Background and PurposeAn ageing population at greater risk of proximal femoral fracture places an additional clinical and financial burden on hospital and community medical services. We analyse the variation in i) length of stay (LoS) in hospital and ii) costs across the acute care pathway for hip fracture from emergency admission, to hospital stay and follow-up outpatient appointments.Patients and MethodsWe analyse patient-level data from England for 2009/10 for around 60,000 hip fracture cases in 152 hospitals using a random effects generalized linear multi-level model where the dependent variable is given by the patient’s cost or length of stay (LoS). We control for socio-economic characteristics, type of fracture and intervention, co-morbidities, discharge destination of patients, and quality indicators. We also control for provider and social care characteristics.ResultsOlder patients and those from more deprived areas have higher costs and LoS, as do those with specific co-morbidities or that develop pressure ulcers, and those transferred between hospitals or readmitted within 28 days. Costs are also higher for those having a computed tomography (CT) scan or cemented arthroscopy. Costs and LoS are lower for those admitted via a 24h emergency department, receiving surgery on the same day of admission, and discharged to their own homes.InterpretationPatient and treatment characteristics are more important as determinants of cost and LoS than provider or social care factors. A better understanding of the impact of these characteristics can support providers to develop treatment strategies and pathways to better manage this patient population.

Objective-Although UK and international guidelines recommend monotherapy, antipsychotic polypharmacy in people with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. The effectiveness of antipsychotic polypharmacy relative to monotherapy is estimated in terms of health care utilization and mortality. Methods-Primary care data from the Clinical Practice Research Datalink, hospital data from the Hospital Episodes statistics and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England during the period 2000-2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to the first occurrence of each of three outcomes: unplanned hospital admissions (allcause), emergency department presentations, and mortality. Results-Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of an unplanned hospital admission (HR=1.14; 95% CI=0.982-1.32), emergency department presentation (HR=0.95; 95% CI=0.80-1.14) or death (HR=1.02; 95% CI=0.76-1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced

Background. High-deductible health plans (HDHPs) are of high interest to employers, policy makers, and insurers because of potential benefits and risks of this fundamentally new coverage model. Objective. To investigate the impact of HDHPs on health care utilization and costs in a heterogeneous group of enrollees from a variety of individual and employer-based health plans. Data. Claims and member data from a major insurer and zip code-level census data. Study Design. Retrospective difference-in-differences analyses were used to examine the impact of HDHP plans. This analytical approach compared changes in utilization and expenditures over time (2007 versus 2005) across the two comparison groups (HDHP switchers versus matched PPO controls).Results. In two-part models, HDHP enrollment was associated with reduced emergency room use, increases in prescription medication use, and no change in overall outpatient expenditures. The impact of HDHPs on utilization differed by subgroup. Chronically ill enrollees and those who clearly had a choice of plans were more likely to increase utilization in specific categories after switching to an HDHP plan. Conclusions. Whether HDHPs are associated with lower costs is far from settled. Various subgroups of enrollees may choose HDHPs for different reasons and react differently to plan incentives.Key Words. High-deductible health plans, health insurance, health care utilization, chronically ill While enrollment in high-deductible health plans (HDHPs) is still a small fraction of the commercially insured market, the growth and experience of these plans are of high interest to employers, policy makers, and the health care industry in general because of the potential benefits and risks of this fundamentally new coverage model. A number of studies have sought to measure the impact of HDHP plans on health care utilization and cost, but various data limitations make further studies important. Using a large statewide database containing utilization data for a large group of enrollees across a