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Long-Term Cost Consequences of Community-Acquired Pneumonia in Adults
Thomas Wasser, PhD, MEd; Jingbo Yu, MHA, PhD; Joseph Singer, MD; Bernard Tulsi, MSc; and Reiko Sato, PhD
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Long-Term Cost Consequences of Community-Acquired Pneumonia in Adults

Thomas Wasser, PhD, MEd; Jingbo Yu, MHA, PhD; Joseph Singer, MD; Bernard Tulsi, MSc; and Reiko Sato, PhD
Irrespective of age or risk stratification, patients will likely experience long-term cost consequences extending far beyond their short-term recovery from a community-acquired pneumonia episode.
Objectives: To estimate the time required for healthcare costs to revert to baseline levels among adults who had an episode of community-acquired pneumonia (CAP).

Methods: This retrospective study utilized claims data from 14 United States regional health plans currently in the HealthCore Integrated Research Database (HIRD). Pneumonia episodes were identified from January 1, 2008, to May 17, 2010, using International Classification of Disease, Ninth Revision, Clinical Modification codes with chest x-ray claims. Study inclusion required continuous enrollment 6 months prior to and 9 months post-diagnosis. The analysis allowed for a 90-day illness episode, and excluded costs but included time during the period to revert to baseline costs. Post-CAP costs, starting at day 91, were followed for 6 months. Results, stratified by age and risk level, were analyzed with the Theil non-parametric regression procedure.

Results: A total of 88,358 CAP patients aged >18 years (37% aged 18-49 and 63% >50 years) were assessed. In the 18 to 49 years group, 47%, 38%, and 16% were from the low, moderate, and high-risk groups, had monthly pre-diagnosis costs of $423, $1173, and $3520, and required an average of 247, 562, and 574 days to return to pre-CAP cost levels, respectively. Among patients aged >50 years, the average monthly pre-diagnosis costs were $527, $1263, and $3411, and costs reverted to pre-CAP levels after an average of 252, 678, and 610 days for the low, moderate, and high-risk groups, respectively.

Conclusions: Despite clinical recovery from a CAP episode in the short term, these results suggest likely long-term cost consequences from a CAP episode, regardless of age or risk.

Am J Pharm Benefits. 2013;5(3):e66-e72
  • The results of this study show that the costs of an episode of community-acquired pneumonia extend beyond the 90-day allowance for the illness.

  • Differences in the length of time to revert to pre-episode costs depend on the age category and risk stratification of patients at the time the episode started.

  • Increased costs for some patients can extend beyond 1 year and may approach 2 years in some cases.
Community-acquired pneumonia (CAP), a commonly diagnosed infective disorder, is one of the leading causes of morbidity and mortality worldwide.1-3 In the United States, an estimated 5 to 6 million cases of CAP are diagnosed every year, which require approximately 1 million hospitalizations and about 10 million visits to physicians’ offices.4-6 CAP affects about 4 million adults in the United States annually, and is considered the country’s seventh-leading cause of death together with infl

uenza among individuals older than 65 years.7 While CAP does not appear to have any gender or racial correlations, it is particularly common among older adults. In a 3-year study that included 46,273 seniors, Jackson et al found rates of CAP ranging from 18.2 to 52.3 cases per thousand person-years among patients aged 65 to 69 years and >85 years, respectively.8 A 2004 review of the total annual cost of CAP in the United States is estimated to be at least $12.2 billion,9 and in a 2010 study, File et al demonstrated that the overall annual costs associated with CAP had grown to more than $17 billion.10

Typically, CAP manifests as acute infections of the pulmonary parenchyma11 and shows up as an acute infiltrate in chest x-rays.4 Clinical symptoms include coughing, sputum production, chest pain, and fever in infected patients. Antibiotic treatment remains the dominant therapeutic intervention. An estimated 25% of all CAP patients require inpatient hospitalization,6 of which the majority are older adults with a wide variety of comorbidities including chronic obstructive pulmonary disease (COPD), or chronic bronchitis (notemphysema), diabetes, heart disease, etc.6,12 While the use of healthcare services by CAP patients in outpatient settings is quite common,1 precise quantitative data are less readily available.

In efforts to gauge the effectiveness of treatment interventions, particularly of antibiotic therapy, researchers have employed a range of traditional outcome measures including mortality rates, rehospitalization rates, and healthcare utilization rates, calculated mostly on the basis of length of hospital stay.13 These traditional outcomes did not necessarily take into consideration outcomes of importance to the patients.2 This was overcome in a number of studies that assessed outcomes and recovery from the patient perspective.14-19 Available evidence suggests that a substantial proportion of CAP patients report pneumonia-associated symptoms 1 month after the initial presentation7,18,20,21 and these could extend to more than 90 days after diagnosis.18

While the aforementioned studies have assessed the time required to recover from an episode of CAP from the perspective of patients by assessing symptom resolution and return to work or normal activities, it would appear that no study has yet evaluated when healthcare resource use returns to pre-CAP levels. The purpose of this study was to estimate the time needed for healthcare resource use to return to pre-CAP baseline levels in adult patients, expressed in terms of costs, and stratified byage and risk in a large commercially insured population.


Data Source

This was a retrospective study that utilized medical and pharmacy claims, and eligibility data for commercially insured patients to evaluate the burden of CAP at the patient level for the period January 1, 2008, to May 17, 2010. All study data were retrieved from the Health-Core Integrated Data Base (HIRD), a comprehensive repository of clinically rich longitudinal claims data drawn from 14 health plans operating in most major population centers across the United States. The HIRD houses data from different types of benefit designs including health maintenance organizations, point of service, preferred provider organizations, and indemnity plans, and tracks enrollment, medical care, prescription drug use, and health care utilization for each patient. All study data were de-identified and accessed using protocols compliant with the regulations of the Health Insurance Portability  and Accountability Act of 1996 (HIPAA). Patient confidentiality and the anonymity were safeguarded throughout the study.

Inclusion and Exclusion Criteria

Included patients had 1 or more medical claims with a primary or secondary diagnosis of pneumonia for an inpatient claim, or a pneumonia diagnosis in any position for an outpatient claim during the study period. Pneumonia was identified based on International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes of 480.xx to 486.xx and 487.0. The service date of the first observed claim for pneumonia was defined as the index date. Other inclusion criteria included a  chest x-ray claim within 14 days of the index date, age 18 years or older, and continuous medical and pharmacy eligibility for 6 months before and 9 months after the index date. To refine CAP identification, patients were excluded if they were hospitalized or institutionalized for any reason in the 14 days prior to the index date. To distinguish one pneumonia episode from another, patients who had a pneumonia diagnosis in the 90 days before the index were also excluded.

Outcome Measures

The primary outcome measures were all-cause related healthcare resource utilization and costs. All-cause costs represented the total amounts paid by the health plan and by patients for medical treatment, pharmaceuticals, office, outpatient, and emergency department (ED) and inpatient services. Costs for office visits, outpatient facility visits, and ED visits were defined as the total cost for all claims at the service location for patients who met the eligibility criteria— diagnosis for pneumonia. In addition, all-cause costs for hospitalizations were defined as the total cost for all claims at an inpatient facility regardless of the primary or secondary diagnosis. The same methods were used to compute pharmacy costs as well. Antibiotic administration costs were included in inpatient, outpatient, office visit, or ED, depending on the site where the treatment was provided.

Statistical Analysis

Because the cost to  treat CAP differs by age and underlying comorbidities, data analyses were stratified on these variables. Three risk groups were defined: high risk—immunocompromising conditions; moderate risk— immunocompetent but with chronic medical conditions; and low risk—immunocompetent without any chronic medical conditions.22,23

Descriptive statistical methodologies and trend analysis were used in this study. Continuous data were reported out as mean ± standard deviation (SD) and discrete data were reported as the percent in each category and the percent of the total count of patients. Cognizant of the potential limitations of the ordinary least squares (OLS) estimator in a straight-line regression analysis where outliers are present in the data, we opted to utilize the Theil regression method to estimate the time needed for healthcare resource use to return to pre-CAP baseline levels. The Theil approach offers a simple yet robust way to address such issues as outliers and nonnormality of the dependent variable, which in this application is the number of days required for the patient to return to normal, pre-episode cost. OLS regression was not used, as it is frequently influenced by outliers and carries assumptions of distribution normality. Theil regression takes each X and Y pair of data within a data set and calculates  all combinations of slope values for every X and Y pair. In the current study, the X variable is time and the Y variable is all-cause costs. The slope values are ordered from highest to lowest, and the median slope value is taken as the slope for that data set. The theory is that high or low X Y pairs of data (due to outliers) will yield very high or low slope values. By taking the median  slope value as the estimate for a data set, the outliers are naturally eliminated while still being included in the data set. This eliminates any bias that might occur by (1) including outliers in data sets that are remote by error,and (2) eliminating the effect of outliers by not being forced to have arbitrary decision rules for what data are included because the Theil regression method uses all data.24

This study used 3 defined time periods, and all patients were required to have complete data for all time periods to be included in the analysis. First, the “episode” of illness was defined as the 90-day period that began when the diagnosis of CAP appeared in the claim. Post-episode data began when this 90-day episode period concluded and continued for 6 months. The pre-episode period began 6 months prior to the appearance of the CAP diagnosis in the claims.

Theil regression was applied beginning with the first cost value 90 days after the index date (defined as the post-episode period), and continued for 6 months. The slope and intercept for each risk stratum by age group were calculated and the slope of the regression line was used as the rate of cost recovery. Using this regression methodology, it was then possible to calculate the number of days required after the CAP episode for costs to return to normal baseline values. From this analysis the days and the total costs post episode were calculated and reported.


Patient Disposition

Of the patients diagnosed with CAP who satisfied the conditions for inclusion during the intake period (N = 281,424), a total of 179,024 were commercially insured and met the age, eligibility, no prior treatment, and service claims requirements. Of those, a total of 88,358 CAP patients were available for assessment because they had complete data for the 6-month pre-episode, 90-day episode, and the 6-month post episode periods—a total of 15 months, as displayed in Figure 1.

Clinical and Demographic Characteristics at Baseline

Of the included CAP patients, the mean (± SD) age was 55.8 (± 17.9) years. There was a slightly larger proportion of females (52.2%). The age group and risk stratification data are presented in Table 1.

Greater proportions of patients were located in the central (32.5%) and southern (31.3%) regions of the United States than in the west (20.2%) and northeast (15.9%). More than one-half (58.4%) of the patients had a 0 Deyo-Charlson Comorbidity Index (DCI) score, which indicates a healthy population without specified chronic conditions. The DCI includes 17 diagnoses identified by ICD-9-CM codes, each with a weighting from 1 to 6. Higher scores represent greater comorbidity burden.25 Slightly more than one-fifth (22.0%) of the patients had a DCI score of 1 and only 3.4% of the study group had a score that exceeded 5. The most commonly occurring comorbidity was heart disease (among 10.6% of the patients) followed by cancer with 4.9%.

In the overall study population, 46.7% of the patients were classified as low risk, 37.6% as moderate risk, and 15.7% as high risk. Among the patients who were 50 years and older, there was a smaller proportion of patients classified as low risk (31.9%), although the proportions of moderate- (46.0%) and high-risk (22.2%) patients were greater in this age category.

Time to Revert to Pre-Diagnosis Costs

Age Stratification

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