US Health Care Expenditures, GDP and Health Policy Reforms: Evidence from End-of-Sample Structural Break Tests.

This research investigates the over-time stability of the aggregate US healthcare expenditure (HCE)-GDP relationship, focusing on periods of healthcare reforms. The most consequential reforms-Medicaid/Medicare and the Affordable Care Act (ACA)-are challenging to study because they occur near the ends of the available data. Using annual national- and state-level data and a battery of structural break tests, we find the HCE-GDP relationship to be overwhelmingly stable.

Estimating the Learning Curve of a Novel Medical Device: Bipolar Sealer Use in Unilateral Total Knee Arthroplasties.

Background: The use of cost-effectiveness analysis for medical devices has proven to be challenging because of the existence of the learning effects in the device-operator interactions. The need for the relevant analytical framework for assessing the economic value of such technologies has been recognized.

Objectives: To present a modified difference-in-differences (DID) cost-effectiveness methodology that facilitates visualization of a new health technology's learning curve.

Opportunities to improve pain management outcomes in total knee replacements: patient-centered care across the continuum.

Despite the importance of pain management to each patient's overall experience with a total knee replacement, opportunities to improve pain care exist. The authors target an unnecessarily fragmented pain management trajectory as one cause of variability in pain outcomes. They propose that a technology-enhanced patient-centered pain management continuum running from the preoperative through the recovery phase offers effective and efficient pain management.

The oh-so straight and narrow path: can the health care expenditure curve be bent?

Although there is much talk about whether or not the current health care reform will 'bend' the health care expenditure 'curve', exactly which 'curve' is to be 'bent' is often ill-specified. This essay notes that the 'curve' defined by the log of US national health care expenditures per capita plotted against the log of the US gross domestic product per capita has been remarkably straight since 1929 despite Medicare and Medicaid and all of the more recent reform attempts. After establishing stationarity and considering cointegration and endogeneity, the slope of this log-log relationship suggests a per capita expenditure-income elasticity of 1.

The long-term outcomes and costs of diabetes mellitus among renal transplant recipients: tacrolimus versus cyclosporine.

Anti-rejection regimens for renal transplants have changed dramatically during the past 20 years, but there are few long-term studies relating cost, mortality, or graft failure simultaneously to disease-pharmacotherapy couplets. We analyzed US Renal Data System data on a matched-pair cohort of first, single organ kidney transplants from 1998 through 2002 over up to 5 years following transplantation for patients on tacrolimus or low-dose cyclosporine, stratifying by whether the recipient had pre-existing or new onset diabetes. Kaplan-Meier survival curves show mortality and survival differences associated with diabetes, but no additional incremental effects of immune suppression regimen.

Impact of substance abuse on access to renal transplantation.

Background: With an ever-increasing demand for kidneys and limited supply pool, it is essential to understand the balance between utility and equity in transplant access. The goal of this project was to evaluate the association between recipient's substance abuse and renal transplant access in patients with end-stage renal disease (ESRD).

Methods: We used data from the United States Renal Data System.

Cost-effectiveness of Medicare's coverage of immunosuppression medications for kidney transplant recipients.

Kidney transplantation is the preferred method of treating patients with end-stage renal disease. Transplantation improves the quality of life of the transplant recipient and also results in reduced treatment costs owing to the cost difference between dialysis and the post-transplant immunosuppression medications. Currently, the USA's Medicare program covers immunosuppression medications for 3 years post-transplant for nonelderly, nondisabled patients, and there is currently a proposal to extend this coverage from 3 years to a lifetime for all transplant recipients.

Cost of lifetime immunosuppression coverage for kidney transplant recipients.

On January 1, 2000, Medicare extended the coverage of immunosuppression medications from 3 years to life for elderly and disabled kidney transplant recipients. This research estimates the impact of extending this lifetime coverage to all kidney transplant recipients on Medicare's cash flows. The study finds that extending coverage to all kidney transplant recipients would have increased Medicare's net cash outflows if the coverage were extended for patients of all income levels.

Economic impact of the beneficial effect of changing vascular anastomotic technique in hemodialysis access.

There is an urgent and compelling need to reduce the morbidity and expense of maintaining hemodialysis vascular access patency. We previously reported the beneficial effects of altering anastomotic technique on vascular access patency from a multicenter clinical trial. Interrupted anastomoses created with nonpenetrating clips showed significant improvement in primary, assisted primary, and secondary patencies of native vein fistulae (AVF) and synthetic arteriovenous grafts (AVG).

Renal graft survival and calcineurin inhibitor.

Background: Tacrolimus is associated with fewer acute rejections than cyclosporine, but a greater risk of new onset diabetes mellitus. When compared to no tacrolimus among nondiabetics in a large patient registry, it is associated with improved graft survival. The current study used the same patient registry to compare more correctly graft survival between nondiabetic renal transplant recipients initially immunosuppressed with either of the two most frequently used calcineurin inhibitors, tacrolimus or modified cyclosporine (CsA).

Cost-effectiveness of extending Medicare coverage of immunosuppressive medications to the life of a kidney transplant.

Unless they maintain Medicare status through disability or age, kidney transplant recipients lose their Medicare coverage of immunosuppression 3 years after transplantation. A significant transplant survival advantage has previously been demonstrated by the extension of Medicare immunosuppressive medication coverage from 1 year to 3 years, which occurred between 1993 and 1995. The United States Renal Data System (USRDS) was analyzed for recipients of kidney transplants from 1995 to 1999.

A multicenter study of permanent hemodialysis access patency: beneficial effect of clipped vascular anastomotic technique.

Objective: There is an urgent and compelling need to reduce the morbidity and expense of maintaining hemodialysis vascular access patency. This large, long-term, retrospective, multicenter study, which compared access patency of autogenous arteriovenous fistulas (AVF) and synthetic bridge grafts (AVG) created with conventional sutures or nonpenetrating clips, was undertaken to resolve conflicting results from previous smaller studies.

Design: Patency data for 1385 vascular access anastomoses (clipped or sutured) was obtained from 17 hospitals and dialysis centers (Appendix).

Incidence and cost of new onset diabetes mellitus among U.S. wait-listed and transplanted renal allograft recipients.

This study sought to determine 1) the incidence and costs of new onset diabetes mellitus (NODM) associated with maintenance immunosuppression regimens following renal transplantation and 2) whether the mode of dialysis pretransplant or the type of calcineurin inhibition used for maintenance immunosuppression affected either the incidence or cost of NODM. The study examined the United States Renal Data System's clinical and financial records from 1994 to 1998 of all adult, first, single-organ, renal transplantations in either 1996 or 1997 with adequate financial records. It used the second diagnosis of diabetes in previously nondiabetic patients to identify NODM.