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The increased use of neuroimaging and innovations in ischemic stroke (IS) treatment have improved outcomes, but the impact on median hospital costs is not well understood.A retrospective study was conducted using Medicare 5% claims data for 75,525 consecutive index IS hospitalizations for patients aged ≥65 years from 2012 to 2019 (values in 2019 dollars). IS episode cost was calculated in each year for trend analysis and stratified by cost components, including neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, and MR angiography [MRA]), treatment (endovascular thrombectomy [EVT] and/or intravenous thrombolysis), and patient sociodemographic factors. Logistic regression was performed to analyze the drivers of high-cost episodes and median regression to assess drivers of median costs.The median IS episode cost increased by 4.9% from $9,509 in 2012 to $9,973 in 2019 (P = .0021). Treatment with EVT resulted in the greatest odds of having a high-cost ($20,000) hospitalization (odds ratio [OR], 71.86; 95% confidence interval [CI], 54.62-94.55), as did intravenous thrombolysis treatment (OR, 3.19; 95% CI, 2.90-3.52). Controlling for other factors, neuroimaging with CTA (OR, 1.72; 95% CI, 1.58-1.87), CTP (OR, 1.32; 95% CI, 1.14-1.52), and/or MRA (OR, 1.26; 95% CI, 1.15-1.38) had greater odds of having high-cost episodes than those without CTA, CTP, and MRA. Length of stay4 days (OR, 4.34; 95% CI, 3.99-4.72) and in-hospital mortality (OR, 1.85; 95% CI, 1.63-2.10) were also associated with high-cost episodes.From 2012 to 2019, the median IS episode cost increased by 4.9%, with EVT as the main cost driver. However, the increasing treatment cost trends have been partially offset by decreases in median length of stay and in-hospital mortality.

OBJECTIVE Clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) treatment are highly time sensitive. Remote robotic (RR)–EVT systems may be capable of mitigating time delays in patient transfer from a primary stroke center (PSC) to a comprehensive/thrombectomy-capable stroke center. However, health economic evidence is needed to assess the costs and benefits of an RR-EVT system. Therefore, the authors of this study aimed to determine whether performing RR-EVT in suspected AIS patients at a PSC as opposed to standard of care might translate to cost-effectiveness over a lifetime. METHODS An economic evaluation study was performed from a US healthcare perspective, combining decision analysis and Markov modeling methods over a lifetime horizon to evaluate the cost-effectiveness of RR-EVT in suspected AIS patients at a PSC compared to the standard-of-care approach. Total expected costs and quality-adjusted life-years (QALYs) were estimated. RESULTS In the cost-effectiveness analysis, RR-EVT yielded greater effectiveness per patient (4.05 vs 3.88 QALYs) and lower costs (US$321,269 vs US$321,397) than the standard-of-care approach. Owing to these lower costs and greater health benefits, RR-EVT was the dominant cost-effective strategy. After initiation of an RR-EVT system, the average costs per year were similar (or slightly reduced), according to this simulation. Sensitivity analyses revealed that RR-EVT remains cost-effective in a wide variety of time delays and cost assumptions. In a one-way sensitivity analysis, RR-EVT remained the most cost-effective strategy when time delays were greater than 2.5 minutes, its complication rate did not exceed 37%, and costs were lower than $54,081. When the cost of the RR-EVT strategy ranged from $19,340 to $54,081 and its complication rate varied from 15% to 37%, the RR-EVT strategy remained the most cost-effective throughout the two ranges. RR-EVT was also the most cost-effective strategy even when its cost doubled (to approximately $40,000) and time delays exceeded 20 minutes. In a probabilistic sensitivity analysis, RR-EVT was the long-term cost-effective strategy in 89.8% of iterations at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS This analysis suggests that RR-EVT as an innovative solution to expedite EVT is cost-effective. An RR-EVT system could potentially extend access to care in underserved communities and rural areas, as well as improve care for socioeconomically disadvantaged populations affected by health inequities.

BackgroundEvidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) MethodsAn economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3–5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model.ResultsCompared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY.ConclusionsThe results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3–5), compared with SC alone over the patient’s lifetime.

lthough intravenous contrast in neuroimaging has become increasingly important in selecting patients for stroke treatment, clinical concerns remain regarding contrast-associated acute kidney injury (CA-AKI). Given the increasing utilization of CT angiography and/or perfusion coupled with cerebral angiography, the purpose of this study was to assess the association of CA-AKI and multi-dose iodinated contrast in acute ischemic stroke (AIS) patients.etrospective review of AIS patients at a comprehensive stroke center was performed from January 2018 to December 2019. Data collection included patient demographics, stroke risk factors, stroke severity, discharge disposition, modified Rankin Scale, contrast type/volume, and creatinine levels (baseline, 48-72 h). CA-AKI was defined as creatinine increase ≥ 25 % from baseline. Bivariate analyses and multivariable logistic regression models were implemented to compare AIS patients with multi-dose and single-dose contrast.Of 440 AIS patients, 215 (48.9 %) were exposed to a single-dose contrast, and 225 (51.1 %) received multi-dose. In single-dose patients, CA-AKI at 48/72 h was 9.7 %/10.2 % compared to 8.0 %/8.9 % in multi-dose patients. Multi-dose patients were significantly more likely to receive a higher volume of contrast (mean 142.1 mL versus 80.8 mL; p lt; 0.001), but there was no significant difference in their creatinine levels or CA-AKI. NIHSS score (OR=1.08, 95 % CI=[1.04,1.13]), and patient transfer from another hospital (OR=3.84, 95 % CI=[1.94,7.62]) were significantly associated with multi-dose contrast.No significant association between multi-dose iodinated contrast and CA-AKI was seen in AIS patients. Concerns of CA-AKI should not deter physicians from pursuing timely and appropriate contrast-enhanced neuroimaging that may optimize treatment outcomes in AIS patients.

Background: Prior investigations have documented disparities in the supply side of Maryland’s Medical Marijuana program. Initially a disproportionate share of licenses to cultivate and distribute m...

Purpose: To examine indebtedness for medical care among racial and ethnic minorities and people with serious psychological distress (SPD) using a nationally representative sample in the United States. Methods: Using the 2014–2017 Medical Expenditure Panel Survey, we examine medical debt among individuals with SPD. We develop a logistic regression model to estimate the odds of medical debt by SPD status. We stratify the odds of medical debt for those with SPD by insurance type. Results: The results indicate that after controlling for predisposing, enabling, and physical needs factors, those experiencing SPD have double the odds of having medical debt compared with those without SPD. Non-Hispanic blacks had higher odds of medical debt compared with non-Hispanic whites. We find that individuals with SPD covered under private health insurance have double the odds of having medical debts; and those who are uninsured have triple the odds of having medical debt compared with their counterparts without SPD. Conclusion: The findings suggest that odds of medical debt are higher among people with SPD, even when insured. Additional health policy initiatives to address medical debt among those with SPD may be warranted.

Objectives To assess the impact of criminal justice-focused state-level prenatal substance use policies on foster care admissions and child removal. Methods Using data from the 2005–2016 Adoption and Foster Care Analysis and Reporting System covering all US states, we utilized state-level variation in the implementation of these policies to assess their impact on substance and alcohol use-related foster care admissions under a difference-in-difference framework. Results The study found that these policies were associated with an increase in the proportion of drug and alcohol use-related foster care admissions. These results were consistent for both non-Hispanic White and Black children. Conclusions The findings imply that states with these policies are more likely to see an increase in admissions to their foster care system as mothers may be discouraged to seek treatment for their substance use disorder during pregnancy and may lack access to appropriate resources to take care of their children. Policy implications The large impact of these policies on non-Hispanic White infants implies that the current opioid crisis might possibly be driving the documented increase in foster care admissions.

Perinatal mental health is a major public health issue in the United States. Yet, much is unknown about unmet mental health care need among pregnant women with a major depressive episode and the reasons for unmet need.Using a nationally representative data set, the study examined mental health treatment utilization, unmet mental health care need, and the reasons for unmet mental health care needs among pregnant women with a major depressive episode compared with nonpregnant women with a major depressive episode (weighted N=128,000).Of pregnant women who had experienced a major depressive episode, 49% reported receiving any mental health treatment, compared with 57% of nonpregnant women with a major depressive episode. The study also found financial barriers to be the primary reason for unmet mental health care need.Despite current treatment guidelines and policy initiatives, most women with major depressive episodes go without any treatment utilization and perceive an unmet need for their mental health care.

The health and financial burden of the opioid epidemic has been disproportionately hard on reproductive-aged parenting women. This crisis not only impacts the well-being of the mothers but is also spilling over to their children and families.Given the alarming rise of opioid use disorder (OUD) among mothers, this study seeks to examine the primary motivations and sources for the most recent prescription opioids misused among this population.Using data from 2015 to 2016 National Survey of Drug Use and Health (NSDUH), this study analyzes data on reproductive-aged parenting women who have misused any prescription opioids in the previous 12 months. All estimates were weighted to account for NSDUH's complex survey design and to make the estimates nationally representative (weighted N ≈ 14.4 million).Results show that physicians (43%) are the most commonly reported source for obtaining prescription opioids among parenting women with OUD, whereas social sources (57%) are the most common source for parenting women who have misused opioids without OUD. A significant proportion of parenting women with OUD reported drug-related reasons (57%) and relief from physical pain (25%) as the two primary motivations for opioid misuse, while parenting women without OUD reported relief from physical pain (45%) and help with emotions or feelings (32%) as primary motivations.Opioid misuse and use disorder among parenting women are a significant health risk. Policy initiatives that encompasses a comprehensive approach toward the crisis are warranted.

There is growing evidence of risks associated with excessive technology use, especially among teens and young adults. However, little is known about the characteristics of those who are at elevated risk of being problematic users. Using data from the 2012 Current Population Survey Internet Use Supplement and Educational Supplement for teens and young adults, this study developed a conceptual framework for modeling technology use. A three-part categorization of use was posited for utilitarian, social and entertainment purposes, which fit observed data well in confirmatory factor analysis. Seemingly unrelated regression was used to examine the demographic characteristics associated with each of the three categories of use. Exploratory factor analysis uncovered five distinct types of users, including one user type that was hypothesized to likely be at elevated risk of problematic use. Regression results indicated that females in their twenties who are in school and have greater access to technology were most likely to fall into this higher-risk category. Young people who live with both parents were less likely to belong to this category. This study highlighted the importance of constructing models that facilitate identification of patterns of use that may characterize a subset of users at high risk of problematic use. The findings can be applied to other contexts to inform policies related to technology and society as well. Supplementary Information The online version of this article (10.1007/s11293-020-09683-1) contains supplementary material, which is available to authorized users.

Research has shown a significant increase in overdose deaths among reproductive-aged parenting women in the United States. Given the alarming rise of opioid use disorder, this study analyzes polysubstance use among reproductive-aged parenting women. Using data from 2015 to 2016 National Survey of Drug Use and Health (NSDUH), this study examines data on prevalence and patterns of polysubstance use among US reproductive-aged parenting women who misused prescription opioids in the past 30 days. Results show that 87% of parenting women who misused prescription opioids reported using other substances concurrently in the past 30 days.

Research has documented a low rate of opioid use disorder (OUD) treatment utilization among individuals involved in the criminal justice system. However, racial disparities in sources of payment for OUD treatment have not been examined in the existing literature.Although substance use disorder (SUD) treatment is relatively rare for all criminal justice system involved racial-groups, previous research has indicated that, among individuals with SUD, members of racial minority groups receive treatment at lower rates than their non-Hispanic White counterparts. Given the alarming rise of OUD in the US and the association between source of payment and utilization of health care services, this study seeks to quantify racial disparities in sources of payment for OUD treatment among individuals with criminal justice involvement.Using data from the 2008-2016 National Survey of Drug Use and Health (NSDUH), this study analyzes data on non-incarcerated individuals with OUD who have had any criminal justice involvement in the previous 12 months. An extension of the Blinder-Oaxaca decomposition method for non-linear models is implemented to determine the extent that differences in OUD treatment utilization across non-Hispanic Blacks and non-Hispanic Whites are explained by observed and measurable characteristics and/or unobserved factors.Results indicate that non-Hispanic Whites are more likely to have their OUD treatment paid by a court (10%) relative to non-Hispanic Blacks (4.0%). Black-White differences in measurable factors explain 87% of the disparity, while the rest is attributed to unobserved factors. Non-Hispanic Blacks are more likely to have their OUD treatment paid by public insurance (77% vs 36%) than non-Hispanic Whites and only 72% of this disparity can be explained by observed characteristics.Our findings indicate racial disparities in sources of payment for OUD treatment among the criminal justice-involved population. Expansion of health insurance coverage and access to substance use disorder treatments would be beneficial for reducing health care disparities.Equitable treatment options in the criminal justice system that incentivize OUD treatment availability may help address racial disparities in sources of payment among the criminal justice-involved population with OUD.Future research should focus on understanding the main factors driving the court's treatment decisions among the criminal justice system involved individuals.

The impact of the opioid epidemic has been particularly hard on reproductive-aged parenting women. Yet, very little is known about opioid use, opioid misuse and opioid use disorder among parenting women with major depressive episode (MDE). Information on sources of opioids intended for misuse and reasons for opioid misuse among this population is also lacking. Using the 2015-2016 National Survey on Drug Use and Health, the study estimates a multinomial logistic regression model to investigate the association between MDE and opioid misuse as well as use disorder among reproductive-aged parenting women (n = 7750). Among reproductive-aged parenting women with prescription opioid use in the past 12 months, having had a MDE was associated with a higher relative risk of misusing prescription pain relievers without use disorder (RRR = 1.38, p .001) and having a use disorder (RRR = 1.99, p .001), relative to using prescription opioid without misuse or use disorder. However, utilization of mental health treatment mitigated the risk for opioid misuse and use disorder. A significant proportion of parenting women regardless of their MDE status identified family or friends and physicians as their main source of opioids. Relief from physical pain and help with feelings or emotions were the two primary motivations for opioid misuse among this population. These findings underscore the importance of maternal depression and mental health treatment in undertaking policy initiatives directed at the opioid crisis and highlights the role of medical providers, family and friends in targeted interventions aimed at this population.