The Relationship of Vitamin D Deficiency to Health Care Costs in Veterans

Transcription

1 MILITARY MEDICINE, 173, 12:1214, 2008 The Reltionship of Vitmin D Deficiency to Helth Cre Costs in Veterns Aln N. Peiris, MD PhD MRCP* ; Beth A. Biley, PhD ; Todd Mnning, BA* ABSTRACT Vitmin D deficiency is often unrecognized nd hs een linked to mny chronic diseses. Vitmin D supplementtion hs een shown to meliorte these chronic diseses nd my reduce the prevlence of some cncers. We nlyzed the helth cre costs ssocited with vitmin D deficiency in Veterns in Northest Tennessee. A retrospective electronic chrt nlysis of the reltionship of 25-hydroxyvitmin D [25(OH)D] sttus to helth cre costs, services, nd utiliztion ws done in 886 veterns. The overll costs were higher y 39% in the vitmin D-deficient group. Vitmin D deficiency ws ssocited with incresed service utiliztion in mny res including more frequent emergency room nd clinic visits s well s incresed inptient sty nd inptient services. The serum level of vitmin D ws lso relted to helth cre costs, lthough to lesser extent. Vitmin D deficiency is closely linked to incresed helth cre costs in veterns. INTRODUCTION Adequte levels of vitmin D re needed for optiml helth. Although the clinicl presenttions linked to severe vitmin D deficiency hve een well recognized, milder degrees of vitmin D deficiency remin n overlooked clinicl entity. 1 Hypovitminosis D is common in ptients, including those with vitmin D intkes exceeding the recommended dily llownce nd in ptients without pprent risk fctors for vitmin D deficiency. 2 Vitmin D deficiency hs een ssocited with reduced one density nd incresed flls. 3 The flls nd ssocited frctures cn e reduced y vitmin D, possily in dose-dependent mnner. 4 Moreover, vitmin D deficiency is linked to incresed prevlence of severl types of cncer 5 nd incresed disese ctivity in immunologiclly medited diseses such s multiple sclerosis 6 nd rheumtoid rthritis 7 s well s incresed mortlity in hemodilysis ptients. 8 Enhnced vitmin D sttus is ssocited with improved mood 9 nd incresed well-eing 10 nd decresed cncer risk in prospective studies. 11 Few studies hve exmined the prevlence of vitmin D sttus in veterns. A study in Wisconsin Veterns Home indicted tht 32% of veterns hd 25(OH)D levels lower thn 30 ng/ml. 12 Similrly, hypovitminosis D with secondry elevtion of prthyroid hormone ws evident despite pprently cceptle intke of vitmin D, irrespective of sesonl sttus in veterns nursing homes. 13 Vitmin D deficiency hs lso een documented in veterns with spinl cord *Mountin Home VAMC, Medicine Service-111, Mountin Home, TN 37684; e-mil: Aln.Peiris@v.gov. Deprtment of Internl Medicine, Est Tennessee Stte University, Johnson City, TN Deprtment of Fmily Medicine, Est Tennessee Stte University, P.O. Box 70621, Johnson City, TN No conflicts of interest relevnt to this rticle re reported. This mnuscript ws received for review in Octoer The revised mnuscript ws ccepted for puliction in April Reprint & Copyright y Assocition of Militry Surgeons of U.S., injury. 14 Although this initil dt indictes tht the prevlence of vitmin D deficiency in veterns to e similr to the generl popultion, 15 no dt exist on the helth cre costs of vitmin D deficiency in veterns. Given the potentil economic impct of vitmin D deficiency, the present study ws undertken to ssess the ssocition etween vitmin D sttus nd helth cre costs in veterns. METHODS Prticipnts nd Procedure The study ws conducted t Veterns Affirs (VA) fcility in the Southestern United Sttes. The Reserch nd Development committee t the VA Medicl Center nd the institutionl review ord t the ffilited university pproved the study. Prticipnts included ll ptients seen t the VA Medicl Center from Jnury 1, 2005 to Mrch 31, 2007 with serum 25(OH)D nlysis. Dt were otined electroniclly through retrospective medicl chrt review fter personl informtion ws redcted. Informtion collected included 25(OH)D levels s well s helth cre costs nd service utiliztion for the 24 months preceding the initil 25(OH)D estimte. The 25(OH)D ssy ws done y immunochemiluminometric ssy (Lcorp, Burlington, North Crolin). Costs were roken down into seprte inptient nd outptient ctegories (i.e., lortory, phrmcy, rdiology, surgery, primry cre, nd emergency room). Totls were lso extrcted for ll costs, inptient costs, nd outptient costs. The costs were estimted y the technicl guidelines vi the Decision Support System nd clinicl Ntionl Dt Extrcts stndrdized y the VA. 16 For ech of the cost ctegories, totl dollr mount ws nlyzed. In ddition, dichotomous service utiliztion vriles were constructed to represent whether ptient hd incurred tht type of cost (not ll of these vriles were used in nlyses, since virtully ll ptients hd costs in some of the ctegories). No cost in 1214 MILITARY MEDICINE, Vol. 173, Decemer 2008

2 Reltionship of Vitmin D Deficiency to Helth Cre Costs prticulr ctegory ment tht tht service ws not used. Fees refer to costs incurred y the VA s result of consulttion nd/or procedures done in the privte sector when such services were inccessile or unville in timely mnner through the VA hospitl. Dt Anlysis Vitmin D level ws nlyzed oth s continuous nd dichotomous vrile indicting deficiency. Vitmin D deficiency ws defined s 25(OH)D 20 ng/ml. 15 Sttisticl nlyses were performed using SPSS (SPSS Inc., version 14.0; Chicgo, Illinois). All vriles were checked for outliers nd normlity of distriution efore nlyses were performed. Correltions, t test, nd 2 nlysis were used to exmine the ssocitions etween vitmin D levels nd the cost nd service utiliztion vriles. TABLE I. Demogrphic, Vitmin D, Costs, nd Helth Cre Utiliztion Dt Men or % Rnge Age (yers) Gender (% mle) 88.6 Rce (% Cucsin) 95.7 Vitmin D level Vitmin D deficiency (%) 40.5 Totl of ll costs $19,257 $296 $292,639 Totl outptient costs $12,262 $296 $168,641 Fees $1,500 $0 $106,812 Emergency room costs $626 $0 $9,119 Lortory costs $746 $0 $4,317 Phrmcy costs $2,903 $0 $42,223 Rdiology costs $788 $0 $21,638 Primry cre costs $1,106 $0 $11,091 Surgery costs $542 $0 $8,987 Totl inptient costs $5,495 $0 $215,124 Lortory costs $297 $0 $12,007 Phrmcy costs $622 $0 $39,350 Rdiology costs $234 $0 $7,765 Surgery costs $688 $0 $32,761 No. of clinic visits No. of inptient stys Length of inptient stys (dys) N 886. Serum 25(OH)D in ng/ml. Less thn 20 ng/ml. RESULTS There were 42,588 unique ptients seen t the VA fcility during the study period nd 886 of these hd serum 25(OH)D nlysis performed. The men ge of the study group ws 66.8 yers, with predominntly mle gender (88.6%). The chrcteristics of the 886 prticipting ptients nd the helth cre prmeters studied re shown in Tle I. The verge prticipnt ws mle nd in his mid-60s, typicl of VA fcility popultion. In ddition, the prticipnts were lrgely Cucsin, representtive of the surrounding community. Vitmin D sttus ws not significntly relted to ge, rce, or gender; however, our smple hd limited numers of femles nd minorities. Although the verge vitmin D level ws 25.5 ng/ml, more thn two in five prticipnts were vitmin D deficient ( 20 ng/ml). Averge expenditures in the vrious ctegories vried widely; however, the verge totl medicl costs for prticipnts ws just under $20,000 for the 24-month period. Prticipnts verged out one primry cre or other clinic visit per month, nd the vst mjority did not hve n inptient hospitliztion. However, the vitmin D-deficient veterns hd significntly greter utiliztion of the emergency room nd clinics s shown in Tle II. Inptient hospitliztion costs ws lso significntly higher in the vitmin D-deficient group. As shown in Tle III, overll medicl expenditures were 39% higher in the vitmin D-deficient group. The significnt increse in outptient nd inptient costs in the vitmin D-deficient group ws due to fees, emergency room visits, phrmcy, lortory, rdiology, nd primry cre expenditures. Surgery costs were not significntly relted to vitmin D sttus either on n inptient or outptient sis. When nlyzed s continuous vrile, the 25(OH)D level ws inversely relted to totl costs (Tle IV). Although serum vitmin D levels did not hve significnt correltion with outptient costs, they were significntly inversely correlted with inptients costs, including lortory nd rdiology costs. Similrly, the level of vitmin D deficiency ws significntly ssocited with utiliztion of emergency room visits nd inptient services, including lortory, phrmcy, nd inptient hospitliztion (Tle V). DISCUSSION To our knowledge, this is the first study to demonstrte tht vitmin D deficiency ws ssocited with oth incresed medicl cre utiliztion nd costs within the vetern popultion. Vitmin D deficiency ws ssocited with n increse in ll outptient nd inptient costs, including phrmcy, rdiology, nd lortory services s well s higher use of clinics, emergency room, nd inptient hospitliztion. The serum vitmin D level ws lso inversely linked to overll costs, especilly inptient costs, including rdiology nd lortory expenditures nd greter numer of emergency room visits. However, it ws cler tht the presence or sence of vitmin D deficiency ws more clerly linked to costs nd utiliztion thn the serum level of vitmin D. The lck of ssocition etween surgery nd vitmin D sttus is interesting nd my relte to the fct tht surgery costs included nesthesiology nd ctul surgicl costs ut not the postopertive expenses. Our dt do not ddress the specific cuses of incresed helth cre costs nd utiliztion. It is likely tht incresed ftigue, decresed clinicl well-eing, nd possily severl chronic ilments such s cncers nd utoimmune diseses linked to ging were likely to ccount for incresed helth cre costs. The widespred occurrence of vitmin D deficiency in oth inptients nd outptients within the United Sttes is MILITARY MEDICINE, Vol. 173, Decemer

3 Reltionship of Vitmin D Deficiency to Helth Cre Costs TABLE II. Assocition etween Vitmin D Deficiency nd Service Utiliztion Utiliztion Vrile Vitmin D Deficient 1 (n 359) Not Vitmin D Deficient (n 527) t p c Outptient service utiliztion Hd fees 36% 32% Hd emergency room visit(s) 70% 62% Hd rdiology costs 85% 81% Hd surgery costs 25% 22% No. of clinic visits Inptient service utiliztion Hd lortory costs 38% 27% Hd phrmcy costs 38% 28% Hd rdiology costs 32% 22% Hd surgery costs 10% 9% Hd inptient stys 38% 28% Length of sty (dys) c p vlue for 1 df, one-tiled test. TABLE III. Assocition etween Vitmin D Deficiency nd Medicl Expenditures Cost Vrile Vitmin D Deficient (n 359) Not Vitmin D Deficient (n 527) t p c Totl of ll costs $23,110 $16, Totl outptient costs $14,120 $10, Fees $2,124 $1, Emergency room costs $763 $ Lortory costs $790 $ Phrmcy costs $3,170 $2, Rdiology costs $883 $ Primry cre costs $1,207 $1, Surgery costs $575 $ Totl inptient costs $6,867 $4, Lortory costs $396 $ Phrmcy costs $758 $ Rdiology costs $314 $ Surgery costs $683 $ c p vlue for 1 df, one-tiled test. well documented. 2,17 Vitmin D deficiency hs een postulted s link to mny chronic illnesses nd s such would e expected to increse costs nd use of helth cre services. It hs een proposed tht providing 1,000 IU of vitmin D dily for ll dult Americns would cost out $1 illion with the expected helth enefits, including reduction in cncer in the rnge of $16 to 25 illion. 18 Despite incresing evidence of the helth enefits of vitmin D, testing for suoptiml vitmin D levels is not widely prcticed. Indeed, our own smple of 886 tested ptients constitutes 2% of ll unique ptients seen during the study period nd indictes likely missed trget of opportunity to identify nd rectify suoptiml vitmin D levels. There is now excellent scientific evidence tht vitmin D does indeed reduce the risk of some cncers 11 nd my meliorte the mnifesttions of severl chronic diseses, 19,20 possily through n immunomodultory function. 21 Studies lso indicte tht vitmin D my enhnce longevity. 22 It is likely tht vitmin D requirements need to e much higher thn the currently recommended dose, especilly during winter months. An intke of 100 g (4000 IU)/dy of vitmin D my e sfe nd physiologic. 10 There is lso some preliminry dt tht suggest tht enhnced vitmin D sttus my hve positive impct on chronic illnesses such s dietes, 23 hypertension, 24 nd hert filure, 25 which re widely prevlent in the vetern popultion. The possiility tht vitmin D my lso hve other less well-recognized enefits such s improving outcomes in the event of flu epidemic remins n intriguing concept. 26 In the present study, there ws more thn $3,262 nnul premium in costs in vitmin D-deficient ptients. Approximte clcultions sed on 30% prevlence of vitmin D deficiency in the 5.5 million unique veterns seen t VA 1216 MILITARY MEDICINE, Vol. 173, Decemer 2008

4 Reltionship of Vitmin D Deficiency to Helth Cre Costs TABLE IV. Assocition etween Level of Vitmin D Deficiency nd Medicl Expenditures Cost Vrile Correltion (r) p Totl of ll costs Totl outptient costs Fees Emergency room costs Lortory costs Phrmcy costs Rdiology costs Primry cre costs Surgery costs Totl Inptient costs Lortory costs Phrmcy costs Rdiology costs Surgery costs N 886. p vlue for 1 df, one-tiled test. TABLE V. Assocition etween Level of Vitmin D Deficiency nd Service Utiliztion Utiliztion Vrile No Yes t p Outptient service utiliztion Hd fees Hd emergency room visit(s) Hd rdiology costs Hd surgery costs Inptient service utiliztion Hd lortory costs Phrmcy costs Rdiology costs Surgery costs Hd inptient stys Note: Additionl service utiliztion vriles numer of clinic visits, numer of inptient stys, nd length of inptient stys were not significntly ssocited with level of vitmin D deficiency. N 886. Column vlues represent serum 25(OH)D in ng/ml. p vlue for 1 df, one-tiled test. fcilities in 2006 indictes significnt potentil svings in the VA helth cre udget. Moreover, the nnul cost of vitmin D supplementtion, including two 25(OH)D ssys, would e less thn $100 nnully per ptient. Incresed wreness nd testing could result in lower costs through in-house estimtion with more rpid return of norml lortory vlues to clinicins. Our study hs certin limittions inherent in retrospective dt nlysis. The single estimte of serum vitmin D, while providing vlule informtion, is less optiml thn repeted seril estimtes. Our popultion smple ws predominntly mle nd Cucsin nd reflected popultion t ltitude of 36 degrees. It is possile tht veterns in sunnier climtes my not experience similr findings. It is interesting to note, however, tht merely living in sunnier climte does not fford protection ginst vitmin D deficiency, s deficiency hs een reported in southern Florid 27 nd Austrli. 28 Given the nture of the study, we cnnot conclude cuslity nd it is possile tht veterns with illness then develop vitmin D deficiency, rther thn the reverse. This is less likely scenrio sed on current knowledge, including the widespred deficiency of vitmin D nd the incresing enefit documented with D supplementtion. 15 It is lso likely tht some veterns lso incurred helth cre costs y concurrently ttending privte helth cre fcilities nd this could not e estimted in our nlysis. In conclusion, vitmin D deficiency is significntly ssocited with oth inptient nd outptient helth cre expenditures nd service utiliztion in veterns seeking cre in Northest Tennessee. The incresed expenditures spnned lortory, phrmcy, nd rdiology costs s well s utiliztion of clinics nd numer of hospitl dmissions. Although the present study does not ddress the resons for vitmin D deficiency in veterns, it is likely tht indequte sunlight exposure nd intke of vitmin D re oth mjor contriutory fctors. We recommend tht clinicins consider lowering the threshold for testing for vitmin D deficiency since the optiml requirement is significntly greter thn current recommendtions. 15 A widespred progrm of food fortifiction my e needed to ensure dequte vitmin D intke. 29 The potentil for reducing inptient hospitliztion nd ssocited cost svings is especilly noteworthy given the trnsition of the VA to predominntly outptient setting. The potentil for improving the qulity of life of veterns with concomitnt reduction in helth cre delivery costs y inexpensive vitmin D supplementtion offers exciting new reserch nd clinicl potentil. Future prospective studies re urgently needed to confirm these findings nd my hve rod pplicility. ACKNOWLEDGMENTS The invlule efforts of Nncy Millign nd Ptsy Ellis of the Mountin Home Veterns Affirs Lirry re pprecited. We re indeted to the ssistnce of Rmon Stout (Chief Lortory Supervisor t Mountin Home VA Medicl Center [VAMC]), Frnk Clderl (Stff Assistnt to the Director), nd Rchel Mitchell (Chief of Fiscl Service t Mountin Home VA Medicl Center). Dr. Guh Krishnswmy (Chief of Allergy nd Immunology, Mountin Home VAMC nd Est Tennessee Stte University) for his helpful review of this rticle. REFERENCES 1. Meyer C: Scientists proe role of vitmin D: deficiency significnt prolem, experts sy. JAMA 2004; 292: Thoms MK, Lloyd-Jones DM, Thdhni RI, et l: Hypovitminosis D in medicl inptients. N Engl J Med 1998; 338: Broe KE, Chen TC, Weinerg J, Bischoff-Ferrri HA, Holick MF, Kiel DP: A higher dose of vitmin d reduces the risk of flls in nursing home residents: rndomized, multiple-dose study. J Am Geritr Soc 2007; 55: Bischoff-Ferrri HA, Willett WC, Wong JB, Giovnnucci E, Dietrich T, Dwson-Hughes B: Frcture prevention with vitmin D supplementtion: met-nlysis of rndomized controlled trils. JAMA 2005; 293: Grnt WB: The likely role of vitmin D from solr ultrviolet-b irrdince in incresing cncer survivl. Anticncer Res 2006; 26: Munger KL, Levin LI, Hollis BW, Howrd NS, Ascherio A: Serum 25-hydroxyvitmin D levels nd risk of multiple sclerosis. JAMA 2006; 296: MILITARY MEDICINE, Vol. 173, Decemer

5 Reltionship of Vitmin D Deficiency to Helth Cre Costs 7. Cutolo M, Ots K, Ls K, et l: Circnnul vitmin D serum levels nd disese ctivity in rheumtoid rthritis: Northern versus Southern Europe. Clin Exp Rheumtol 2006; 24: Wolf M, Shh A, Gutierrez O, et l: Vitmin D levels nd erly mortlity mong incident hemodilysis ptients. Kidney Int 2007; 72: Lnsdowne AT, Provost SC: Vitmin D 3 enhnces mood in helthy sujects during winter. Psychophrmcology (Berl) 1998; 135: Vieth R, Kimll S, Hu A, Wlfish PG: Rndomized comprison of the effects of the vitmin D3 dequte intke versus 100 mcg (4000 IU) per dy on iochemicl responses nd the welleing of ptients. Nutr J 2004; 3: Lppe JM, Trvers-Gustfson D, Dvies KM, Recker RR, Heney RP: Vitmin D nd clcium supplementtion reduces cncer risk: results of rndomized tril. Am J Clin Nutr 2007; 85: Drink PJ, Kruse PF, Nest LJ, Goodmn BM: Determinnts of vitmin D levels in nursing home residents. J Am Med Dir Assoc 2007; 8: McMurtry CT, Young SE, Downs RW, Adler RA: Mild vitmin D deficiency nd secondry hyperprthyroidism in nursing home ptients receiving dequte dietry vitmin D. J Am Geritr Soc 1992; 40: Bumn WA, Zhong YG, Schwrtz E: Vitmin D deficiency in veterns with chronic spinl cord injury. Metolism 1995; 44: Holick MF: Vitmin D deficiency. N Engl J Med 2007; 357: VIReC Reserch User Guide: VHA DSS Clinicl Ntionl Dt Extrcts FY2000-FY2004. Hines, IL, Veterns Affirs Informtion Resource Center, August 2004 (revised August 2005). 17. Linneur SA, Vondrcek SF, Griend JP, Ruscin JM, McDermott MT: Prevlence of vitmin D insufficiency in elderly multory outptients in Denver, CO. Am J Geritr Phrmcother 2007; 5: Grnt WB, Grlnd CF, Gorhm ED: An estimte of cncer mortlity rte reductions in Europe nd the US with 1,000 IU of orl vitmin D per dy: recent results. Cncer Res 2007; 174: Hypponen E, Lr E, Reunnen A, Jrvelin MR, Virtnen SM: Intke of vitmin D nd risk of type 1 dietes: irth-cohort study. Lncet 2001; 358: Wilkinson RJ, Llewelyn M, Toossi Z, et l: Influence of vitmin D deficiency nd vitmin D receptor polymorphisms on tuerculosis mong Gujrti Asins in west London: cse-control study. Lncet 2000; 355: Mrtineu AR, Wilkinson RJ, Wilkinson KA, et l: A single dose of vitmin D enhnces immunity to mycocteri. Am J Respir Crit Cre Med 2007; 176: Autier P, Gndini S: Vitmin D supplementtion nd totl mortlity: met-nlysis of rndomized controlled trils. Arch Intern Med 2007; 167: Pitts AG, Lu J, Hu FB, Dwson-Hughes B: The role of vitmin D nd clcium in type 2 dietes: systemtic review nd met-nlysis. J Clin Endocrinol Met 2007; 92: Formn JP, Giovnnucci E, Holmes MD, et l: Plsm 25-hydroxyvitmin D levels nd risk of incident hypertension. Hypertension 2007; 49: Schleithoff SS, Zittermnn A, Tenderich G, Berthold HK, Stehle P, Koerfer R: Vitmin D supplementtion improves cytokine profiles in ptients with congestive hert filure: doule-lind, rndomized, plceo-controlled tril. Am J Clin Nutr 2006; 83: Cnnell JJ, Vieth R, Umhu JC, et l: Epidemic influenz nd vitmin D. Epidemiol Infect 2006; 134: Levis S, Gomez A, Jimenez C, et l: Vitmin d deficiency nd sesonl vrition in n dult South Florid popultion. J Clin Endocrinol Met 2005; 90: vn der Mei IA, Ponsony AL, Engelsen O, et l: The high prevlence of vitmin D insufficiency cross Austrlin popultions is only prtly explined y seson nd ltitude. Environ Helth Perspect 2007; 115: Hirvonen T, Sinkko H, Vlst L, Hnnil ML, Pietinen P: Development of model for optiml food fortifiction: vitmin D mong dults in Finlnd. Eur J Nutr 2007; 46: MILITARY MEDICINE, Vol. 173, Decemer 2008