Matthew L. Maciejewski

Health Care Costs in the Last Week of Life: Associations with End of Life Conversations

BACKGROUND Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. METHODS Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. RESULTS Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were

The Relationship of Patient Satisfaction with Care and Clinical Outcomes

1876 (

Impact of morbid obesity on medical expenditures in adults.

177) for patients who reported EOL discussions compared with

Association Between Bariatric Surgery and Long-term Survival

2917 (

Survival Among High-Risk Patients After Bariatric Surgery

285) for patients who did not, a cost difference of

Correlates of Health-Related Quality of Life in Overweight and Obese Adults with Type 2 Diabetes

1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). CONCLUSIONS Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Bariatric Surgery and Long-term Durability of Weight Loss

OBJECTIVES The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status). METHODS A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis. RESULTS Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores. CONCLUSIONS Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.

Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression

CONTEXT:Morbid obesity (body mass index (BMI) ≥40 kg/m2) is associated with substantially increased morbidity and mortality from chronic health conditions and with poorer health-related quality of life; however, less is known about the impact of morbid obesity on healthcare expenditures.OBJECTIVE:To examine the impact of morbid obesity on healthcare expenditures using a nationally representative sample of US adults.DESIGN, SETTING, AND PARTICIPANTS:We performed a cross-sectional analysis of 16 262 adults from the 2000 Medical Expenditure Panel Survey, a nationally representative survey of the noninstitutionalized civilian population of the United States. Per capita healthcare expenditures were calculated for National Institutes of Health BMI categories, based on self-reported height and weight, using a two-part, multivariable model adjusted for age, gender, race, income, education level, type of health insurance, marital status, and smoking status.MAIN OUTCOME MEASURES:Odds of incurring any healthcare expenditure and per capita healthcare expenditures associated with morbid obesity in 2000.RESULTS:When compared with normal-weight adults, the odds of incurring any healthcare expenditure in 2000 were two-fold greater among adults with morbid obesity. Per capita healthcare expenditures for morbidly obese adults were 81% (95% confidence interval (CI): 48–121%) greater than normal-weight adults, 65% (95% CI: 37–110%) greater than overweight adults, and 47% (95% CI: 11–96%) greater than adults with class I obesity. Excess costs among morbidly obese adults resulted from greater expenditures for office-based visits, outpatient hospital care, in-patient care, and prescription drugs. Aggregate US healthcare expenditures associated with excess body weight among morbidly obese US adults exceeded

Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics

11 billion in 2000.CONCLUSIONS:The economic burden of morbid obesity among US adults is substantial. Further research is needed to identify interventions to reduce the incidence and prevalence of morbid obesity and improve the health and economic outcomes of morbidly obese adults.

Improving the measurement of self-reported medication nonadherence

IMPORTANCE Accumulating evidence suggests that bariatric surgery improves survival among patients with severe obesity, but research among veterans has shown no evidence of benefit. OBJECTIVE To examine long-term survival in a large multisite cohort of patients who underwent bariatric surgery compared with matched control patients. DESIGN, SETTING, AND PARTICIPANTS In a retrospective cohort study, we identified 2500 patients (74% men) who underwent bariatric surgery in Veterans Affairs (VA) bariatric centers from 2000-2011 and matched them to 7462 control patients using sequential stratification and an algorithm that included age, sex, geographic region, body mass index, diabetes, and Diagnostic Cost Group. Survival was compared across patients who underwent bariatric surgery and matched controls using Kaplan-Meier estimators and stratified, adjusted Cox regression analyses. EXPOSURES Bariatric procedures, which included 74% gastric bypass, 15% sleeve gastrectomy, 10% adjustable gastric banding, and 1% other. MAIN OUTCOMES AND MEASURES All-cause mortality through December 2013. RESULTS Surgical patients (n = 2500) had a mean age of 52 years and a mean BMI of 47. Matched control patients (n = 7462) had a mean age of 53 years and a mean BMI of 46. At the end of the 14-year study period, there were a total of 263 deaths in the surgical group (mean follow-up, 6.9 years) and 1277 deaths in the matched control group (mean follow-up, 6.6 years). Kaplan-Meier estimated mortality rates were 2.4% at 1 year, 6.4% at 5 years, and 13.8% at 10 years for surgical patients; for matched control patients, 1.7% at 1 year, 10.4% at 5 years, and 23.9% at 10 years. Adjusted analysis showed no significant association between bariatric surgery and all-cause mortality in the first year of follow-up (adjusted hazard ratio [HR], 1.28 [95% CI, 0.98-1.68]), but significantly lower mortality after 1 to 5 years (HR, 0.45 [95% CI, 0.36-0.56]) and 5 to 14 years (HR, 0.47 [95% CI, 0.39-0.58]). The midterm (>1-5 years) and long-term (>5 years) relationships between surgery and survival were not significantly different across subgroups defined by diabetes diagnosis, sex, and period of surgery. CONCLUSIONS AND RELEVANCE Among obese patients receiving care in the VA health system, those who underwent bariatric surgery compared with matched control patients who did not have surgery had lower all-cause mortality at 5 years and up to 10 years following the procedure. These results provide further evidence for the beneficial relationship between surgery and survival that has been demonstrated in younger, predominantly female populations.