Healthcare Utilization

 
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III.A.2.0

Lead Author(s): 

Charles G. Helmick, MD

Supporting Author(s): 

Sylvia I. Watkins-Castillo, PhD

AORC prevalence continues to increase in the aging US population, with related increases in healthcare utilization. The increase in total ambulatory care visits, together with the increasing number of joint replacements and related hospitalizations, both impact healthcare utilization. The AORC case definition is more appropriate to use within the healthcare system, which is based on health condition codes. However, the AORC case definition will miss adults with mild arthritis that is not mentioned at the visit, or for whom arthritis may not be a priority when multiple conditions are present. For estimates in the following discussions, AORC condition codes, found in ICD-9-CM Codes section are used.

In 2013, AORC-related diagnoses were listed in 105.7 million healthcare visits and represented more than 10% of all healthcare visits. Hospitalizations accounted for 6% of AORC visits, while ambulatory care accounted for 94% (77% physician office, 6% outpatient, and 11% emergency department). (Reference Table 3A.3.0.1 PDF CSV)

When looking at how the ten subtypes of AORC affect the four types of healthcare utilization below, remember that the estimates are not mutually exclusive due to the potential for multiple diagnoses in a single visit. (Reference Table 3A.3.0.2 PDF CSV; Table 3A3.0.3 PDF CSV; Table 3A.3.0.4 PDF CSV; and Table 3A.3.0.5 PDF CSV)

Hospitalizations

The Healthcare Cost and Utility Project (HCUP) 2013 Nationwide Inpatient Sample (NIS) estimates that 6.4 million hospitalizations were associated with a diagnosis of AORC, or 21.4% of all hospitalizations that year. AORC was the presenting or first-listed diagnosis for only 1% of all hospitalizations, suggesting the role of AORC is more of an important comorbidity or contributor to other conditions which are the reason for the hospitalization. Nearly one-half of the 6.4 million AORC hospitalizations were associated with osteoarthritis (46%), while joint pain/effusion/other unspecified joint disorders, gout, and soft tissue disorders were each listed in more than 10% of hospitalizations. Multiple AORC diagnoses are coded in 17% of hospitalizations with an AORC diagnosis. Osteosteoarthritisrthritis is the least likely to have another AORC diagnosis, while carpal tunnel syndrome is most likely to include multiple diagnoses. (Reference Table 3A.3.0.1 PDF CSV and Table 3A.3.0.2 PDF CSV)

AORC-associated hospitalizations by sex, race/ethnicity, and geographic region resembled those for all 2013 hospitalizations; however, they differed in age, skewing toward the 65 & older age group (59.1% vs. 41.7%). (Reference Table 3A.3.1.0.1 PDF CSV; Table 3A.3.1.0.2 PDF CSV; Table 3A.3.1.0.3 PDF CSV; Table 3A.3.1.0.4 PDF CSV)  

Hospitalizations for specific types of AORC differed by demographic variables. Women comprised 59% of total AORC hospitalizations, but much more for hospitalizations with rheumatoid arthritis (75%), fibromyalgia (89%), and diffuse connective tissue disease (87%).  Men comprised 41% of total AORC hospitalizations, but much more for hospitalizations with gout (67%) and soft tissue disorders (52%). (Reference Table 3A.3.1.0.1 PDF CSV)

Those younger than age 65 comprised 41% of total AORC hospitalizations, but much more for hospitalizations with fibromyalgia (68%), diffuse connective tissues disease (67%), and carpal tunnel syndrome (61%). (Reference Table 3A.3.1.0.2 PDF CSV)

 Non-Hispanic blacks comprised 12% of total AORC hospitalizations, but much more for hospitalizations with gout (18%) and diffuse connective tissue disease (24%). (Reference Table 3A.3.1.0.3 PDF CSV)  

Hospitalizations for specific types of AORC did not differ much by geographic region. (Reference Table 3A.3.1.0.4 PDF CSV)


Length of Stay (LOS)

The mean LOS for AORC-associated hospitalizations in 2013 was slightly greater than that for all hospitalizations (4.9 vs 4.7 days); differences by demographic groups were greater for AORC hospitalizations (than all hospitalizations) for women (4.8 vs 4.4 days), those 18 to 44 years (5.0 vs. 3.6 days), non-Hispanic blacks (5.6 vs 4.4 days), Hispanics (5.3 vs. 3.6 days), and those in the western geographic region (4.8 vs. 4.3 days). Among the 10 specific types of AORC the mean LOS was strikingly longer for those with soft tissue disorders and other specified rheumatic conditions both overall (6.5 and 6.5 vs. 4.9 days) and by every demographic subgroup. (Reference Table 3A.3.1.1.1 PDF CSV; Table 3A.3.1.1.2 PDF CSV; Table 3A.3.1.1.3 PDF CSV; Table 3A.3.1.1.4 PDF CSV

 

Hospital Charges

Hospital charges are based on individual record discharges. The fees included may vary from patient to patient, but generally include hospital room, supplies, medications, laboratory fees, and care staff, such as nurses. They generally do not include professional fees (doctors) and non-covered charges. Emergency charges incurred prior to admission to the hospital may be included in total charges. It is important to note that charges are not necessarily the actual amount paid by Medicare, insurers, or patients. However, they are the only medical expenditure cost available in the major databases based on ICD-9-CM diagnostic codes and provide an overall picture for comparison purposes. Because multiple diagnoses are often made with an admission, actual charges related to a specific AORC may be much smaller. This is true of cost estimates provided in the Economic Burden section also.

Mean hospital charges for AORC-associated hospitalizations generally paralleled, but were consistently higher than charges for all hospitalizations, both overall (+$5,900) and for all demographic subgroups. Higher mean charges among demographic subgroups were most striking for women (+$8,200), persons 18-44 years (+$18,800), non-Hispanic whites (+$9,900), non-Hispanic blacks (+$10,900), Hispanics (+$33,700), other non-Hispanics (+$10,700), and those in the South (+$9,500) and West (+$16,100).

Total charges for AORC-associated hospitalizations were $310.9 billion in 2013, comprising 24% of all hospital charges for the year. This percentage was relatively consistent for all sex and age groups except those 18 to 44 years, where it was only 11%. Among racial/ethnic groups, AORC total charges were 19% for non-Hispanic others, while they were 30% among non-Hispanic whites. AORC-associated hospitalization total charges were 29% of all hospitalizations in the Midwest in 2013.

Among the 10 AORC subgroups, hospitalizations with osteoarthritis accounted for $138.4 billion, or 45% of total charges for AORC-associated hospitalizations, while hospitalizations with joint pain/effusion/other, gout, and soft tissue disorders accounted for 16%, 13%, and 13% respectively). (Reference Table 3A.3.1.1.1 PDF CSV; Table 3A.3.1.1.2 PDF CSV; Table 3A.3.1.1.3 PDF CSV; Table 3A.3.1.1.4 PDF CSV)

 

Discharge Status

Discharge from the hospital to long-term care, which includes skilled nursing facilities, intermediate care, and other similar facilities, or to home health care occurred more frequently among AORC-associated hospitalizations than among all hospitalizations (44% vs 29%). This was true regardless of sex, age, race/ethnicity, or region of residence. By demographic characteristics, the highest proportion of discharge to long-term care or home health care was found among females (48%), age 65 and over (55%), and residents of the Northeast region (52%).

Among the 10 AORC subgroups there were no striking differences in discharge to long-term care or home health care compared with all AORC hospitalizations. Discharge to home was more frequent, and resembled all hospitalizations (66%), among those with carpal tunnel syndrome (68%), fibromyalgia (67%), diffuse connective tissue disease (64%), and spondylarthropathies (59%). (Reference Table 3A.3.1.3.1 PDF CSV; Table 3A.3.1.3.2 PDF CSV; Table 3A.3.1.3.3 PDF CSV;Table 3A.3.1.3.4 PDF CSV)

 

Ambulatory Care Visits

From the 2013 surveys on ambulatory care, there were an estimated 99.3 million ambulatory care visits associated with a diagnosis of AORC, more than 10% of all ambulatory care visits that year, for a rate of 40.1/100 adults in the general population. An AORC-related condition was listed as the presenting (first) diagnosis for between 2.8% and 5.4% of all ambulatory care visits, depending on the healthcare site visited. Physicians’ offices accounted for 82% of all ambulatory AORC visits, vastly exceeding emergency department (12%) or outpatient (7%) sites. (see Table 3A.3.0.1 PDF CSV) As with hospital discharges, multiple AORC diagnoses were given in 15% to 20% of patient ambulatory visits. (Reference Table 3A.3.0.3 PDF CSV; Table 3A.3.0.4 PDF CSV; and Table 3A.3.0.5 PDF CSV)

In 2013, AORC-associated ambulatory care visits resembled all 2013 ambulatory care visits by sex, race/ethnicity, and geographic region; they differed in age, being lower in the 18 to 44-year age group (21% vs. 32%) and higher in the 45 to 64-year age group (44% vs. 36%) and the 65 and older age group (34% vs. 32%).  (Reference Table 3A.3.2.0.1 PDF CSV; Reference Table 3A.3.2.0.2 PDF CSV; Table 3A.3.2.0.3 PDF CSV; Table 3A.3.2.0.4 PDF CSV) (Note: Detailed data by type of ambulatory setting shown in Tables 3A.3.2.1.x, 3A.3.2.2.x(.1 to .4), and 3A.3.2.3.x, and can be accessed from the “Tables” tab in the upper right corner.)

Among the 10 AORC subgroups, 2 in 5 of the 99.3 million total ambulatory visits (41%) were associated with joint pain/effusion/other unspecified joint disorders or “other specified rheumatic conditions”; osteosteoarthritisrthritis and soft tissue disorders were the most common specific condition (~20% each). (Reference Table 3A.3.2.0.1 PDF CSV)

AORC-associated ambulatory care visits for specific types of AORC differed by demographic variables.  Women comprised 62% of all AORC-associated ambulatory care visits; their proportion was much higher for fibromyalgia (79%) and diffuse connective tissue disease (90%), but much lower for gout and other crystal arthropathies (27%). Men comprised 39% of all AORC-associated ambulatory care visits; their proportion was much higher for gout (72%). (Reference Table 3A3.2.0.1 PDF CSV)

The 18 to 44-year old group comprised 21% of all AORC-associated ambulatory care visits; their proportion was a bit higher for diffuse connective tissue disease (31%), fibromyalgia (27%), and carpal tunnel syndrome (26%). Those aged 45 to 64 years comprised 44% of all AORC –associated ambulatory care visits; this proportion was similar for most specific types of AORC. Those aged 65 and older comprised 34% of all AORC-associated ambulatory care visits; their proportion was much higher for osteoarthritis (51%) and gout (50%), and much lower for fibromyalgia (20%). (Reference Table 3A.3.2.0.2 PDF CSV)

Non-Hispanic whites (65% of the US population) comprised 73% of all AORC-associated ambulatory care visits, but only 59% of those for gout. Comparisons for other race/ethnic groups, as well as geographic regions were difficult to determine due to small sample sizes and unreliable data. (Reference Table 3A.3.2.0.3 PDF CSV; Table 3A.3.0.4 PDF CSV)

 

Physician Office Visits

Some 81 million AORC-related ambulatory care visits were physician office visits (PHYS); these accounted for 82% of all ambulatory care visits.  An AORC-related condition was listed as the presenting (first) diagnosis for 5.4% of all PHYS visits. (Reference Table 3A.3.0.1 PDF CSV)

Overall, 2013 AORC-related PHYS visits resembled those for all 2013 PHYS visits by sex, race/ethnicity, and geographic region; they differed in age, being lower in the 18 to 44-year age group (20% vs. 29%), higher in the 45 to 64-year age group (46% vs. 37%), and similar in the 65 and older age group (34%).

Among the 10 AORC subgroups, nearly 2 in 5 of the 81 million AORC-related PHYS visits (37%) were associated with joint pain/effusion/other unspecified joint disorders; osteoarthritis and soft tissue disorders were about 21% each. (Reference Table 3A.3.2.1.1 PDF CSV)

AORC-related PHYS visits for specific types of AORC differed by demographic variables.  Women comprised 61% of all AORC-associated PHYS visits; their proportion was much higher for rheumatoid arthritis (77%) and diffuse connective tissue disease (90%).  Men comprised 39% of all AORC-associated PHYS visits; their proportion was much higher for gout (71%). (Reference Table 3A.3.2.1.1 PDF CSV)

Persons aged 18 to 44 comprised 20% of all AORC-associated PHYS visits; their proportion was higher for diffuse connective tissue disease (29%) and soft tissue disorders (26%), while lower for osteoarthritis (7%) and rheumatoid arthritis (13%). Those aged 45 to 64 comprised 46% of all AORC–associated PHYS visits; their proportion pf PHYS visits was higher for fibromyalgia (55%) and carpal tunnel syndrome (50%).  Those aged 65 and older comprised 34% of all AORC-associated PHYS visits; their proportion was much higher for osteoarthritis (51%) (Reference Table 3A.3.2.1.2 PDF CSV).

Non-Hispanic whites comprised 74% of all AORC-associated PHYS visits; their proportion was higher for rheumatoid arthritis (80%), spondylarthropathies (79%), and lower for gout (65%) and carpal tunnel syndrome (68%). Comparisons for other race/ethnic groups were difficult to determine. (Reference Table 3A.3.2.1.3 PDF CSV)  

There was little difference by geographic region. (Reference Table 3A.3.2.1.4 PDF CSV).

 

Outpatient Clinic Visits

Some 6.5 million AORC-related ambulatory care visits were to outpatient (OP) clinics; these accounted for 7% of all ambulatory care visits. An AORC-related condition was listed as the presenting (first) diagnosis for 4.4% of all OP visits. (Reference Table 3A.3.0.1 PDF CSV)2013 AORC-related OP visits resembled those for all 2013 OP visits by sex, race/ethnicity, and geographic region; they differed in age, being lower in the 18 to 44-year age group (25% vs. 38%), and higher in the 45 to 64-year age group (49% vs. 39%) and the 65 and older age group (27% vs. 23%) (Reference Table 3A.3.2.2.1 PDF CSV).

Among the 10 AORC subgroups, more than 2 in 3 of the 6.5 million AORC-related OP visits (69%) were associated with joint pain/effusion/other unspecified joint disorders and osteoarthritis; soft tissue disorders and rheumatoid arthritis accounted for about 12% each. (Reference Table 3A.3.2.2.2 PDF CSV)

AORC-related OP visits for specific types of AORC differed by demographic variables. Women comprised 69% of all AORC-associated OP visits; their proportion was much higher for rheumatoid arthritis (83%) and diffuse connective tissue disease (88%). Men comprised 31% of all AORC-associated OP visits; their proportion was much higher for gout (81%) and osteoarthritis (67%) (Reference Table 3A.3.2.2.1 PDF CSV).

Persons aged 18 to 44 comprised 25% of all AORC-associated OP visits; their proportion was higher for diffuse connective tissue disease (38%) and carpal tunnel syndrome (38%). Those aged 45 to 64 comprised 49% of all AORC-associated OP visits; their proportion was higher for rheumatoid arthritis (63%). Those aged 65 and older comprised 27% of all AORC-associated OP visits; their proportion was much higher for osteoarthritis (40%) (Reference Table 3A.3.2.2.2 PDF CSV).

Non-Hispanic whites comprised 58% of all AORC-associated OP visits; their proportion was higher for spondylarthropathies (71%) and fibromyalgia (70%). Comparisons for other race/ethnic groups were difficult to determine. (Reference Table 3A.3.2.2.3 PDF CSV)

There was little difference by geographic region. (Reference Table 3A.3.2.2.4 PDF CSV)

 

Emergency Department Visits 

Emergency department (ED) visits for AORC-related diagnoses, totaling 11.7 million, accounted for 12% of all ambulatory care visits in 2013 and 11% of all emergency department visits. An AORC-related condition was listed as the presenting (first) diagnosis for 2.8% of all ED care visits. (Reference Table 3A.3.0.1 PDF CSV)

2013 AORC-related ED visits resembled those for all 2013 ED visits by sex and geographic area; they differed in age, being lower in the 18 to 44-year age group (29% vs. 49%) and higher in the 45 to 64-year age group (34% vs. 29%) and the 65 and older age group (37% vs. 23%). (Reference Table 3A.3.2.3.2 PDF CSV)

Among the 10 AORC subgroups, 3 in 5 of the 11.7 million AORC-related ED visits were associated with joint pain/effusion/other unspecified joint disorders and osteoarthritis; soft tissue disorders and fibromyalgia accounted for 13% and 12%, respectively. (Reference Table 3A.3.0.1 PDF CSV)

AORC-related ED visits for specific types of AORC differed by demographic variables. Women comprised 61% of all AORC-associated ED visits; their proportion was much higher for rheumatoid arthritis (77%), fibromyalgia (79%) and diffuse connective tissue disease (90%). Men comprised 39% of all AORC-associated ED visits; their proportion was much higher for gout (69%). (Reference Table 3A.3.2.3.1 PDF CSV)

Persons aged 18 to 44 comprised 29% of all AORC-associated ED visits; their proportion was higher for diffuse connective tissue disease (40%), fibromyalgia (43%), and carpal tunnel syndrome (51%). Those aged 45 to 64 comprised 34% of all AORC-associated ED visits; this proportion was similar for most specific types of AORC. Those aged  65 and older comprised 37% of all AORC-associated ED visits; their proportion was much higher for osteoarthritis (66%), rheumatoid arthritis (49%), gout (56%), spondylarthropathies (50%), and other specified rheumatic conditions (49%). (Reference Table 3A.3.2.3.2 PDF CSV)

Race/ethnicity was not a defined variable in the NEDS database. There was little difference by geographic region. (Reference Table 3A.3.2.3.4 PDF CSV)

Edition: 

  • Fourth Edition

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