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Address correspondence to Rajender R. Aparasu, PhD, FAPhA, Health and Biomedical Sciences Building 2, Office 4052, 4849 Calhoun Road, Houston, TX 77204-5047, USA.
To determine the all-cause health care resource utilization and costs among long-term nursing home (LTNH) residents with and without overactive bladder (OAB).
Design
Retrospective cohort study.
Setting and Participants
Minimum Data Set (MDS)–linked Medicare Part A, B, and D claims data from 2013 to 2015 were analyzed. LTNH residents aged 65 years or older with a diagnosis of OAB (n = 216,731) were propensity score matched with LTNH residents without OAB (n = 300,327) (non-OAB cohort).
Methods
We measured health care resource utilization and costs associated with OAB by setting (inpatient, outpatient, emergency department, or prescription) during the 6 months following nursing home admission. Descriptive and multivariate (negative binomial for health care resource utilization and 2-part model for costs) analyses were performed to examine the health care resource utilization and costs among LTNH residents with and without OAB. The annual cost attributed to OAB was calculated as the difference between total annual OAB costs and total annual non-OAB costs.
Results
A total of 214,505 patients were included in each matched cohort. Across all health care resource categories, LTNH residents with OAB had higher health care resource utilization and costs compared to the non-OAB cohort (all P < .001). The mean annual direct total cost was $57,984 in the OAB cohort compared with $54,285 in the non-OAB cohort. The annual cost of OAB in nursing homes was estimated at $793 million. Adjusted analyses revealed that the OAB cohort was 9% more likely to have hospitalization and emergency department visits, 15% more likely to have outpatient visits, 27% more likely to have physician visits, and 12% more likely to have prescription counts compared with the non-OAB cohort.
Conclusions and Implications
The study findings suggest that LTNH residents with OAB have significantly more health care resource utilization compared with patients without OAB. These results provide health care decision makers with recent estimates of the burden of OAB in LTNH to assist them with resource planning.
It is projected that over the next few decades, the United States will experience a marked demographic shift, with older adults (≥65 years of age) outnumbering those ≤18 years of age for the first time in history.
For many older adults, life events or declining health may result in a transition from living in the community to nursing home facilities and with the growing older population in the United States, it is likely that the number of adults transitioning from the community to nursing home facilities will increase substantially. In fact, between 2000 and 2013 the proportion of Medicare Advantage beneficiaries in nursing homes increased by 125%.
An aging population experiences a higher burden of health concerns, and admission to a nursing home often occurs when the patient's health needs have become difficult for them to manage on their own or with in-home caregivers.
Overactive bladder (OAB), a prevalent symptom complex consisting of urinary urgency, with or without urgency urinary incontinence, usually accompanied by frequency and nocturia, is one condition more commonly experienced by older adults.
OAB can be complicated by other conditions including dementia; 64% of Medicare beneficiaries living in nursing homes have Alzheimer's disease or a related dementia.
One recent study indicated that the comorbidity of OAB and dementia was associated with increased risk of falling and fracturing and urinary tract infections.
Prevalence and effect on health-related quality of life of overactive bladder in older Americans: Results from the epidemiology of lower urinary tract symptoms study.
The national costs of OAB have been estimated at US$65.9 billion in 2007, with $51.4 billion due to direct medical expenditure, and $14.6 billion due to indirect costs. These costs are projected to increase to $82.6 billion by 2020,
The economic burden of overactive bladder (OAB) and its effects on the costs associated with other chronic, age-related comorbidities in the United States.
in the majority, been derived from community-dwelling populations. The estimates of costs of OAB among nursing home populations that exist are outdated.
With advances in the management of OAB over the last 2 decades coupled with a growing older population who are at risk of both developing OAB and transition to nursing home facilities, more recent estimates of the resource utilization and costs among this population are necessary for appropriate health care planning.
Objective
To evaluate the all-cause health care resource utilization and medical costs among LTNH residents with and without OAB.
Methods
Data Source
This study was conducted using the Minimum Data Set (MDS)–linked Medicare data from Part A, B, and D claims from July 1, 2013, to July 31, 2015. The MDS is a federally mandated nursing home health assessment tool administered to all residents in Medicare/Medicaid-certified nursing facilities in the United States. The assessment tool captures details on physical, psychological, and psychosocial functioning, active clinical diagnoses, health conditions, treatments, and services. Medicare Part A covers hospital care, initial care in skilled nursing facilities, hospice care, and home health care whereas Part B covers services such as laboratory, ambulance, outpatient mental health, and other physician services that are not included in Part A. Each Part A and Part B record contains up to 10 diagnoses recorded according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Part D, launched in 2006, covers prescription benefits for Medicare beneficiaries. Each Part D Prescription Drug Event claim comprises information for prescription drug fills, including drug name, fill date, days' supply, and quantity. The study protocol was approved by the CMS Privacy Board and the Committee for the Protection of Human Subjects from the authors' (S.S. and R.A.'s) institute.
Study Design and Study Cohort
This retrospective cohort study included older adult (≥65 years) LTNH residents with OAB (OAB cohort) and without OAB (non-OAB cohort). An LTNH resident was defined as any individual with a nursing home stay of at least 101 consecutive days. OAB cohort included residents if they had (1) nursing home stay of at least 180 days; (2) presence of OAB diagnosis before nursing home admission (prevalent OAB); and (3) medical and pharmaceutical coverage 6 months before and after nursing home admission. Patients with OAB were defined based on at least 1 claim of OAB diagnosis (ICD-9-CM codes: 596.5, 596.51, 788.3, 788.31, 788.33, 788.41, 788.43, 788.63, 788.91) in inpatient or outpatient settings or at least 1 prescription claim for OAB-specific medications (antimuscarinics, mirabegron, or onabotulinumtoxinA). Antimuscarinic medications included darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium. For the comparative assessment, the non-OAB cohort included residents if they had (1) age 65 years or older during nursing home admission; (2) nursing home stay of at least 180 days; (3) no diagnosis of or a prescription for OAB 6 months before and after nursing home admission; and (4) medical and pharmaceutical coverage 6 months before and after nursing home admission.
Measures
The outcomes of this study were health care resource utilization and costs and were compared between patients with and without OAB. Health care resource utilization was characterized by the type of medical service claims and included inpatient, outpatient, physician, and emergency department (ED) visits, as well as prescription counts, measured during the 6-month period following nursing home admission. Hospitalizations were identified using MEDPAR files and defined based on short and long stay at the hospital. Outpatient visits were identified using outpatient claims for any visit occurring at a hospital in an outpatient department. Physician visits were identified using Carrier files; Berenson-Eggers Type of Service (BETOS) codes M1A, and M1B, and ED visits were identified using MEDPAR files,
Number of prescriptions were identified from Part D prescription claims data.
Mean total medical costs included inpatient, outpatient, physician, ED, prescription drug costs, and other costs among residents during the 6-month period following nursing home admission. We extrapolated this cost to annual cost by multiplying the 6-month cost by 2. To obtain total costs attributed to OAB, we calculated the difference between total annual OAB costs and total annual non-OAB costs. In the event that a negative payment amount was identified for inpatient utilization, it was converted to zero dollars. The negative reimbursement happens when coinsurance and/or deductible exceeds the reimbursement due to the provider. Costs were inflated to 2017 US dollars using the medical component of the Consumer Price Index.
Covariates
The baseline demographic and clinical characteristics for each cohort were captured 6 months before nursing home admission from Medicare part A, B, and D claims and from the MDS assessment tool at admission. Demographic characteristics including age, sex, race or ethnicity, marital status, health plan and geographic region were described. Clinical characteristics included prior history of falls, Elixhauser comorbidities, medication use (antidepressants, diuretics, beta-blockers, calcium channel blockers, anticonvulsants, angiotensin-converting enzyme inhibitors, antipsychotics, antiparkinson agents, and alpha-blockers), body mass index, cognition, functional status, and level of anticholinergic burden. Cognition was measured using the MDS cognition scale, a validated measure of the presence and severity of cognitive impairment in nursing home residents using items from the MDS.
Functional status was measured using the activities of daily living items in the MDS, which measure 5 progressive levels of care dependency in completing fundamental activities.
Finally, level of anticholinergic burden was measured using the Anticholinergic Cognitive Burden (ACB) scale. This scale captures the accumulative anticholinergic cognitive burden among older adults resulting from all medications taken.
Descriptive analyses were used to characterize demographic and clinical characteristics of the study cohort. To balance the OAB and non-OAB cohorts, propensity score matching was used with respect to all baseline characteristics described above in a 1:1 ratio. A 5→1 greedy matching algorithm without replacement was used to perform 1:1 matching of patients with OAB with patients without OAB. This was implemented using the Proc PSMATCH in SAS (SAS Inc, Cary, NC). Balance across all covariates pre- and postmatching was measured using the standardized differences or Cohen d. Balance between the OAB and non-OAB cohorts was indicated by standardized differences of <0.10 on baseline covariates.
Descriptive statistics, including means and median with appropriate measures of variance (standard deviation) were used to report health care resource utilization and costs. All analyses for health care resource utilization and costs were performed in the propensity score-matched cohort. We performed paired t test in the matched cohort to compare health care resource utilization and costs. As health care resource use data are typically right skewed, to determine the resource use among LTNH residents with and without OAB, data were analyzed using negative binomial regression models with a log-link function. Negative binomial regression models the log of utilization and coefficients obtained from these models were expressed as incidence rate ratios [IRR; 95% confidence interval (CI)]. To determine the health care costs, a 2-part model using a gamma-distribution with log-link function was used. Baseline demographic and clinical characteristics were not included in the model because those were well balanced in the matched sample. Since there is the possibility that some nursing home residents did not have ED or hospitalization-related encounters over a 6-month period, the two-part model was used to model a dependent variable with lot of zeros and many positive values.
Therefore, the probability of any health care expenditures was evaluated by a probit model using the entire sample. Further, generalized linear model was used for those with any expenditures.
Results
Baseline Characteristics
Among 521,980 LTNH residents, 216,731 were identified with prevalent OAB, among whom 214,505 were propensity score matched with 214,505 (out of 300,327) LTNH residents without OAB (non-OAB cohort) (Table 1; Figure 1). Prior to matching, the standard differences indicated imbalances between cohorts in 11 characteristics at baseline: compared to the non-OAB cohort a greater percentage of the OAB cohort were non-Hispanic white (86.4% vs 79.8%), located in the Midwest (32.3% vs 24.7%), had a prior history of falls (32.3% vs 24.7%), had depression (37.7% vs 32.8%), had claims for antidepressants (55.7% vs 32.8%), were obese (21.5% vs 17.1%), and had intact cognition (79.2% vs 74.4%). On the other hand, a greater percentage of the non-OAB cohort were non-Hispanic black (14.2% vs 9.4%), were Medicare/Medicaid dual eligible (53.6% vs 47.9%), were located in the South (41.9% vs 36.5%) and had severe cognitive impairment (11.7% vs 8.5%). After matching, no significant differences in baseline characteristics were observed and the distributions of age and sex between the cohorts were similar: 45.2% of the OAB cohort were ≥85 years of age and 70.7% were female, compared to 45.8% being ≥85 years of age and 70.4% female in the non-OAB cohort. In the matched sample, the most common comorbidities were hypertension (OAB cohort: 87.1%; non-OAB cohort: 86.9%), cardiac arrhythmias (OAB cohort: 46.9%; non-OAB cohort: 47.0%), and diabetes (OAB cohort: 42.7%; non-OAB cohort: 42.5%). Most of the matched cohort had intact cognition (OAB cohort: 76.1%; non-OAB cohort: 78.4%) and similar mean (standard deviation) ACB scores [OAB cohort: 1.02 (1.72); non-OAB cohort: 0.96 (1.63)]. Additional clinical characteristics are reported in Table 1.
Table 1Baseline Characteristics of Patients With and Without OAB, Before and After Propensity Score Matching
In the 6 months following nursing home admission, unadjusted health care resource utilization was higher in the OAB cohort relative to the non-OAB cohort across all categories (Table 2). The mean number of hospitalizations (0.55 vs. 0.51, P < .001), outpatient visits (6.50 vs. 5.66, P < .001), physician visits (1.87 vs. 1.47, P < .001), and ED visits (0.96 vs. 0.88, P < .001) were higher in the OAB cohort compared with the non-OAB cohort. In the negative binomial model, relative to the non-OAB cohort, the OAB cohort was 9% more likely to be hospitalized (IRR 1.09, CI 1.08-1.10) and have ED visits (IRR 1.09, CI 1.08-1.10), 15% more likely to have outpatient visits (IRR 1.15, CI 1.14-1.16), 27% more likely to have physician visits (IRR 1.27, CI 1.26-1.28), and 12% more likely to have prescription counts (IRR 1.12, CI 1.11-1.13) in the 6 months following nursing home admission (Table 2).
Table 2Health Care Resource Utilization in Patients With and Without OAB During the Study Period
In the 6 months following nursing home admission, mean total direct costs were higher in the OAB cohort compared with the non-OAB cohort across all cost categories. All costs were multiplied by 2 and reported as annual cost (Table 3). The mean annual direct total cost was $3699 higher in the OAB cohort compared with the non-OAB cohort ($57,984 vs. $54,285) (P < .001). Mean (standard deviation) health care costs were driven by those related to hospital admission, which were $12,386 ($27,360) in the OAB-cohort compared to $11,738 ($27,410) in the non-OAB cohort; followed by outpatient visits, which were $4775 ($7473) in the OAB cohort compared with $4638 ($8267) in the non-OAB cohort. The estimated annual cost for OAB among LTNH residents was $793 million (calculated based on the 6-month costs of $6,218,922,155 for OAB and $5,822,238,144 for non-OAB).
Table 3Mean Annual Health Care Costs Among LTNH Residents
Total mean annual health care costs also include costs associated with skilled nursing facility, pathology, laboratory, medical devices, as well as other costs.
Total mean annual health care costs also include costs associated with skilled nursing facility, pathology, laboratory, medical devices, as well as other costs.
57,984 (54,068)
54,285 (54,365)
3699 (76,560)
<.001
SD, standard deviation.
∗ Total mean annual health care costs also include costs associated with skilled nursing facility, pathology, laboratory, medical devices, as well as other costs.
This retrospective cohort study evaluated health care resource utilization and costs among LTNH residents with and without OAB. Across all categories of health care resource utilization and costs, LTNH residents with OAB had higher health care utilization and costs compared with LTNH residents without OAB, with annual costs for OAB in nursing homes estimated at more than $700 million. Although the incremental differences per person observed here were relatively low, because of the high prevalence of OAB, these costs represent a substantial economic burden.
The analysis found that OAB was associated with 9% increased all-cause hospital admissions, 15% increased outpatient department visits, 27% increased physician visits, and 9% increased ED visits during 6 months of nursing home stay. The finding that patients with OAB in LTNH have higher health care resource utilization is consistent with previous reports among other commercially insured populations with OAB. Tang et al
Impact of urinary incontinence on healthcare resource utilization, health-related quality of life and productivity in patients with overactive bladder.
reported higher health care resource utilization (including surgery, pad use, and hospitalization) among individuals with wet OAB compared with individuals with dry OAB. Likewise, Yehoshua et al
also found higher health care resource utilization among individuals with wet OAB with respect to hospital admissions, outpatient visits, prescriptions filled, and diagnostic tests performed compared with individuals without OAB. However, neither of these studies were specific to nursing home residents.
The mean annual direct costs associated with OAB in the present study was similar to those previously reported.
to estimate the cost of OAB in the United States, a cost input of $57,800 was used for the annual cost of an OAB-related nursing home stay in 2007. Cost inputs for physician, specialty, and ED visits were not included in the OAB-related nursing home stay in Ganz et al, and unfortunately details on what was included in that cost component were not provided to facilitate further comparison. Published estimates of the total health care costs associated with OAB among nursing home residents indicate that OAB represents a substantial economic burden; however, recent and US-specific estimates are lacking. In 2000, Hu et al
estimated that the cost of OAB among institutionalized patients [considering diagnostic, treatment (including physician visits), and routine care (nursing labor, laundry and absorbent pads)] and costs of consequences (skin conditions, urinary tract infections, and falls/broken bones) totaled 3.5 billion. The primary cost driver in that study was routine care, representing 3.3 billion.
estimated that nursing home care costs for OAB in 2005 was €338 ($392) million in Canada, €1.6 ($1.86) billion in Germany, €1.8 ($2.09) billion in Italy, €261 ($302.8) million in Sweden, €23 ($26.7) million in Spain, and €579 ($671.6) million in the United Kingdom. In the present study, the costs for OAB among nursing home residents was notably lower at $793 million. This may be explained by different parameters of direct health care costs being considered as well as the study population, including the number and type of nursing home residents with OAB across studies. As the present study relied on Medicare claims, resource costs were limited to those captured within the Medicare data and would not have captured aspects of routine nursing care, such as cost of nursing labor, laundry, and incontinence supplies (ie, absorbent pads), which were the primary cost drivers in Hu et al.
As the US population ages, a growing number of individuals are estimated to transition to nursing home facilities, and up to 65% of these individuals may have OAB.
Office of the Assistant Secretary for Planning and Evaluation (ASPE) Transition Rates from the Community to Nursing Home Care Among Older Adult Medicaid Enrollees, 2006-2009.
US Department of Health & Human Services,
Bethesda, MD2016
In anticipation of the growing number of individuals anticipated to make this transition, the present study provides health care decision makers with recent estimates of the burden of OAB among nursing home residents. The study findings can assist health care resource planning decisions and allow nursing homes to plan resources appropriately for the management of OAB.
Limitations
As this study provides estimates of health care resource utilization and costs among Medicare-insured LTNH residents with OAB, results would not be generalizable to individuals with OAB not residing in nursing homes nor those who have Medicare Advantage insurance. Although a majority of the study sample were considered cognitively intact based on the MDS, this may limit generalizability of the study findings. All costs were multiplied by 2, as the study period was 6 months, and reported as annual costs. As this was an observational study using retrospective claims data, no causal inferences can be made. Additionally, as administrative claims data are collected for billing rather than research purposes, the data may be subject to misclassification.
Conclusions and Implications
The health care resource utilization and costs required for managing patients with OAB in LTNH represent a growing burden in an aging population and were estimated at $793 million annually in the present study. Health care resource costs were significantly higher among LTNH residents with OAB ($57,984) compared with a matched cohort without OAB ($54,285). These results fill an important gap in the literature on the OAB-specific burden in nursing homes in the United States. These findings will be useful for health care planning to aid the decesion makers in anticipating costs and resource utilization associated with OAB in LTNH residents for optimalallocation of resources.
Acknowledgment
We would like to thank Meagan Harwood MPH for contributing to the drafting, reviewing and editing of this manuscript. Meagan Harwood is an employee of Broadstreet Health Economics & Outcomes Research, which received payment from Astellas Pharma Global Development, Inc.
References
United States Census Bureau
2017 National Population Projections Tables. 2017.
Prevalence and effect on health-related quality of life of overactive bladder in older Americans: Results from the epidemiology of lower urinary tract symptoms study.
The economic burden of overactive bladder (OAB) and its effects on the costs associated with other chronic, age-related comorbidities in the United States.
Impact of urinary incontinence on healthcare resource utilization, health-related quality of life and productivity in patients with overactive bladder.
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