflux testing/evaluation Outpatient E & M

Inpatient E & M

Emergency room E & M Critical care E & M Nursing facility/home care E & M

Radiation therapy

Abbreviations: CPT, Current Procedural Terminology; E & M, Evaluation and Management.

To minimize the chances of incorporating costs due to nonlaryngeal malignancies coexisting with other dysphonia ICD9 codes, the radiation therapy CPT codes were included only if related to the laryngeal cancer ICD-9 codes. To temporally link pharmacy claims to a dysphonia diagnosis, pharmacy claims had to occur within 2 weeks after a medical encounter (new or return) with a dysphonia diagnosis, and there was no claim for the medication in the 3 months prior to the index date.3 Each encounter resulting in a pharmacy claim within the described parameters was tabulated over the 12-month post–index date and assigned to the relevant provider. Because of the potential number of unique medications that could be related to treating a laryngeal disorder, the therapeutic drug class according to the MarketScan database dictionary was used. Therapeutic drug

classes included antihistamine, antibiotic, antifungal, antineoplastic, sympathomimetic (contained antihistamine/ decongestant combinations), anti-inflammatory EENT (contained nasal steroids), antacid, histamine 2 antagonist, gastrointestinal miscellaneous (contained proton pump inhibitors), antiallergic (contained nasal antihistamines), leukotriene modifiers, and adrenal (contained oral steroids).3 Total direct costs were the sum of each medical encounter, procedure claim, and pharmacy claim (with the above definitions) incurred over the 12-month post–index period. Two total and mean cost per person estimates in 12 months were calculated using both of the above methods to identify procedures related to a dysphonia diagnosis.3 Costs for medical encounters and procedures were the gross payment to the provider, which was the amount eligible for payment

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

1102

Otolaryngology–Head and Neck Surgery 147(6)

under the medical plan. Medication costs were the ingredient cost, which is the discount below the average wholesale price, plus the dispensing fee. Costs were adjusted to 2008 using the Consumer Price Index. All MarketScan database management and statistical analyses were performed with Stata version 11.1 (StataCorp, College Station, Texas). To identify factors that were related to the direct costs involved in the evaluation and management of patients with laryngeal disorders, a generalized linear regression with gamma distribution, a statistical model for outcome variables with skewed distributions, such as health care costs, and/or for data that can only take on positive values, was used.13 The dependent variable was the mean cost per person in 12 months. A priori independent variables were age, sex, geographic region, urban versus rural, dummy variables of years from 2004 to 2008, number of comorbidities, provider type, visit type, and laryngeal pathology. To examine the relative impact of these independent variables on the mean cost estimates, a referent group within each independent variable (men, 70 years of age, living in the Northeast, year 2004, 1 comorbid condition, seen by PCP, outpatient, nonspecific dysphonia) was determined a priori. The relative dollar amount increase or decrease compared with the referent group within each independent variable category was determined. The natural log coefficients for each covariate are provided for calculations of adjusted mean costs per person in 12 months. Two separate approaches were performed using each of the previously described methods to identify procedures linked to a dysphonia diagnosis.

Results Of 54,600,465 unique patients enrolled in the MarketScan databases during January 1, 2004, to December 31, 2008, 536,943 (1%) unique patients had a dysphonia diagnosis based on ICD-9 codes, of whom 309,300 (57.6%) had 12 months of follow-up data. Mean (SD) age was 47.3 (21.3) years, and 63.5% of the study population was female.3 Characteristics and diagnoses of the 309,300 patients are displayed in Table 3. For the 2 regression analyses, age, sex, geographic region, number of comorbid conditions, type of provider, visit type, and laryngeal pathology were significantly associated with the health care expenditures (all P values \.05) (Tables 4 and 5). Urban versus rural status did not influence the direct costs. Costs increased with increasing age, were greater for male patients, and were higher in the South and Northeast compared with the West and North-central regions (Tables 4 and 5). Direct costs were higher in 2008 compared with 2004, higher for inpatient compared with outpatient care, higher with increasing number of comorbid conditions, and lowest if a patient was treated by a PCP only (Tables 4 and 5). Among the various laryngeal pathologies, the greatest direct costs were for laryngeal cancer and patients with multiple diagnoses, and the least costs were for acute laryngitis (Tables 4 and 5). A subgroup analysis was performed to examine how the frequency of dysphonia diagnoses varied by provider type,

Table 3. Characteristics and Diagnoses (All Providers) of the Dysphonic Population with 12 Months Post–Index Date Follow-up (n = 309,300) Variable Geographic location Northeast North-central South West Unknown Dysphonia diagnostic category Unilateral vocal fold paralysis Bilateral vocal fold paralysis Vocal fold paresis Nonspecific dysphonia Acute laryngitis Benign laryngeal/vocal fold pathology Other larynx/vagus Chronic laryngitis Laryngeal cancer Laryngeal spasm Late effect cerebrovascular disease, other speech deficits Multiple diagnoses

%

11.4 25.8 45.1 16.9 0.8 0.86 0.03 0.23 21.31 43.57 7.42 0.38 7.85 1.24 2.00 0.81 14.30

age, and sex over the 12-month post–index date. Primary care providers were 10 times as likely as otolaryngologists to provide a diagnosis of acute laryngitis. In contrast, otolaryngologists were 1.7 times as likely to give multiple diagnoses, 1.3 times as likely to provide a diagnosis of laryngeal cancer, 2.5 times as likely to diagnose nonspecific dysphonia, 4 times as likely to diagnose benign laryngeal/vocal fold pathology, 3 times as likely to diagnosis vocal fold paralysis, and almost 5 times as likely to give a diagnosis of chronic laryngitis as PCPs. Male patients were 6.2 times more likely to have a diagnosis of laryngeal cancer compared with female patients, and female patients were 1.5 times more likely to have a diagnosis of acute laryngitis compared with male patients. The diagnosis of laryngeal cancer was less than 1% of diagnoses among patients \40 years and was provided more commonly as age increased, accounting for roughly one-quarter of diagnoses among .70-year-olds. Patients .70 years were 12.5 times as likely as patients in the 40- to 49-year category to have a laryngeal cancer diagnosis. In contrast, the frequency of acute laryngitis was roughly 32% to 40% of diagnoses among 0- to 40year-olds and declined after age 40. Patients 0 to 9 years old were 6.8 times as likely to have acute laryngitis compared with those .70 years. The natural log coefficients provided in Tables 4 and 5 can be used to calculate adjusted mean annual direct costs per person using the equation Exp(b0 1 b1_age 0-9 1 b2_age 10-19 1 . . .) = cost estimate, where Exp refers to the function anti–natural log, b0 is the constant, and bi are

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

Cohen et al

1103

Table 4. Generalized Linear Regression Model with Procedures on Same Day as Dysphonia Diagnosis Natural Log Coefficienta Coefficient, $b 95% Confidence Interval, $ P Value

Covariate Constant Age, y 0-9 10-19 20-29 30-39 40-49 50-59 60-69 .70 Sex Male Female Region Northeast North-central South West Year 2004 2008 Number of comorbid conditions 1 2 3 Provider Primary care Otolaryngology Other specialist Multiple Visit Outpatient Inpatient Emergency room Critical care Multiple Diagnosis Nonspecific dysphonia Unilateral vocal fold paralysis Bilateral vocal fold paralysis Vocal fold paresis Acute laryngitis Other larynx/vagus Benign laryngeal/vocal fold pathology Chronic laryngitis Laryngeal malignancy Laryngeal spasm Late effect cerebrovascular disease, other speech deficits Multiple diagnoses

6.058 –247 –232 –211 –208 –185 –164 –137

\.001 \.001 \.001 \.001 \.001 \.001 \.001

Reference –66

–73 to –59

\.001

Reference –0.040 0.056 –0.045

Reference –16 22 –17

–26 to –5 12 to 32 –29 to –6

.005 \.001 .003

Reference 0.053

Reference 21

2 to 41

.034

Reference 0.079 0.289

Reference 32 101

12 to 51 91 to 112

.001 \.001

Reference 0.261 0.458 1.095

Reference 110 219 577

98 to 121 200 to 237 559 to 595

\.001 \.001 \.001

Reference 0.965 0.075 0.780 0.697

Reference 632 30 460 393

484 to 780 –4 to 65 –326 to 1246 249 to 536

\.001 .08 .25 \.001

Reference 0.155 –0.213 0.268 –0.449 0.263 0.375 0.063 1.054 0.141 –0.005 1.225

Reference 66 –75 120 –171 117 173 25 719 59 –2 787

26 to 105 –232 to 82 34 to 205 –181 to –163 52 to 183 154 to 191 12 to 39 637 to 801 33 to 85 –38 to 33 757 to 817

.001 .35 .006 \.001 \.001 \.001 \.001 \.001 \.001 .91 \.001

–0.976 –0.922 –0.819 –0.763 –0.647 –0.564 –0.508 Reference

–267 –252 –232 –232 –214 –196 –164 Reference

Reference –0.165

a

–286 to –272 to –253 to –257 to –243 to –228 to –192 to

Natural log coefficients for cost calculations in the equation Exp(b01 b1_age 0-9 1 b2_age 10-19 1 . . .) = annual adjusted mean direct cost per person, where Exp refers to the function anti–natural log, b0 is the constant, and bi are the natural log coefficients for each covariate. b Coefficients show relative dollar amount increase or decrease compared with the referent group within each covariate.

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

1104

Otolaryngology–Head and Neck Surgery 147(6)

Table 5. Generalized Linear Regression Model with Procedures within 4 Weeks of Dysphonia Diagnosis Natural Log Coefficienta Coefficient, $b 95% Confidence Interval, $ P Value

Covariate Constant Age, y 0-9 10-19 20-29 30-39 40-49 50-59 60-69 .70 Sex Male Female Region Northeast North-central South West Year 2004 2008 Number of comorbid conditions 1 2 3 Provider Primary care Otolaryngology Other specialist Multiple Visit Outpatient Inpatient Emergency room Critical care Multiple Diagnosis Nonspecific dysphonia Unilateral vocal fold paralysis Bilateral vocal fold paralysis Vocal fold paresis Acute laryngitis Other larynx/vagus Benign laryngeal/vocal fold pathology Chronic laryngitis Laryngeal malignancy Laryngeal spasm Late effect cerebrovascular disease, other speech deficits Multiple diagnoses

5.974 –285 –263 –235 –226 –192 –158 –132 Reference

Reference –0.200

Reference –97

–107 to –88

\.001

Reference –0.069 0.035 –0.049

Reference –32 16 –23

–45 to –18 4 to 29 –37 to –8

\.001 \.001 .003

Reference 0.071

Reference 35

9 to 60

Reference 0.097 0.364

Reference 48 150

23 to 73 138 to 163

\.001 \.001

Reference 0.210 0.434 1.101

Reference 105 248 704

91 to 120 224 to 271 680 to 727

\.001 \.001 \.001

Reference 0.875 0.039 0.759 0.659

Reference 658 19 536 440

484 –23 –444 264

to 832 to 61 to –1517 to 616

\.001 .38 .28 \.001

Reference 0.284 –0.195 0.302 –0.508 0.194 0.396 0.041 1.720 0.094 0.122 1.791

Reference 155 –83 167 –234 101 222 20 2118 47 61 1826

98 –287 54 –246 23 199 3 1916 14 10 1763

to 212 to 120 to 279 to –223 to 179 to 246 to 37 to 2319 to 79 to 112 to 1889

\.001 .42 .004 \.001 .011 \.001 .024 \.001 .005 .02 \.001

a

–313 –291 –266 –261 –233 –202 –173

to –257 to –234 to –204 to –191 to –152 to –114 to –91

\.001 \.001 \.001 \.001 \.001 \.001 \.001

–0.820 –0.746 –0.644 –0.580 –0.459 –0.361 –0.315 Reference

.008

Natural log coefficients for cost calculations in the equation Exp(b01 b1_age 0-9 1 b2_age 10-19 1 . . .) = annual adjusted mean direct cost per person, where Exp refers to the function anti–natural log, b0 is the constant, and bi are the natural log coefficients for each covariate. b Coefficients show relative dollar amount increase or decrease compared with the referent group within each covariate.

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

Cohen et al

1105

the natural log coefficients for each covariate. Adjusted mean annual direct costs for a female patient 0 to 9 years old with acute laryngitis seen by a PCP as an outpatient living in the West during the year 2004 with 1 comorbid condition = Exp(6.058 – 0.976 – 0.165 – 0.449 – 0.045) = e^4.423 = $83 (Table 4). In contrast, the adjusted mean annual direct costs for a woman .70 years old with acute laryngitis seen by a PCP as an outpatient living in the West during the year 2004 with 1 comorbid condition = Exp(6.058 – 0.165 – 0.449 – 0.045) = e^5.399 = $221 (Table 4).

Discussion Patients with laryngeal disorders incur significant health care costs.7 The specific laryngeal pathology was related to patients’ health care spending. The least costly laryngeal disease was acute laryngitis, possibly reflecting its selflimited nature. In contrast, the most expensive was laryngeal cancer (Tables 4 and 5). Because procedure costs were only calculated for up to 1 month after a dysphonia diagnosis, the costs related to laryngeal cancer are likely underestimated, as treatment of the disease and associated morbidity likely extend beyond 1 month postdiagnosis. Treatment specific to laryngeal cancer affects the costs, with chemoradiation found to be more costly than total laryngectomy with postoperative radiation for stage III and IV laryngeal cancer.14 For early glottic cancer, radiation is more costly than endoscopic excision and also brings hidden costs of increased travel and greater work absence.15-17 Patients with multiple dysphonia diagnoses provided on 1 or more visits also had significantly higher expenditures (Tables 4 and 5). This subgroup may have more than 1 etiology noted during a specific medical encounter or a progression of symptoms resulting in a change in diagnosis over time, subsequently requiring more complicated management and necessitating multiple provider visits in various settings, thereby incurring more costs. Furthermore, the number of chronic conditions has been associated with increased health care utilization and greater costs.18,19 Among our patients, it was determined that those with 2 comorbid conditions spent between $32 and $48 more, and patients with 3 spent between $101 and $150 more than patients with 1 comorbid condition (Tables 4 and 5). Even among patients with head and neck cancer of similar stage, greater comorbidity scores were linked to increased costs.9 Studies comparing management strategies among patients with complex laryngeal disease states and with comorbid conditions may lead to improved health and cost outcomes. Cost variation was also observed among different geographic regions. The North-central and West regions incurred the lowest expenses compared with the Northeast and South (Tables 4 and 5). A prior study found that the health status of populations in different regions may account for 29% of the geographic variation noted in health care expenditures.10 The quantity and supply of medical services, predominance of internists and subspecialists, organization

of practice, market structure, provider profit-seeking behavior, and cultural or social preferences have been suggested as other sources of variability.10,20 Moreover, in studies examining regional differences in health care expenditures, the quality of care and satisfaction of care received were not higher in areas that spent more.21,22 In our population, the type of provider and medical encounter affected the direct costs. Patients who saw an otolaryngologist incurred roughly $100 more in expenses than patients seeing a PCP only (Tables 4 and 5). In our subgroup analysis, otolaryngologists more commonly provided multiple diagnoses, suggesting they treat more chronic and complex disorders than PCPs, who were 10 times more likely to diagnose acute laryngitis, the least expensive laryngeal disorder. Laryngeal examination by an otolaryngologist is an essential aspect in the evaluation and management of laryngeal disorders. Our subgroup analysis found that otolaryngologists more commonly diagnosed laryngeal-specific pathology, such as laryngeal cancer, benign laryngeal/vocal fold pathology, and vocal fold paralysis compared with PCPs. Although treatment by an otolaryngologist may be inherently more costly than by a PCP, otolaryngologists have also introduced important treatment advances, such as office-based treatment of vocal fold paralysis and laryngeal papilloma, which provide good outcomes and reduced costs.23,24 In addition, patients requiring multiple provider visits spent between $577 and $704 more than patients who only saw a PCP, and inpatient care was between $632 and $658 more costly than outpatient care (Tables 4 and 5). Such differences may reflect the treatment of more complicated laryngeal disorders. A prior study found that dysphonia diagnoses differed by care setting, with laryngeal cancer accounting for 35.7% of inpatient diagnoses versus 5.6% of outpatient diagnoses and acute laryngitis accounting for 41.9% of outpatient diagnoses compared with 5.2% of inpatient diagnoses.3 Continued investigations aimed at exploring differences in costs between different practice patterns are needed. Demographic factors influenced the health care expenditures related to the evaluation and management of laryngeal disorders. Female patients spent between $66 and $97 less than did male patients (Tables 4 and 5). Mean direct costs were highest among the elderly (70 years) and steadily decreased for each younger decade (Tables 4 and 5). In our subset analysis, male patients more commonly had a diagnosis of laryngeal cancer, and female patients more commonly had acute laryngitis, potentially affecting gender-related costs. With laryngeal cancer more common among the .70-year-olds and acute laryngitis more frequent among younger age groups, a similar phenomenon may explain age-related cost differences. Hoffman et al19 also noted that the elderly were more likely to have chronic conditions. As discussed previously, the number of comorbid conditions among patients with laryngeal disorders also affected the direct cost estimates. Certain methodological issues must be addressed. Potential sources of bias exist in data from administrative claims

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

1106

Otolaryngology–Head and Neck Surgery 147(6)

databases. The accuracy of CPT and ICD-9 codes, such as the source of PCP-based diagnosis of laryngeal cancer, could not be confirmed. Although measures of disease severity and ethnicity could influence the health care spending of patients with laryngeal disorders, such data were not available. In addition, conservative definitions of which medication and procedure claims were linked to a dysphonia diagnosis were used, which may have led to underestimating the true costs.3 Finally, because our patients were covered by Medicare or employersponsored health insurance plans, results may not be generalizable to the uninsured or Medicaid population. Nonetheless, this large national population-based study provides important insights about factors affecting the direct costs involved in the evaluation and management of laryngeal disorders.

3.

4.

5.

6. 7.

Conclusion Multiple variables were associated with the health care expenditures of patients with laryngeal disorders. The type of laryngeal pathology was related to direct costs, with laryngeal cancer and multiple diagnoses being the most expensive. As patients’ general health worsened, as measured by an increasing number of comorbid conditions, the direct costs rose. Regional differences were noted, with the Northeast and South being the most expensive. Patients treated exclusively by a PCP spent less than those receiving care from an otolaryngologist and multiple providers, and inpatient care was more costly than outpatient care. The elderly incurred greater costs than did younger patients, and male patients had greater costs than did female patients. Additional investigations examining the variability in health care expenditures associated with the evaluation and management of laryngeal disorders are needed and may serve as the basis to compare different management strategies and to identify inefficiencies. Author Contributions

8.

9.

10.

11.

12.

13.

Seth M. Cohen, Design, conduct, analysis, interpretation, writing, final approval; Jaewhan Kim, Design, conduct, analysis, interpretation, writing, final approval; Nelson Roy, Design, conduct, analysis, interpretation, writing, final approval; Carl Asche, Design, conduct, analysis, interpretation, writing, final approval; Mark Courey, Design, conduct, analysis, interpretation, writing, final approval.

14.

15.

Disclosures Competing interests: Seth M. Cohen received research funding from the AAO-HNS; Carl Asche is a consultant for Bayer, Genzyme, Takeda, and Novartis. Sponsorships: None.

16.

17.

Funding source: AAO-HNS. The AAO-HNS had no role in study design, conduct, collection, analysis, and interpretation of the data or writing or approval of the manuscript.

18.

References 1. Haycox A. What Is Health Economics? London, UK: Hayward Medical Communications; 2009. 2. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the ‘‘top 10’’ physical

19. 20.

and mental health conditions affecting six large US employers in 1999. J Occup Envrion Med. 2003;45:5-14. Cohen SM, Kim J, Roy N, Asche C, Courey M. Direct health care costs of laryngeal diseases and disorders. Laryngoscope. 2012;122:1582-1588. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:1988-1995. Cohen SM, Dupont WD, Courey MS. Quality of life impact of non-neoplastic voice disorders: a meta-analysis. Ann Otol Rhinol Laryngol. 2006;115:128-134. Benninger MS, Ahuja AS, Gardner G, Grywalski C. Assessing outcomes for dysphonic patients. J Voice. 1998;12:540-550. Cohen SM. Self-reported impact of dysphonia in a primary care population: an epidemiological study. Laryngoscope. 2010;120:2022-2032. Cylus J, Hartman M, Washington B, Andrews K, Catlin A. Pronounced gender and age differences are evident in personal health care spending per person. Health Aff (Millwood). 2011; 30:153-160. Lang K, Sussman M, Friedman M, et al. Incidence and costs of treatment-related complications among patients with advanced squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg. 2009;135:582-588. Zuckerman S, Waidmann T, Berenson R, Hadley J. Clarifying sources of geographic differences in Medicare spending. N Engl J Med. 2010;363:54-62. Cohen SM, Kim J, Roy N, Asche C, Courey M. Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012;122:343-348. US Department of Commerce Economics and Statistics Administration, US Census Bureau. Census regions and divisions of the United States. www.census.gov/geo/www/us_reg div.pdf. Accessed August 1, 2011. Hardin JW, Hilbe JM. Generalized Linear Models and Extensions. 2nd ed. College Station, TX: Stata Press; 2007. Davis GE, Schwartz SR, Veenstra DL, Yueh B. Cost comparison of surgery vs organ preservation for laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2005;131:21-26. Higgins KM. What treatment for early-stage glottis carcinoma among adult patients: CO2 endolaryngeal laser excision versus standard fractionated external beam radiation is superior in terms of cost utility? Laryngoscope. 2011;121:116-134. Myers EN, Wagner RL, Johnson JT. Microlaryngoscopic surgery for T1 glottic lesions: a cost-effective option. Ann Otol Rhinol Laryngol. 1994;103:28-30. Smith JC, Johnson JT, Cognetti DM, et al. Quality of life, functional outcome, and costs of early glottis cancer. Laryngoscope. 2003;113:68-76. Lehnert T, Heider D, Leicht H, et al. Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. 2011;68:387-420. Hoffman C, Rice D, Sung HY. Persons with chronic conditions: their prevalence and costs. JAMA. 1996;276:1473-1479. Marciniak TA, Ellerbeck EF, Radford MJ, et al. Improving the quality of care for Medicare patients with acute myocardial

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016

Cohen et al

1107

infarction: results from the Cooperative Cardiovascular Project. JAMA. 1998;279:1351-1357. 21. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending, part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-287. 22. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare

spending, part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298. 23. Rees CJ, Postman GN, Koufman JA. Cost savings of unsedated office-based laser surgery for laryngeal papilloma. Ann Otol Rhinol Laryngol. 2007;116:45-48. 24. Bove MJ, Jabbour N, Krishna P, et al. Operating room versus office-based injection laryngoplasty: a comparative analysis of reimbursement. Laryngoscope. 2007;117:226-230.

Downloaded from oto.sagepub.com at Duke University Libraries on April 14, 2016