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Full Report: A Study of Chronic Illness in VermontA chronic medical condition is one that places significant limitations on the patient and requires ongoing intervention and interaction with medical services. National research found that in 2005, nine of every ten dollars spent for medical care on American adults (excluding dental care and expenses for medical equipment and supplies) was spent to treat persons with chronic conditions [1]. The same research found that 36% of Americans between 18 and 34 years of age, and over 90% of Americans over 65 years of age, had at least one chronic condition. This chapter explores chronic illness in Vermont and its impact on medical costs and utilization.
Chronic Illness Outline [click on section to jump ahead]
General Findings
Cost of chronic illness in Vermont: Vermont inpatient data indicate that over half of all inpatient stays in Vermont include a diagnosis for at least one chronic condition. In the age group over 65 years, this jumps to 84% of all hospitalizations. The health care cost and utilization impact of these hospitalizations is considerable.
- Hospital charges for Vermont hospitalizations involving a diagnosis for a chronic condition are on average $7,000 more than hospitalizations that did not involve a chronic condition [2].
- Lengths of stay for chronic condition hospitalizations averaged 1.7 days longer than other stays[3].
Smoking cessation: Several of the most prevalent chronic illnesses in Vermont (ischemic heart disease, pulmonary heart disease, chronic obstructive pulmonary disease (COPD), and adult asthma) can be prevented or managed through lifestyle choice. Smoking cessation is of primary importance in the prevention of these conditions:
- Ischemic heart disease is the most prevalent chronic illness in Vermont. Patients with a history of tobacco use are almost three times more likely to be hospitalized for ischemic heart disease than those without a history of tobacco use.
- Chronic obstructive pulmonary disease (COPD) is diagnosed in over 10% of Vermont hospitalizations. Tobacco use is the primary cause of COPD, which in turn is a major cause of pulmonary heart disease. Smoking reduction would have a direct impact on the incidence of both of these diseases.
- Asthma attacks are a common cause of costly emergency room visits. Smoking and second-hand smoke are among the known triggers of adult asthma attacks[4].
Policy that focuses on smoking cessation in Vermont has the potential to reduce or prevent some of the resource intensive hospitalizations that drive health care costs.
Geographic link between risk factors and disease: Maps of risk factor and disease prevalence by Vermont County illustrate a clear geographic link. For example, hypertension, diabetes, and tobacco use are all risk factors of ischemic heart disease. These risk factors are most prevalent in Rutland, Franklin, Bennington, and Orleans counties. Ischemic heart disease is also diagnosed most often in these counties. Understanding the geographic spread of risk factors can help to target intervention programs to prevent the development of chronic illness.
The 2009 Quality Report chapter on chronic illness examines the most prevalent chronic conditions in Vermont and describes how at least some hospitalizations for these conditions can be reduced through lifestyle changes, medication, and proper outpatient care. This chapter also looks at the areas of highest disease and risk factor prevalence within the state. Finally, the chapter presents areas of further study that have potential to inform health care policy and prevention programs, including state and federal statistics regarding chronic illness in Vermont, emerging research linking chronic illness to socio-economic status, and a developmental chronic care cost calculator.
Recommendations
Focus on prevention
Chronic illnesses are often times managed or possibly prevented through lifestyle choice, medication, and effective outpatient care. There is clear evidence that hospitalizations involving each of these chronic illnesses are more expensive and require more resources than stays that do not involve a chronic illness. Programs and initiatives focusing on prevention is an effective strategy for preventing unnecessary hospitalizations for chronic illness, and thereby reducing health care costs.
Of primary importance is the fact that all of these illnesses are strongly affected by tobacco use. Chronic respiratory disease is diagnosed in over 12% of Vermont hospitalizations each year. Tobacco use is a major cause of respiratory disease. Focused smoking cessation programs would directly impact these hospitalizations. When left unchecked, chronic respiratory disease can often lead to heart problems. Targeted smoking cessation programs therefore have the potential to reduce hospitalizations beyond respiratory illness.
Ischemic heart disease, the most common chronic illness in Vermont, has risk factors in addition to tobacco use, including high blood pressure, high cholesterol, diabetes, and obesity. Over 10,000 hospitalizations involving ischemic heart disease diagnosis occur in Vermont each year. Hospital charges for ischemic heart disease are a conservative $6,000 more than stays that do not involve ischemic heart disease. Preventing unnecessary hospitalizations through lifestyle choice (smoking cessation and healthy weight management) and effective outpatient treatment (hypertension, cholesterol, and diabetes) has the potential to vastly impact health care costs.
Further study in chronic illness
Smoking cessation and other intervention programs will be most effective when targeting the greatest “at risk” population. Further study in the following areas is recommended to identify and target this population:
- The hospital discharge data used in this report highlights specific Vermont counties in which risk factors such as tobacco use and hypertension are most prevalent (Rutland, Bennington, Franklin, and Orleans counties). Additional data regarding Vermonters treated at neighboring state hospitals is needed to develop a complete description of chronic illness in the state.
- Emerging national research suggests that prevalence of chronic illness is linked to socio-economic status. It is recommended that further study be performed to see if these national trends are consistent within Vermont[5].
- State and federal statistics provide detailed demographic information about lifestyle risk factors such as tobacco use and obesity. It is recommended that this information is also utilized to create prevention programs that target the greatest “at risk” audience.
Finally, as emphasis on the prevention of chronic illness rises, new tools are becoming available to capture the full burden of chronic care on the health care system. The developmental Chronic Care Cost Calculator highlighted in this chapter is one tool that has the potential to capture chronic care costs in Vermont and warrants further study.
What is Chronic Illness? [back to top]
The specific conditions that define chronic illness can differ by health care agency, but the basic definition of a chronic condition is consistent. Chronic illness is typically defined as a condition that (a) places limitations on independent living, self-care, and social interactions and (b) results in the need for ongoing intervention and interactions with medical products, services, or special equipment. Most definitions also stipulate that the condition must last for at least 12 months.
Definitions of Chronic Illness
The Chronic Care Data Warehouse[6], which provides researchers with Medicare beneficiary, claims, and assessment data, defines 21 chronic conditions. This definition will be used for the analysis in this chapter, since it provides clear boundaries for the conditions to be included and substantially overlaps with other definitions. The 21 chronic conditions identified by the Chronic Care Data Warehouse are as follows:
· Acute Myocardial Infarction
· Alzheimer's Disease
· Alzheimer's Disease, Related Disorders, or Senile Dementia
· Atrial Fibrillation
· Cataract
· Chronic Kidney Disease
· Chronic Obstructive Pulmonary Disease
· Depression
· Diabetes
· Glaucoma
· Heart Failure
· Hip/Pelvic Fracture
· Ischemic Heart Disease
· Osteoporosis
· Rheumatoid arthritis/ Osteoarthritis (RA/OA)
· Stroke / Transient Ischemic Attack
· Breast Cancer
· Colorectal Cancer
· Prostate Cancer
· Lung Cancer
· Endometrial Cancer
The Healthcare Cost and Utilization Project[7] (HCUP) provides a Chronic Care Indicator tool, which uses a more inclusive definition. Along with the 21 conditions defined by the Chronic Care Data Warehouse, this tool includes diagnoses for HIV/AIDS, some chronic substance abuse and mental health conditions, specific ulcers and digestive conditions, anemia, asthma, and all cancers except basal cell carcinomas.
The Dartmouth Atlas of Health Care[8] documents variation in medical resource use across the country and uses a more restrictive definition of chronic illness. In its 2008 report on care of patients with severe chronic illness the Atlas focuses on the following nine chronic illnesses: malignant cancer/leukemia, chronic pulmonary disease, coronary artery disease, congestive heart failure, peripheral vascular disease, severe chronic liver disease, diabetes with end organ damage, chronic renal failure, and dementia.
Data source and methodology [back to top]
The data used in this analysis are from Vermont Inpatient Hospital Discharge Data files for 2002 through 2007. The data files are publicly available and do not contain patient or physician identification. The data files include patient demographic and clinical information such as age, gender, diagnoses, and procedures performed and additional information such as payer source, admission source and discharge status for each patient. The files are generated from inpatient discharge claims from all Vermont hospitals through the uniform billing format. The data are maintained by the Vermont Department of Health under contract with the Department of Banking, Insurance, Securities, and Health Care Administration and undergo extensive review for completeness and accuracy.
The data files only include treatment provided on an inpatient basis. Conditions treated on an outpatient basis are not reflected. The data are also limited to patients receiving care in Vermont hospitals. Vermont residents who received care in an out-of-state hospital are also not reflected in this data set.
The data files provide considerable information on patient diagnoses. Each discharge includes a major diagnosis and up to 19 additional secondary diagnoses. Throughout this chapter, the major diagnosis is referred to as the “primary” diagnosis. Any other diagnoses listed are referred to as “secondary” diagnoses. In this context, “secondary” refers to any non-primary diagnosis, and not specifically the second diagnosis listed.
This chapter uses six years of hospital discharge data, from 2002 through 2007. This allows the analysis of trends over this time period. Where trends have been stable, this also allows the development of a per-year statistic, rather than relying on a single year of data to be representative.
Which chronic illnesses are most prevalent in Vermont? [back to top]
This analysis uses the federal Chronic Care Data Warehouse definition of chronic conditions applied to the Vermont Hospital Discharge Data set. This definition provides clear boundaries for the conditions to be included and substantially overlaps with other definitions of chronic illness.
Using the 21 chronic illnesses specified by the Chronic Care Data Warehouse, Table 1 lists the most prevalent chronic illness in Vermont. All other chronic illness diagnoses occurred in fewer than 5% of hospital admissions per year. The case per year statistic is calculated by averaging the number of cases each year from 2002 through 2007.
Fifty-two percent of all hospitalizations in Vermont from 2002 to 2007 included at least one of the 21 chronic conditions specified by the Chronic Care Data Warehouse. Forty-two percent of Vermont hospitalizations during this time included a diagnosis for at least one of the five most common chronic conditions – ischemic heart disease, diabetes, chronic obstructive pulmonary disorder, depression, heart failure. In the over 65 year age group, 84% of Vermont hospitalizations from 2002 to 2007 included at least one of the 21 chronic conditions, and 67% included at least one of the top five.
The VPQ 2008 Quality Report provided an overview of quality of care in Vermont for patients with diabetes[9]. This chapter of the 2009 Quality Report focuses on the other common types of chronic illness in Vermont – heart disease (including ischemic heart disease) and respiratory disease (including COPD). These conditions are explored through the context of reducing resource intensive hospitalizations via early intervention and outpatient treatment.
Heart Disease [back to top]
This analysis uses the Chronic Care Data Warehouse definition of chronic conditions and data from the Vermont Hospital Discharge Dataset. This definition provides clear boundaries for the conditions to be included and substantially overlaps with other definitions of chronic illness.
Ischemic Heart Disease
Ischemic heart disease is the medical term for a condition known informally as coronary artery disease. The disease is characterized by a restriction of blood flow in the arteries resulting in a reduced blood supply to the heart. Ischemic heart disease is a common cause of congestive heart failure, and a major reason for hospitalization and death in the US.
Major risk factors for ischemic heart disease include age, smoking, high cholesterol, high blood pressure, diabetes, family history, and obesity. Men are at greater risk than women, but the gender disparity decreases with age. Maintaining a healthy weight, getting moderate exercise, and quitting smoking are lifestyle changes that tend to prevent or slow the onset of ischemic heart disease. Seeking medication to manage high cholesterol, high blood pressure, and diabetes may also help to control this disease.
General Findings
Ischemic heart disease was diagnosed in more than one in six hospitalizations in Vermont from 2002 to 2007. In approximately one quarter of these stays, ischemic heart disease was the primary reason for hospitalization. Rates of hospitalization remained consistent from 2002 to 2007. Throughout this time period, ischemic heart disease has been the most prevalent chronic illness in Vermont.
Although some of the risk factors for ischemic heart disease are not under the patient’s control (age, gender, family history), others may be managed via lifestyle and/or medication. Table 2 shows these risk factors and their relationship to ischemic heart disease diagnoses in Vermont from 2002 to 2007. Each odds ratio indicates that an individual with the listed risk factor is that many times more likely to have an ischemic heart disease diagnosis than an individual without that risk factor.
High blood pressure and diabetes are the risk factors most commonly associated with ischemic heart disease, closely followed by tobacco use. The odds of having an ischemic heart disease diagnosis are about four times greater for patients with high blood pressure or diabetes than for patients without these conditions. Early identification and proper management of high blood pressure and diabetes may help to reduce the hospitalization rate for ischemic heart disease. Smoking cessation also has considerable potential to prevent these hospitalizations.
The potential to reduce health care cost and utilization by preventing ischemic heart disease is great. Table 3 below shows the average charges and lengths of stay for patients with ischemic heart disease. It is clear that these hospitalizations require greater resources than the average stay.
Local Trends
Residents of Rutland, Orleans, and Franklin counties were most likely to be hospitalized in Vermont with a diagnosis of ischemic heart disease. Individuals in Essex, Orange, Windsor, and Windham counties were less likely to be hospitalized in Vermont with this diagnosis. Vermont residents hospitalized out of state were not included in this analysis.
Figure 1: Hospitalizations involving a diagnosis for ischemic heart disease;
2002-2007 average, risk-adjusted for age and gender
Hypertension, diabetes, and tobacco use were identified as critical risk factors for ischemic heart disease. It is therefore not surprising that many of the counties that experienced high rates of hospitalizations for ischemic heart disease also experienced high rates of hospitalizations involving these risk factors. Note that Figure 2 reflects only hospitalizations involving these risk factors, and is therefore not representative of overall state prevalence of these conditions. Tobacco use, in particular, is likely to occur without hospitalization.
Figure 2: (a) Hospitalizations involving a diagnosis for hypertension, (b) hospitalizations involving a diagnosis for diabetes, and (c) hospitalization with a mention of tobacco use; 2002-2007 average, risk-adjusted for age and gender
Pulmonary Heart Disease (Cor Pulmonale)
Pulmonary heart disease (Cor Pulmonale) is a frequent consequence of chronic obstructive pulmonary disorder (COPD), the third most common chronic illness in Vermont (Table 1). In general, pulmonary heart disease is a cardiac disorder that is caused by lung disease. Lung disease can slow or block blood flow into the lungs, which results in increased lung pressure. The right side of the heart has to pump harder to overcome this increased pressure, leading to a decrease in cardiac output. Pulmonary heart disease is not synonymous with heart failure; however, the condition can often lead to congestive heart failure of the right side of the heart.
In order to prevent pulmonary heart disease, it is critical to treat the underlying lung disorder because once heart disease occurs, it may no longer be reversible by treating the underlying cause. High incidence of hospitalizations for congestive heart failure with associated pulmonary heart disease complications may indicate poor treatment of the underlying lung disease. Although many chronic lung diseases can lead to pulmonary heart disease, the most common cause is chronic obstructive pulmonary disease (COPD). COPD and methods of prevention are discussed in detail in this chapter’s section on Respiratory Disease.
Vermont hospitalizations for congestive heart failure involving pulmonary heart disease increased more than 40% from 2002 to 2007. This increase is consistent with the national trend (see Figure 3). It is likely that improved methods of detection are at least partially responsible for this increase.
Local trends
Figure 4 indicates that residents of Rutland, Chittenden, and Caledonia counties were most likely to be hospitalized with congestive heart failure including complications from pulmonary heart disease.
Figure 4: Congestive heart failure hospitalizations involving a secondary diagnosis for pulmonary heart disease; 2002-2007 average, risk-adjusted for age and gender
Respiratory Disease [back to top]
This analysis uses the Chronic Care Data Warehouse definition of chronic conditions and data from the Vermont Hospital Discharge Data Set. This definition provides clear boundaries for the conditions to be included and substantially overlaps with other definitions of chronic illness.
Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is the third most common chronic illness in Vermont (Table 1). COPD is primarily composed of two related diseases – chronic bronchitis and emphysema. In both diseases, the flow of air through the airways and out of the lungs is obstructed. This results in a decrease in the lung’s ability to maintain the body's oxygen supply and remove carbon dioxide. This typically manifests as shortness of breath after minimal exertion.
COPD results primarily from smoking tobacco. Years of smoking can cause damage to the airways in the lungs, which continues to progress with continued use of tobacco. Although shortness of breath may not be immediately noticeable, early warning signs of COPD include chronic cough and increased mucus production. Recognizing these early signs is important because lifestyle modifications, such as smoking cessation and avoiding respiratory irritants, can prevent additional damage to the airways and potentially reduce long term consequences and needs.
COPD is also the most common cause of pulmonary heart disease (Cor Pulmonale). Pulmonary heart disease is a cardiac disorder in which the right side of the heart has to pump harder to overcome increased pressure in the lungs due to lack of air flow. The condition can often lead to congestive heart failure of the right side of the heart. In order to prevent pulmonary heart disease, it is critical to treat the underlying lung disorder, typically COPD. High rates of congestive heart failure hospitalizations with pulmonary heart disease complications may indicate that the underlying lung disease is not being adequately treated.
General Findings
A review of Vermont inpatient data from 2002 to 2007 yielded the following information about hospitalizations involving COPD and pulmonary heart disease. In general, hospitalizations involving COPD or pulmonary heart disease cost more and require additional services than stays that do not involve these conditions.
Less than two percent of hospitalizations involved COPD as a primary diagnosis, but over ten percent of hospitalizations involved COPD as a co-morbidity (secondary diagnosis).
- Less than two percent of hospitalizations involved COPD as a primary diagnosis, but over ten percent of hospitalizations involved COPD as a co-morbidity (secondary diagnosis).
- On average, hospital charges for stays in which COPD is a co-morbidity are about $4,000 more and lasted 1.5 days longer than stays without a COPD secondary diagnosis ($17,700 versus $13,100; 4.4 days versus 5.9 days)
- Nine percent of congestive heart failure hospitalizations involved a secondary diagnosis for pulmonary heart disease.
- Congestive heart failure stays involving pulmonary heart disease averaged $3,000 more and were longer than stays that did not involve pulmonary heart disease ($14,900 versus $11,900; 5.9 days versus 4.6 days).
The number of Vermont hospitalizations for COPD remained reasonably stable from 2002 to 2007. As discussed in the section on pulmonary heart disease, the number of hospitalizations for congestive heart failure involving pulmonary heart disease rose by over 40% during this time period. This trend is troubling. It would be ideal to see COPD treatment resulting in fewer complications from pulmonary heart disease. The fact that the rate of COPD hospitalizations is stable while pulmonary heart disease complications are increasing suggests that more can be done to treat this condition. It should be noted that the increase in pulmonary heart disease may be partially attributed to improved diagnostic techniques, and that this analysis does not reflect outpatient care for COPD. However, it is likely that more can be done to prevent high cost hospitalizations through effective treatment of COPD and particularly smoking cessation.
Local Trends
Tobacco use is the primary cause of COPD, which is in turn a primary cause of pulmonary heart disease. Figure 5 shows the rates of hospitalizations involving (a) tobacco use, (b) COPD, and (c) pulmonary heart disease in Vermont counties. The relationship between (b) COPD and (c) pulmonary heart disease is clear, with residents of Rutland and Bennington counties being most likely to be hospitalized with these conditions. The relationship between hospitalizations involving (a) tobacco use and (b) COPD is not quite as clear, although Rutland and Orleans counties showed high rates for both conditions. It is important to note that Figure 5 reflects only hospitalizations involving these conditions, and not overall prevalence in the state. Tobacco use, in particular, is likely to occur without hospitalization.
Figure 5: (a) Hospitalizations with a mention of tobacco use, (b) hospitalizations involving a diagnosis for COPD, and (c) hospitalizations involving a diagnosis for pulmonary heart disease; 2002-2007 average, risk-adjusted for age and gender
Adult Asthma
Adult asthma is not specifically listed in the Chronic Care Data Warehouse definition of chronic illnesses, but almost 3,000 Vermont hospitalizations involving this condition occur each year. Secondary diagnoses for asthma in adults have risen consistently from 2002 to 2007. Since these hospitalizations tend to be more costly than those without an asthma diagnosis, this condition warrants attention.
Asthma is a chronic disease that is characterized by inflammation of the airways, restricting passage of air into the lungs. The result is episodes of wheezing, coughing, chest tightness, and shortness of breath. With adequate outpatient care, asthma is largely controllable and hospitalization can be prevented. Because the characteristics of hospital stays and outpatient care for asthma differ between children and adults, only adult asthma cases are considered in this section.
General Findings
Almost 90% of asthma diagnoses in Vermont hospitals are secondary diagnoses. Patients hospitalized with a secondary asthma diagnosis pay higher total charges on average ($16.1K versus $14.1K) and experience slightly longer lengths of stay (5.0 days versus 4.7 days) than patients with no asthma diagnosis. Of the smaller number of patients hospitalized with a primary asthma diagnosis, 75% were admitted from the Emergency Room (ER). These patients were 3.6 times more likely to come through the ER than patients with no asthma diagnosis.
Research indicates that both smoking and second-hand smoking (also referred to as passive smoking) can trigger asthma attacks4. Tobacco smoke can cause an increase of mucus in the lungs, which can block airways and initiate coughing, wheezing, and shortness of breath. Both smoking cessation and the removal of tobacco smoke from the environment can prevent attacks. These actions, as well as proper outpatient care for asthma, can potentially reduce resource intensive hospital stays and costly ER processing.
The number of hospitalizations with a primary asthma diagnosis has remained relatively constant from 2002 to 2007. However, the number of hospitalizations including a secondary asthma diagnosis has increased by over 45% during this time period. This trend is consistent with national data (Figure 6), and may reflect some improvements in diagnostic techniques during this time period.
How can hospitalizations for chronic illness be prevented? [back to top]
Each chronic illness highlighted in this chapter (ischemic heart disease, pulmonary heart disease, COPD, adult asthma) discusses prevention of the condition. Of primary importance is the fact that all of these illnesses are affected by tobacco use. In particular, smoking is the primary cause of COPD, which is in turn the primary cause of pulmonary heart disease. A reduction in tobacco use would have a direct impact on the incidence of these conditions. Ischemic heart disease is also affected by smoking. Data from 2002 to 2007 shows that patients with a history of tobacco use are almost three times more likely to be hospitalized with ischemic heart disease than those who do not smoke. Finally, smoking and second-hand smoke can trigger attacks in individuals with asthma, which result in costly hospital admissions, likely through the ER.
Ischemic heart disease, the most common chronic illness in Vermont, has additional risk factors of note. For example, high blood pressure, high cholesterol, diabetes, and obesity have the potential to reduce hospitalizations for ischemic heart disease if they are managed effectively. Some of these factors can be affected by lifestyle choices and others can be managed through early detection and careful medication and monitoring.
Where chronic conditions have not been prevented through lifestyle choices, resource intensive hospitalizations are best prevented through early detection and treatment of the condition. Early treatment of COPD, for example, can prevent this disease from developing pulmonary heart disease. Early management of high blood pressure, high cholesterol, and diabetes can reduce the risk of ischemic heart disease. Effective outpatient care and monitoring of these conditions can prevent resource intensive hospitalizations.
Further study in chronic illness [back to top]
Risk factor prevalence
Reducing chronic illness hospitalizations in Vermont will require careful management of risk factors such as tobacco use and obesity. To monitor risk factor prevalence, the Center for Disease Control and Prevention coordinates the Behavioral Risk Factor Surveillance System[10] (BRFSS), a state-based system of surveys that collect data on health risk behaviors.
The latest BRFSS reports for Vermont contain information regarding Vermonter’s tobacco use, exercise habits, and body weight statistics. Among other useful information, the reports indicate that:
- 16.8% of adult Vermonters are current smokers (18.4% of males, 15.3% of females);
- Almost 50% of current adult smokers are in the 18-34 year age group;
- 81% of adult Vermonters report engaging in physical activity outside their normal job; and
- 58% of Vermonters are either overweight (35%) or obese (23%).
A review of the BRFSS reports from recent years could reveal trends in these risk factors in Vermont. The detailed demographic information contained in these reports could also provide valuable information regarding where to target intervention programs. Addressing the risk factors in the areas of highest prevalence will make the biggest impact on reducing costly hospitalizations for chronic conditions.
Socio-economic status
Emergent research suggests that Americans living in the poorest communities are hospitalized more frequently for certain chronic conditions than Americans living in wealthier areas5. This research revealed the following statistics regarding the chronic conditions highlighted in this chapter. Poorer communities are defined as zip codes with a median household income in the lowest quartile, or lowest 25 percent, nationwide. All comparisons are to patients from wealthier communities in 2006:
Patients from poorer communities were
- 87% more likely to be hospitalized for asthma;
- 77% more likely to be hospitalized for diabetes;
- 69% more likely to be hospitalized for COPD; and
- 51% more likely to be hospitalized for congestive heart failure.
Further study could be performed to determine if these observations are upheld within the communities in Vermont. The existing research did not examine trends in risk factors, such as smoking, hypertension, and obesity, by socio-economic status. Understanding the trends in these risk factors could help to inform decision making regarding where to target interventions to make the biggest impact on reducing chronic condition hospitalizations in Vermont.
Chronic Illness Cost Calculator
The Center for Disease Control recently released a Chronic Disease Cost Calculator to help states estimate the prevalence and financial impact of chronic illness among Medicaid beneficiaries. The Chronic Disease Cost Calculator estimates the state Medicaid expenditures for six chronic diseases – congestive heart failure (CHF), heart disease, stroke, hypertension, diabetes, and cancer. The tool includes both federal and state payments for Medicaid and reflects how much money the Medicaid program spends on this set of chronic diseases within a state in one year.
Data Source
Estimates in the Chronic Disease Cost Calculator[11] are based on the Medical Expenditure Panel Survey (MEPS) and represent aggregate annual costs to state Medicaid programs for beneficiaries with these conditions. The tool uses data from 2001-2005 and adjusts estimates to 2007 dollars. As stated above, the Cost Calculator estimates the financial burden caused by chronic illness on state Medicaid programs for beneficiaries with select chronic conditions. Because many people who suffer from chronic disease actually have two or more different chronic diseases, double-counting of the associated medical costs often occurs. The statistical analysis used to generate the cost estimates minimizes double-counting (i.e., overlap of disease costs) of Medicaid dollars going to multiple diseases. As such, the estimates generated are costs attributable to each of these diseases and can be compared across diseases.
States do not have to provide data to use the calculator. Using the MEPS prevalence estimates, comparable costs can be generated for any state as well as nationally. The tool is also customizable allowing states that have access to and resources for analyzing their own data to input their own prevalence rates in order to generate total costs of the selected chronic diseases in their state.
As with any analysis based on administrative data, there are a few notable limitations. The calculator estimates medical costs of these select chronic diseases to Medicaid only; other costs of chronic disease, including costs to other payers such as Medicare, productivity losses and reductions in the quality of life, are not included in the estimates because these costs are not borne by Medicaid. Additionally, the data used in the analysis pre-dates the Medicare Part D prescription drug expansion, which is expected to shift a share of prescription drug costs from Medicaid to Medicare for persons eligible for both programs. Finally, the results of the Cost Calculator are estimates and may differ from results generated using other data sources and/or methodologies.
Future iterations of the calculator will include estimates of the prevalence and costs of asthma, arthritis and depression, estimates of the medical costs to other payers such as Medicare, estimates of the indirect costs of lost productivity, and projections of future costs.
Vermont Findings
Prevalence of these six chronic illnesses was higher in Vermont (8.7%) than in the nation as a whole (6.5%). However, Medicaid cost per beneficiary was lower in Vermont than in the country overall. The only condition for which cost per beneficiary was higher in Vermont was treatment for hypertension. The cost per beneficiary for hypertension treatment was $2,250 in Vermont compared to $2,180 for the US overall. Each of the remaining five chronic conditions cost less to treat per beneficiary in Vermont by 2-5%.
Of the six chronic illnesses examined in the Chronic Disease Cost Calculator, hypertension was the most prevalent among Vermont Medicaid beneficiaries. Over 18% of this population reported treatment for or problems with this condition. The next most common was diabetes (9% of the beneficiaries), closely followed by heart disease (8.7% of the beneficiaries). The least common among Vermont Medicaid beneficiaries was congestive heart failure, with only 1.4% of that population reporting treatment for or problems with this condition.
Estimated Medicaid costs for the six chronic illnesses align approximately with their prevalence. The highest costs were from hypertension treatment, followed by diabetes and stroke. Cancer treatment consumed the lowest amount of Medicaid costs during this period. Table 4 presents the prevalence and Medicaid costs for each of the six chronic illnesses.
Vermont Findings by Age
As expected, the Chronic Disease Cost Calculator showed that each of the chronic illnesses was more prevalent in the older population. Figure 8 shows the prevalence by age group for hypertension, diabetes, heart disease, and cancer. The graph shows the percent of the Medicaid beneficiary population to have reported treatment for or problems with each condition by age group. The tool did not contain sufficient data to generate the age group prevalence for stroke and CHF.
Heart disease demonstrated the greatest percent increase between age groups. It is interesting to note that diabetes prevalence increased dramatically from the age 18-44 group to the age 45-64 group, but less dramatically from the age 45-64 group to the age 65+ group. This may suggest that the onset of diabetes is typically earlier than that of the other chronic conditions.
Not surprisingly, the largest portion of Medicaid costs went to treat beneficiaries in the oldest age group. Over two thirds (69%) of Medicaid costs for these six conditions were consumed by patients over the age of 65. About 23% of Medicaid costs were attributable to patients age 45-64, and the remaining 8% was used for patients age 18-44.
Vermont Findings by Gender
The Chronic Disease Cost Calculator indicated that heart disease, stroke, hypertension, diabetes, and cancer were more prevalent in the female Medicaid beneficiary population. Table 5 shows the prevalence by gender for each of these conditions. The prevalence provides the percent of the gender-specific Medicaid beneficiary population to have reported treatment for or problems with each condition. Due to small cell sizes, the Cost Calculator cannot report estimates for congestive heart failure by gender.
The high prevalence of these chronic illnesses among female beneficiaries may be artificially elevated (confounded) by an interaction between age and gender. The section above confirms that chronic illness is most prevalent among the older population. If this population is primarily female, then the prevalence among females may appear to be higher. Unfortunately, the Chronic Disease Cost Calculator does not provide concurrent reporting by age and gender, so it is not possible to test for this interaction. Since numerous research studies have indicated that heart disease is more common among males than females, it is likely that the data in Table 5 is somehow affected by age.
Conclusions
Prevention of chronic illness through lifestyle choices (smoking cessation, healthy weight management) and effective outpatient treatment (hypertension, cholesterol, diabetes) has the potential to vastly impact health care costs. Among these six common chronic conditions, hypertension (high blood pressure) is by far the most prevalent. Additionally, high blood pressure is a major risk factor for developing additional chronic conditions such as heart disease, congestive heart failure, and stroke. As such, focused efforts in reducing or delaying the onset of hypertension, for example, may save the state considerable long-term costs.
[1] Machlin, S., Cohen J. and Beauregard, K. Health Care Expenses for Adults with Chronic Conditions, 2005. Statistical Brief #203. May 2008. Agency for Healthcare Research and Quality, Rockville, MD. [2] Using hospital discharge data (see Data Source and Methodology section): $17,000 versus $9,700, effect size 0.31 [3] Using hospital discharge data (see Data Source and Methodology section): 5.3 days versus 3.6 days, effect size 0.25 [4] United States Environmental Protection Agency: “Indoor Environmental Asthma Triggers - Secondhand Smoke”, September 07, 2007 [5] Wier, L. (Thomson Reuters), Merrill, C.T. (Thomson Reuters), and Elixhauser, A. (AHRQ). Hospital Stays among People Living in the Poorest Communities, 2006. HCUP Statistical Brief #73. May 2009. Agency for Healthcare Research and Quality, Rockville, MD
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