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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.
The average monthly costs for all risk groups combined in the pre-diagnosis period for the 18 to 49 years age group was $1190, which was substantially lower than the $1487 per month in the 50 years and older group. After the 90 days allowed for the episode of CAP, patients in the younger group reverted to baseline cost levels in a shorter time (446 days) versus 491 days among the patients who were 50 years and older.

Our next step was to define the cost during the episode of the 90-day CAP illness and the 6-month postepisode period for the 2 age groups. For the 18 to 49 years of age cohort, the mean total cost of the CAP episode from beginning to end was $12,453. Of this $9117 (73.2%) accumulated during the 3-month episode period and an additional $3336 (26.8%) accumulated until the cost returned to pre-CAP episode baseline costs. For the 50 years and older cohort the mean total cost of the CAP episode from beginning to end was $15,908. Of this, $11,233 (70.6%) accumulated during the 3-month episode period and $4675 accumulated in the 491 days needed to return to the baseline costs.

Risk Stratification

Among the patients aged 18 to 49 years, the average costs per month before they were diagnosed with CAP were $423, $1173, and $3520 in the low-, moderate-, and high-risk categories, respectively. The average time required to return to these baseline cost levels were 247,562, and 574 days in the low-, moderate-, and high-risk strata, respectively, as shown in Table 2. The pre-episode costs were not substantially different for CAP patients older than 50 years. The average pre-episode monthly costs  were $527, $1263, and $3411, in the low-, moderate-, and high-risk categories, respectively. The average time to revert to baseline expenditures among low-risk patients in the older than 50 years category was remarkably similar (252 days) to patients in the younger 18 to 49 years group (247 days). The numbers of days to revert to pre-diagnosis costs in the moderate and high-risk strata, however, were substantially longer in the moderate-risk group (678 days), the longest among all the groups, and in the high-risk group (610 days) than among the younger 18 to 49 years old patient segment (562 and 574 days, respectively). Table 2 presents the data for mean (± SD) pre-episode costs and the days needed to return to pre-episode costs for the patients 50 years and over. Figure 2 displays the baseline (which are the month-tomonth costs during the pre-episode period), as well as the monthly costs during the episode and the 6-month post-episode costs by risk stratification level for  patients aged 50 years and over.

DISCUSSION

This study assessed the length of time that elapsed before CAP patients in 2 broad age categories (18-49 and >50 years) were able to curtail spending on healthcare resources and revert to baseline (pre-CAP episode) level expenditures. The return to pre-diagnosis cost levels was evaluated in light of published reports on the time needed for symptomatic recovery from CAP. No earlier study appeared to have employed such a risk stratification scheme, and none estimated the burden of CAP by calculating the cost impact beyond the CAP episode. As a result, this study was able to report not only the cost of the episode, but both the duration of time to return to normal costs and the actual episode and post-episode costs.

The number of days to revert to baseline cost levels in the moderate-risk stratum was substantially shorter (562 days) among the younger patients versus 678 days among those older than 50 years. The gap reduced somewhat for the high-risk patients, with an average of 574 days elapsing before recovery among the younger patients, and 610 days for patients in the older age group. While earlier studies on CAP symptomatology did not evaluate recovery by risk strata, our results were consistent withone of their central findings, ie, CAP symptoms did not necessarily resolve following the completion of a course of antibiotic therapy.14-19 In fact, our data indicated that cost was probably the last parameter to return back to the pre-CAP baseline value.

Several prior studies relied on clinical outcome measures including mortality, disease recurrence rates, and adverse events, while others assessed outcomes from a patient’s perspective via health related quality-of-life (HRQL) measures. One clinical study that evaluated 102 CAP patients reported that respiratory symptoms were resolved within 14 days, while conditions that  were associated with patient well-being took a longer time.2 Furthermore, the authors argued that once the pre-pneumonia status of patients was factored in, patients were observed to recover fully after 6 months. They noted that the persistence of  symptoms for more than 28 days and accompanying HRQL impairment were more reflective of age and comorbidity status rather than the lingering effects of the CAP infection itself.2 Our results correlate well with this important finding in that other associated costs of the episode due to other illnesses and comorbidities extend well beyond the actual respiratory symptoms encountered with the CAP episode. This study demonstrates that the risk factors are directly related to the increased recovery time of the higher-risk strata, and are associated with higher cost regardless of age group.

Because our study relied on an economic measure (reversion to baseline costs) as a surrogate for recovery, we were not positioned to address questions associated with patients’ perceptions of their quality of life or the impact of their symptoms over time. Consistent with existing literature, however, we found that even though there may be clinical recovery from an acute episode of CAP over a relatively short period of time, well within 3 months, there are lingering CAP symptoms that still require medical care that extend beyond 3 months. Furthermore, the longer-term effects of the CAP event may prevent costs from returning to normal pre-episode levels for up to 9 months post-diagnosis or longer. Our findings suggested that the long-term cost consequences linked to CAP are independent of patients’ age and their risk profile.

In the treatment of CAP, one of the principal objectives in any circumstance is to relieve patient symptoms in the interim while ultimately eliminating the causative pathogens over a reasonable period of time. In most scenarios, the shortest time to full symptom resolution is the most desirable outcome, and because of the economic burdens associated with prolonged periods to full recovery, the elapsed time is of particular interest to payer organizations. This research suggests that the cost to return to normal costs extends to 9 months post-diagnosis or about 6 months after the CAP episode has been clinically concluded.

Limitations and Benefits of This Research

While comorbidity levels and DCI values were measured for the patient groups in this study, patient comorbidities were not linked to the time that elapsed before patients reverted to baseline costs. Furthermore, this study did not assess the medications or dosing information and treatment strategies utilized during this study. It has been demonstrated that dosing regimen and treatment strategies for infectious diseases have important implications for patient outcomes, and typically impact the major cost areas.26 This study only included those data on patients that survived their CAP episode and survived not only the 90-day period allotted for the episode but also the full 9 months including the CAP episode. This is a limitation only to the extent that any costs of death due to CAP are not included. This is mitigated by the high survivability of the vast majority of CAP patients.

While the use of claims data for research purposes has several known limitations, their use in this study allowed us to examine a large sample of commercially insured patients with well-adjudicated and accurate records. Data on disease severity and concomitant conditions are included in the costs reported and likely reflect the total disease burden associated with CAP. Another challenge is that patients can present a wide range of pulmonary and extra-pulmonary symptoms that could be due to typical bacterial pathogens as well as atypical pathogens. To acknowledge this heterogeneity in CAP, this study utilized a wide variety of ICD-9-CM codes that could be reflective of CAP and also required x-ray claims to further refine the likelihood of CAP identification.

CONCLUSIONS

The cost of the CAP episode extends beyond the clinical symptom phase. Despite treatment advances, CAP patients who experience short-term clinical recovery may still face long-term clinical and economic consequences regardless of their age and risk stratum. Knowledge of such lingering impact is important in formulating efficacious treatment and prevention strategies. It is also of value to payers faced with covering healthcare costs for extended periods after the resolution of the initial acute condition.

Author Affiliations: From HealthCore, Inc (TW, JY, JS, BT), Wilmington, DE; Pfizer Inc (RS), Collegeville, PA.

Funding Source: This research project was sponsored by Pfizer Inc.

Author Disclosures: Dr Wasser reports employment with Health-Core, Inc. Ms Yu discloses that she was an employee of HealthCore duringthe period when this research project was conducted. Dr Singer and Mr Tulsi disclose that they are employees of HealthCore, the research subsidiary of WellPoint, who were paid consultants to Pfizer Inc in the development of this manuscript and in the development and execution of this study. Dr Sato discloses that she is an employee of Pfizer Inc,which provided funding for this study.

Authorship Information: Concept and design (TW, JY, JS, RS); acquisition of data (TW, JY); analysis and interpretation of data (TW, JY, RS); drafting of the manuscript (TW, JY, BT); critical revision of the manuscript for important intellectual content (TW, JY, RS); statistical analysis (TW, JY); obtaining funding (RS); administrative, technical, or logistic support (TW); and supervision (TW, JS, RS).

Address correspondence to: Thomas Wasser, PhD, MEd, 800 Delaware Ave, Wilmington, DE 19801. E-mail: twasser@healthcore.com.
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