Abstract
Background: Data on the average US costs of an outpatient visit, emergency room (ER) visit or hospitalization for migraine are scant, with the most recent available values based on healthcare charges reported from 1994 data.
Methods: We estimated healthcare costs associated with outpatient and ER visits and inpatient hospitalizations related to migraine retrospectively obtained from the 2007 Medstat MarketScan Commercial Claims & Encounters database. Tabulated costs reflected payments from insurers, patients and other sources. All costs were adjusted to 2010 US dollars.
Results: The estimated mean cost (95% CI) for migraine-related care per outpatient visit (N = 680,946) was $139.88 ($139.35–140.41); per ER visit (N = 88,128) was $775.09 ($768.10–782.09); and per inpatient hospitalization (N = 5516) was $7317.07 ($7134.96–7499.17). The most frequently coded procedures at outpatient and ER visits were subcutaneous or intra-muscular injection, and for hospitalizations was computed tomography. Estimated annual US healthcare costs in 2010 for migraine associated with: outpatient visits were $3.2 billion, ER visits were $700 million, and inpatient hospitalizations were $375 million.
Conclusions: Direct healthcare costs associated with patient visits and hospitalizations for migraine headaches have increased since previously published estimates. Further research is needed to understand the current overall healthcare cost burden per patient and within the US population.
Keywords
Introduction
In the US population, the prevalence of migraine among individuals aged 12 and older is estimated to be 17.1% in women and 5.6% in men, is significantly higher among whites (female 17.3%, male 5.7%) versus blacks (female 13.7%, male 4.1%), and peaks between the ages of 30 and 39 years (1). Although migraine may be one of the best understood neurological disorders, many migraine sufferers go undiagnosed and/or undertreated.
The overall cost of migraine is difficult to measure. Migraine represents not only the burden of pain and suffering from the headache itself, but also has a psychosocial impact, ranging from psychological to socio-economic. In one study, the large majority of migraine sufferers (79%) reported a negative impact on relationships and daily activities with family and friends (2). In another study, 44% of patients reported feeling depressed because of their migraines and felt that their physicians did not understand the extent to which their migraines interfered with their lives (3). Further, women migraineurs have reported feeling a lack of empathy from those around them. Overall, patients felt that migraines left them feeling a lack of control (2). In addition, female migraine sufferers miss an estimated 8.3 days of work per year in the USA, as well as 7.6 days with reduced productivity at work due to migraines (4). On average, a total loss of 20 workdays due to migraine (including both absenteeism and productivity loss) were reported in a large study in the USA, Latin America, Europe, and other countries (5).
Three previous direct healthcare cost estimates for migraine care, including prescription costs, reported values in the range of $500–1165 per migraineur per year (6–8). It should be noted that these cost estimates reflected data for patients who sought healthcare use for migraine within a given year or period, and excluded patients for whom healthcare for migraine was not obtained. In 1999, physician visits, followed by prescription drug costs, represented the majority of migraine-associated direct costs for both sexes (4). Overall, patients who suffer with migraines have significantly greater average healthcare costs compared with matched non-migraine controls (9). Although these studies have reported an overall cost of migraine care per patient year, data on the average US costs of an outpatient visit, emergency room (ER) visit or hospitalization for migraine are scant, with the most recent available population values based on healthcare charges reported by Hu et al. from 1994 data, which were $106 for an outpatient visit, $157 for an ER visit and $4918 for an inpatient hospitalization, with the estimated overall charges for migraine care, including prescription drug costs, at over $1.03 billion annually (4). Yet these data are often required for economic analyses comparing the cost-effectiveness of alternate interventions for migraine (10). In order to understand migraine healthcare costs based on more recent data, the objective of this analysis was to estimate the healthcare costs associated with an outpatient visit, ER visit or inpatient hospitalization related to migraine headache from 2007 data.
Methods
Data were obtained from the Medstat MarketScan Commercial Claims & Encounters database for the 2007 calendar year, which was the most recent year of data available to us for both outpatient and inpatient claims. Costs within the database represent healthcare claims payments from all sources, including insurers, patients, and others. All costs were adjusted to 2010 (July) US dollars using the Medical Care component of the Consumer Price Index (11).
Migraine-related medical encounters initially selected for analysis included all healthcare claims observed on a date of service with a primary or secondary ICD-9 diagnosis code (for outpatient and ER services) or all inpatient healthcare claims observed with a principal diagnosis (usually the discharge diagnosis) for migraine (346.0-346.9).
Concomitant primary ICD-9 codes deemed likely related to migraine
Outpatient visits were defined as those occurring in physician offices, urgent care centers, outpatient hospitals and other outpatient settings excluding acute care hospitals. ER visits were defined as those occurring in hospital ERs or acute care hospitals (both on an outpatient basis). Inpatient hospitalization claims were defined to include those classified as services performed in inpatient hospitals or categorized as other inpatient care.
The database query resulted in the initial selection of 1,509,700 claim line items for outpatient visits. Among these claim line items, 413,469 had a concomitant primary diagnosis code other than those listed for migraine. Claim line items with codes deemed likely related to migraine attack were retained, and line items for all other codes (n = 369,062) were deleted, leaving 1,140,638 line items for analysis, corresponding to 680,946 outpatient visits.
For ER visits, the database query resulted in the initial selection of 487,466 claim line items. Among these claim line items, 124,384 had a concomitant primary diagnosis code other than those listed for migraine. Claim line items with codes deemed likely related to migraine attacks were retained, and line items for all other codes (n = 108,759) were deleted, leaving 378,707 line items for analysis, corresponding to 88,128 ER visits.
The query of the database resulted in the initial selection of 126,648 claim line items for inpatient hospitalizations. Among these claim line items, 34,315 had a primary diagnosis code other than those listed for migraine. Claim line items with codes deemed likely related to migraine attack were retained, and line items for all other codes (n = 20,952) were deleted leaving 105,696 line items for analysis, corresponding to 5516 inpatient hospitalizations.
Costs associated with each type of healthcare encounter were tabulated as the sum of payments (from all sources) for services rendered for the eligible claim line items within each encounter based on the eligible principal ICD-9 codes as defined above. Costs are reported as means, with 95% confidence intervals estimated assuming the distribution of means to be normal (Central Limit Theorem) given the very large sample sizes.
To help place the results of the analysis in a broader context, we also conducted an extrapolation of the estimated healthcare costs to the US population as a whole. For outpatient and ER visit costs, this was accomplished by first estimating the number of individuals in the US population with migraine based on 2010 US Census projections (12), and data on the prevalence of migraine within the US population aged 12+ from a national sample of US households (1). Data from the American Migraine Prevalence and Prevention (AMPP) study, based on a stratified random sample of US households, were then tabulated to estimate the annual frequency of outpatient (1.00 visits/year) and ER visits (0.13 visits/year) among US migraineurs (including both those who utilized health care and those who did not) (13). The estimated number of US migraineurs was then multiplied by the estimated number of outpatient and ER visits per migraineur per year to estimate total annual US outpatient and ER visits. The annual number of US inpatient hospitalizations for migraine was estimated directly from 2008 Healthcare Cost and Utilization Project (HCUP) data for US inpatient hospital discharges with a principal diagnosis of migraine (ICD-9 codes 346.0-346.9) (14). These national estimates of annual resource use were then multiplied by the estimated costs for each type of service use as estimated from the Medstat database, to project a total annual US healthcare cost.
Results
The most frequent Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure codes for each visit
For outpatient visits, the most commonly listed procedure codes (Table 2) were injections for migraine symptom relief, including subcutaneous or intra-muscular as the most frequent (6.7%), followed by promethazine HCl (5.9%), ketorolac tromethamine, per 15 mg (4.3%), and meperidine hydrochloride, per 100 mg (2.3%). Similarly, the most commonly listed ER visit procedure codes (Table 2) were also injections, including subcutaneous or intra-muscular as the most frequent (15.8%), intravenous, single or initial drug (9.9%), intravenous, each additional drug (7.6%), and promethazine HCl up to 50 mg (6.6%). Computed tomography, head or brain, without contrast material was also relatively frequent in the ER (9.0%). Inpatient hospitalizations were associated with a high frequency of imaging codes (Table 2), including computed tomography, head or brain, without contrast material (19.3%) and magnetic resonance imaging, brain, without contrast material, followed by contrast material and further sequences (17.2%) and magnetic resonance imaging, brain, without contrast material (12.2%).
Estimated annual cost in the US for healthcare services related to migraine
Outpatient and ER visits projected based on 2010 US Census data and inpatient hospitalization data were estimated for the 2008 population. All costs were adjusted to 2010 US dollars.
Discussion
The results of this analysis show direct healthcare costs that are higher than those previously reported in the 1994 Medstat MarketScan data analysis by Hu et al., but to a varying degree depending upon the type of resource used (4). Hu et al. reported healthcare charges of $106 for a migraine outpatient visit, $157 for an ER visit and $4918 for an inpatient hospitalization, which compares to values of $140, $775 and $7318, respectively in the present study. Migraine-related charges as reported by Hu and colleagues (4) might have overestimated the actual costs. It should be noted that the differences from the Hu et al. study are likely to be even greater given that the data were based on healthcare charges, which are likely to be significantly greater than payments for healthcare services, as was used in this analysis. For instance, an average US cost-charge ratio for hospital care of 0.53 has been previously reported (15). Total annual US healthcare costs for migraine associated with outpatient visits, ER visits and inpatient hospitalizations were estimated to be $4.3 billion within the present study. It should be noted that this figure underestimates the full economic impact of migraine as it does not include drug costs or indirect costs (e.g. work and productivity losses) attributable to migraine.
Migraine care is almost always provided on an outpatient basis, and after a diagnosis is established, drug therapy can become the major cost. However, in migraine sufferers who remain undiagnosed or who are poorly managed, direct medical costs due to more frequent office visits, ER visits and hospitalizations have the potential to be much higher than the cost of medication (16). Migraine can cost employers upwards of $14.5 billion annually due to absenteeism, diminished productivity, and medical costs (4) and poor diagnosis and/or undertreatment of migraines may contribute to increasing direct costs.
The data in this analysis demonstrate that the cost drivers during outpatient and ER visits included injectible treatments with the added cost of physician and/or technician services. In addition, the cost drivers for inpatient hospitalizations included CT scans or magnetic resonance imaging, both of which are expensive yet unsuccessful diagnostic tools for migraine. Moreover, neither tool is a migraine treatment. In order to reduce these unnecessary costs, better diagnosis of migraines and more viable migraine treatments are needed.
The likelihood of using prescription medication is dependent on whether migraine sufferers see a prescribing physician about their headache (17), which makes at minimum, a diagnostic visit to the physician necessary. However, nearly half of women suffering from migraines choose not to consult their physician about them (17). In those who do consult their physician, and in whom an appropriate/correct diagnosis of migraine is made, specific anti-migraine medication may be ineffective or poorly tolerated (17); or they may be prescribed medications, such as triptans, opioids or butalbital, whose intake should be limited due to the risk of developing medication overuse headaches (MOH) (18,19). In short, migraine management is not always optimal despite multiple therapeutic options.
Ideally, healthcare costs can be diminished or maintained with better migraine management. More importantly, appropriate patient education and optimal medication use may result in superior clinical outcomes. One study demonstrated that better management of migraines led to lower direct medical costs over time (16). Treatment consisted of group education sessions led by a registered nurse practitioner (RNP), followed by consultation with an RNP or physician who prescribed clinically appropriate use of triptans, tricyclic antidepressants, beta-blockers, and valproic acid (the latter two as second-line agents). The results demonstrated that while the cost of medications (i.e. triptans) increased over time, headache-related visits to physicians’ offices and emergency departments were reduced by 32% and 49%, respectively. In addition, the frequency of severe headaches was reduced in 86% of patients who initially reported suffering from severe headaches at least 2 days per week (16). The study reported net savings of more than $18,700, among 264 patients, in a 6-month period, despite the increased cost of medication. The authors attributed the improvement in costs to the disease management program as a whole, i.e. accurate diagnosis, appropriate treatment regimens based on individual patient needs, and patient awareness/education about their migraines.
Another important issue in migraine management is the low persistency in medication use. Despite the safety and efficacy of triptans, several studies of pharmacy claims data demonstrate low retention of triptan prescription refills (reviewed in (20)). Katic and colleagues found that nearly 54% of patients did not refill their initial triptan after just one prescription (20). Lack of efficacy in particular has been cited as a reason for switching from lower-dose triptans to alternative triptans (20,21). In addition, the rate of ‘between-class switching’ to opioids/NSAIDs at the time of the first refill in the Katic study (20) was considered high (80% in those filling a non-triptan prescription). Other reasons for low persistency have been suggested, including high cost and tolerability issues with the various triptans (22). Furthermore, it is possible that some patients with diagnosis of depression/anxiety requiring the use of concomitant medications (such as serotonin-specific reuptake inhibitors or serotonin-norepinephine reuptake inhibitors) discontinued triptans due to potential concerns regarding drug interactions.
The current analysis did not include pharmacy-related cost estimates or indirect costs, such as absenteeism or presenteeism, and focused on the cost of care received during physician office visits, ER visits and inpatient hospitalizations. These results, which show an increase in direct healthcare costs since prior analyses, together with the results of previous studies on the persistency of prescription refills for migraine medications, highlight the unmet need for better tolerated and efficacious migraine-specific treatments. In addition, the results of this analysis further support the need for patient education and better overall management of migraine headache to reduce the socio economic burden of disease.
Footnotes
Acknowledgements
We thank Jane Liao of Merck Sharp & Dohme Corp. for programming assistance in extracting data from the Medstat MarketScan database, and Sheila Erespe of Merck Sharp & Dohme Corp. for editorial assistance.