Publications

2010

The United States far outspends Canada on health care, but the sources of additional spending are unclear. We evaluated the importance of incomes, administration, and medical interventions in this difference. Pooling various sources, we calculated medical personnel incomes, administrative expenses, and procedure volume and intensity for the United States and Canada. We found that Canada spent $1589 per capita less on physicians and hospitals in 2002. Administration accounted for the largest share of this difference (39%), followed by incomes (31%), and more intensive provision of medical services (14%). Whether this additional spending is wasteful or warranted is unknown.

Cutler, David M, Bryan Lincoln, and Richard Zeckhauser. 2010. “Selection Stories: Understanding Movement Across Health Plans.” Journal of Health Economics 29 (5). Publisher's Version
Fang, Margaret, David M Cutler, and Allison Rosen. 2010. “Trends in Thrombolytic Use for Ischemic Stroke in the United States.” Journal of Hospital Medicine 5 (7): 406-409. Website Abstract

BACKGROUND: Although recombinant tissue plasminogen activator (tPA) improves outcomes from ischemic stroke, prior studies have found low rates of administration. Recent guidelines and regulatory agencies have advocated for increased tPA administration in appropriate patients, but it is unclear how many patients actually receive tPA.

OBJECTIVE: To determine whether national rates of tPA use for ischemic stroke have increased over time.

METHODS: We identified all patients with a primary diagnosis of ischemic stroke from years 2001 to 2006 in the National Hospital Discharge Survey (NHDS), a nationally representative sample of inpatient hospitalizations, and searched for procedure codes for intravenous thrombolytic administration. Clinical and demographic factors were obtained from the survey and multivariable logistic regression used to identify independent predictors associated with thrombolytic use.

RESULTS: Among the 22,842 patients hospitalized with ischemic stroke, tPA administration rates increased from 0.87% in 2001 to 2.40% in 2006 (P < 0.001 for trend). Older patients were less likely to receive tPA (adjusted odds ratio [OR] and 95% confidence interval [CI]; 0.4 [0.3-0.6] for patients ≥80 years vs. <60 years), as were African American patients (0.4 [0.3-0.7]). Larger hospitals were more likely to administer tPA (3.3 [2.0-5.6] in hospitals with at least 300 beds compared to those with 6-99 beds).

CONCLUSIONS: Although tPA administration for ischemic stroke has increased nationally in recent years, the overall rate of use remains very low. Larger hospitals were more likely to administer tPA. Further efforts to improve appropriate administration of tPA should be encouraged, particularly as the acceptable time-window for using tPA widens.

Cutler, David M, and Keith Ericson. 2010. “Cost-Effectiveness Analysis in Markets With High Fixed Costs.” Pharmacoeconomics 26 (10): 867-875. Publisher's Version Abstract

We consider how to conduct cost-effectiveness analysis when the social cost of a resource differs from the posted price. From the social perspective, the true cost of a medical intervention is the marginal cost of delivering another unit of a treatment, plus the social cost (deadweight loss) of raising the revenue to fund the treatment. We focus on pharmaceutical prices, which have high markups over marginal cost due to the monopoly power granted to pharmaceutical companies when drugs are under patent. We find that the social cost of a branded drug is approximately one-half the market price when the treatment is paid for by a public insurance plan and one-third the market price for mandated coverage by private insurance. We illustrate the importance of correctly accounting for social costs using two examples: coverage for statin drugs and approval for a drug to treat kidney cancer (sorafenib). In each case, we show that the correct social perspective for cost-effectiveness analysis would be more lenient than researcher recommendations.

Ruhnke, Greg, Marcelo Coca-Perraillon, Barrett T Kitch, and David M Cutler. 2010. “Trends in mortality and medical spending in patients hospitalized for community-acquired pneumonia: 1993-2005.” Medical Care 48 (12). Website Abstract

BACKGROUND: Community-acquired pneumonia (CAP) is the most common infectious cause of death in the United States. To understand the effect of efforts to improve quality and efficiency of care in CAP, we examined the trends in mortality and costs among hospitalized CAP patients.

METHODS: Using the National Inpatient Sample between 1993 and 2005, we studied 569,524 CAP admissions. The primary outcome was mortality at discharge. We used logistic regression to evaluate the mortality trend, adjusting for age, gender, and comorbidities. To account for the effect of early discharge practices, we also compared daily mortality rates and performed a Cox proportional hazards model. We used a generalized linear model to analyze trends in hospitalization costs, which were derived using cost-to-charge ratios.

RESULTS: Over time, length of stay declined, while more patients were discharged to other facilities. The frequency of many comorbidities increased. Age/gender-adjusted mortality decreased from 8.9% to 4.1% (P < 0.001). In multivariable analysis, the mortality risk declined through 2005 (odds ratio, 0.50; 95% confidence interval, 0.48-0.53), compared with the reference year 1993. The daily mortality rates demonstrated that most of the mortality reduction occurred early during hospitalization. After adjusting for early discharge practices, the risk of mortality still declined through 2005 (hazard ratio, 0.74; 95% confidence interval, 0.70-0.78). Median hospitalization costs exhibited a moderate reduction over time, mostly because of reduced length of stay.

CONCLUSIONS: Mortality among patients hospitalized for CAP has declined. Lower in-hospital mortality at a reduced cost suggests that pneumonia is a case of improved productivity in health care.

Cutler, David M. 2010. “Health Reform Passes the Cost Test.” Wall Street Journal.
2009
Cutler, David M, Murray Aitken, and Ernst Berndt. 2009. “Prescription Drug Spending Trends in the United States: Looking Beyond the Turning Point.” Health Affairs 28 (1): 151-160. Publisher's Version
Cutler, David M, Edward L Glaeser, and Allison B Rosen. 2009. “Is The U.S. Population Behaving Healthier?” Social Security Policy in a Changing Environment, edited by Jeffrey Liebman and David M Cutler. Publisher's Version
Cutler, David M, Mary Beth Landrum, and Kate Stewart. 2009. “Intensive Medical Care and Cardiovascular Disease Disability Reductions.” Health at Older Ages: The Causes and Consequences of Declining Disability Among the Elderly, edited by David M Cutler and David Wise. Chicago: University of Chicago Press. Publisher's Version
Cutler, David M, Mary Beth Landrum, and Kate Stewart. 2009. “Clinical Pathways to Disability.” Health at Older Ages: The Causes and Consequences of Declining Disability Among the Elderly, edited by David Cutler and David Wise. Chicago: University of Chicago Press. Publisher's Version
Cutler, David M, Mary Beth Landrum, and Kate Stewart. 2009. “How Do The Better Educated Do It? Socioeconomic Status and Ability to Cope with Underlying Impairment.” Developments in the Economics of Aging, edited by David Wise. Chicago: University of Chicago Press. Publisher's Version
Cutler, David M, and Edward L Glaeser. 2009. “Why Do Europeans Smoke More Than Americans?” Developments in the Economics of Aging, edited by David Wise. Chicago: University of Chicago Press. Publisher's Version
Cutler, David M, and Allison B Rosen. 2009. “Challenges in Building Disease-Based National Health Accounts.” Medical Care 47 (7): S7-S13. Publisher's Version
Cutler, David M, and Alex Gelber. 2009. “Changes in the Incidence and Duration of Periods Without Insurance.” New England Journal of Medicine 360 (17): 1740-1748. Publisher's Version
Cutler, David M. 2009. “The Next Wave of Corporate Medicine -- How We All Might Benefit.” New England Journal of Medicine 361 (6): 549-551. Website
Cutler, David M, Dana P Goldman, Yuhui Zheng, Federico Girosi, Pierre-Carl Michaud, and Jay S Olshansky. 2009. “The Benefits of Risk Factor Prevention in Americans Aged 51 and Older.” American Journal of Public Health 99 (11): 2096-2101. Website
Brauer, Carmen, Marcelo Coca-Parraillon, David M Cutler, and Allison B Rosen. 2009. “Incidence and Mortality of Hip Fractures in the United States.” JAMA 302 (14): 1573-1579. Website Abstract

Context Understanding the incidence and subsequent mortality following hip fracture is essential to measuring population health and the value of improvements in health care.

Objective To examine trends in hip fracture incidence and resulting mortality over 20 years in the US Medicare population.

Design, Setting, and Patients Observational study using data from a 20% sample of Medicare claims from 1985-2005. In patients 65 years or older, we identified 786 717 hip fractures for analysis. Medication data were obtained from 109 805 respondents to the Medicare Current Beneficiary Survey between 1992 and 2005.

Main Outcome Measures Age- and sex-specific incidence of hip fracture and age- and risk-adjusted mortality rates.

Results Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100 000 (95% confidence interval [CI], 921.7-992.9) for women and 414.4 per 100 000 (95% CI, 401.6-427.3) for men. The age-adjusted incidence of hip fracture increased from 1986 to 1995 and then steadily declined from 1995 to 2005. In women, incidence increased 9.0%, from 964.2 per 100 000 (95% CI, 958.3-970.1) in 1986 to 1050.9 (95% CI, 1045.2-1056.7) in 1995, with a subsequent decline of 24.5% to 793.5 (95% CI, 788.7-798.3) in 2005. In men, the increase in incidence from 1986 to 1995 was 16.4%, from 392.4 (95% CI, 387.8-397.0) to 456.6 (95% CI, 452.0-461.3), and the subsequent decrease to 2005 was 19.2%, to 369.0 (95% CI, 365.1-372.8). Age- and risk-adjusted mortality in women declined by 11.9%, 14.9%, and 8.8% for 30-, 180-, and 360-day mortality, respectively. For men, age- and risk-adjusted mortality decreased by 21.8%, 25.4%, and 20.0% for 30-, 180-, and 360-day mortality, respectively. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis. The incidence decrease is coincident with increased use of bisphosphonates.

Conclusion In the United States, hip fracture rates and subsequent mortality among persons 65 years and older are declining, and comorbidities among patients with hip fractures have increased.

Stewart, Susan T, David M Cutler, and Allison B Rosen. 2009. “Forecasting the Effects of Obesity and Smoking on U.S. Life Expectancy.” New England Journal of Medicine 361: 2252-2260. Website
Lapado, Joseph, Farouc Jaffer, Udo Hoffmann, Carey Thomson, David M Cutler, Fabian Bamberg, William Dec, Milt Weinstein, and Scott Gazelle. 2009. “Clinical Outcomes and Cost-Effectiveness of Coronary Computed Tomography Angiography in the Evaluation of Patients with Chest Pain.” Journal of the American College of Cardiology 54 (25): 2409-2422. Website Abstract

OBJECTIVES: The aim of this study was to project clinical outcomes, health care costs, and cost-effectiveness of coronary computed tomography angiography (CCTA), as compared with conventional diagnostic technologies, in the evaluation of patients with stable chest pain and suspected coronary artery disease (CAD).

BACKGROUND: CCTA has recently been found to be effective in the evaluation of patients with suspected CAD, but investigators have raised concerns related to radiation exposure, incidental findings, and nondiagnostic exams.

METHODS: With published data, we developed a computer simulation model to project clinical outcomes, health care costs, and cost-effectiveness of CCTA, compared with conventional testing modalities, in the diagnosis of CAD. Our target population included 55-year-old patients who present to their primary care physicians with stable chest pain.

RESULTS: All diagnostic strategies yielded similar health outcomes, but performing CCTA-with or without stress testing or performing stress single-photon emission computed tomography-marginally minimized adverse events and maximized longevity and quality-adjusted life-years (QALYs). Health outcomes associated with these strategies were comparable, with CCTA in men and women yielding the greatest QALYs but only by modest margins. Overall differences were small, and performing the most effective test-compared with the least effective-decreased adverse event rates by 3% in men and women. Comparable increases in longevity and QALYs were 2 months and 0.1 QALYs in men and 1 month and 0.03 QALYs in women. CCTA raised overall costs, partly through the follow-up of incidental findings, and when performed with stress testing, its incremental cost-effectiveness ratio ranged from $26,200/QALY in men to $35,000/QALY in women. Health outcomes were marginally less favorable in women when radiation risks were considered.

CONCLUSIONS: CCTA is comparable to other diagnostic studies and might hold good clinical value, but large randomized controlled trials are needed to guide policy.

Lapado, Joseph, Jill R Horwitz, Milt Weinstein, and David M Cutler. 2009. “Adoption and Spread of New Imaging Technology: A Case Study.” Health Affairs 28 (6): 1122-1132. Website Abstract

Technology is a major driver of health care costs. Hospitals are rapidly acquiring one new technology in particular: 64-slice computed tomography (CT), which can be used to image coronary arteries in search of blockages. We propose that it is more likely to be adopted by hospitals that treat cardiac patients, function in competitive markets, are reimbursed for the procedure, and have favorable operating margins. We find that early adoption is related to cardiac patient volume but also to operating margins. The paucity of evidence informing this technology's role in cardiac care suggests that its adoption by cardiac-oriented hospitals is premature. Further, adoption motivated by operating margins reinforces concerns about haphazard technology acquisition.

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