Prevalence, Health Care Utilization, and Costs of Fibromyalgia, Irritable Bowel, and Chronic Fatigue Syndromes in the Military Health System, 2006-2010
| By Dorris, Joseph | |
| Proquest LLC |
ABSTRACT Objective: We compared prevalence, health care utilization, and costs over time for nonelderly adults diagnosed with fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), and chronic fatigue syndrome (CFS) in relation to timing of federal approvals for FMS drugs. Data Source: We used military health care claims from
INTRODUCTION
Medically unexplained physical symptoms (MUPS) are func- tional disorders without known etiology or structural cause. As reviewed elsewhere, there is no agreement on MUPS diag- nostic nosology or diagnostic criteria.1-4 Such disorders, char- acterized by symptom clusters, are commonly referred to as psychosomatic disorders, or viewed as mood disorders with comorbid pain, gastrointestinal syndromes, or profound fatigue.4-6 Numerous reports document the concurrence of mood disorders and MUPS,7-12 but there is little empirical evidence for psychological etiology.13
Three common MUPS conditions are fibromyalgia syn- drome (FMS), irritable bowel syndrome (IBS), and chronic fatigue syndrome (CFS). The exact prevalence of these condi- tions is unknown but 2% of the U.S. population are estimated to have a FMS diagnosis,14,15 at least 10% are assumed to have IBS,16,17 and 0.4% are estimated to have CFS.18 Com- pared to civilian populations, higher rates of CFS19 and FMS have been reported among U.S. military veterans deployed to the Persian Gulf during the 1991 Gulf War.20 Such health conditions have long been recognized by the U.S. military as impacting readiness and job productivity.21
MUPS conditions are of interest to health care systems because of high health care utilization and costs.22,23 High costs are attributed to the number of diagnostic tests and procedures needed to rule out other conditions,24,25 comor- bid conditions that complicate diagnostic evaluations,23,25-27 and number of drug prescriptions.23,25,28-31 Medications contributing to high FMS costs include antidepressants,23,32 anxiolytics, nonsteroidal anti-inflammatory drugs, gabapentin, pregabalin, and duloxetine.33 Since the
Study Purpose
As part of an internal
METHODS
Data Source and Definitions
Procedures for data extraction of administrative claims data from the Military Health System Data Repository conformed to guidelines established by the
Definitions of Outcome Variables
Prevalence was derived by the yearly proportion of the beneficiary population who submitted claims with a pri- marydiagnosisofFMS,IBS,orCFS,andmetourinclu- sion criteria.
Health care utilization was measured by the number of ambulatory encounters per person per fiscal year. Ambula- tory encounters included any services or procedures provided in outpatient clinics, hospital outpatient departments, emer- gency departments, or ambulatory surgical facilities.
All encounters were included in the analysis even if the encounter did not specify a MUPS diagnosis. Costs were standardized to 2010 dollars. Total cost data were based on claims paid by DoD for ambulatory encounters, inpatient stays, ancillary costs (i.e., radiology, pathology/laboratory), filled prescriptions, facility costs, and professional services. Costs incurred in military treatment facilities were standard- ized using published 2010 DoD "Green Book" rates, which contain a 50/50 contribution split of Operations & Manage- ment, and military personnel rates. Costs incurred in civilian facilities were standardized using
Definitions of Explanatory Variables
Age was grouped into four categories: 18 to 24, 25 to 34, 35 to 44, and 45 to 64 years. Although age was analyzed with both continuous and categorical variables, we report on the categorical age values because they yielded similar patterns within the final models, and were more indicative of groupwise patterns than the continuous effect of age, linear or nonlinear.
Beneficiary category refers to the type of sponsor or family member eligible for DoD health care coverage. Spon- sors are active duty or military retired personnel from the
Service affiliation is the sponsor's branch of uniformed services, categorized as
Health care system refers to use of military treatment facilities (MTF) or civilian facilities. Comparisons between the systems were restricted to beneficiaries who used the military system only and the civilian system only.
Prime versus non-Prime reflects the type of beneficiary enrollment in
Within
Statistical Analysis
Using SAS software version 9.2 (
Stata software version 10.1 (
RESULTS
Prevalence
The number of MUPS cases for the selected conditions steadily increased in 5 years, from 20,585 (total population N = 4,936,721) to 33,654 (total population N = 5,183,395). Eighty percent of MUPS cases were female and this per- centage remained stable over time. Figure 1 shows FMS prevalence rates, based on the number of beneficiaries for each year. Between 2006 and 2007, the prevalence rate increased 0.026%; between 2007 and 2008, the prevalence rate increased 0.070%. Prevalence rates for IBS and CFS negligibly increased in a smooth projection over the 5 years. The correlations of determination for the prevalence rates over time indicate strong correlations between the number of cases and time for FMS and CFS cases; for IBS, only a moderate association was found.
The FMS prevalence trend analysis (Table I), controlling for demographic variables, found the highest prevalence among the 45 to 64 age group, females, and those affiliated with the
The IBS model showed significantly higher prevalence compared to the reference groups for females ( p < 0.001, 95% CI [0.113,0.129]); 25 to 34 age group(p < 0.001,95% CI [0.058, 0.082]), 35 to 44 age group ( p < 0.001, 95% CI [0.071, 0.096]), and 45 to 64 age group ( p < 0.001, 95% CI [0.089, 0.111]);
The CFS model showed highest prevalence rates among the 45 to 64 age group ( p < 0.001, 95% CI [0.008, 0.016]), females ( p < 0.001, 95% CI [0.006, 0.012]),
Health Care Utilization
Among beneficiaries who used civilian systems only, the number of FMS cases increased from 7,042 (2006) to 13,121 (2010) over 5 years. Among those who used military systems only, there was a little change in the number of FMS cases per year over time. For IBS, the number of civilian system only cases increased from 1,997 to 2,637 over 5 years, whereas the number of military system only cases decreased from 998 to 725 over 5 years. For CFS, there was a modest increase over time in the number of beneficiaries who used civilian system only (305-505), whereas the number using military treatment facilities only decreased (90 to 61).
The increase in average number of ambulatory encounters per person per year for FMS cases increased less for civilian care system (35.37 in 2006 to 39.01 in 2010) than for military care system (27.78 in 2006 to 33.72 in 2010). The average number of ambulatory encounters for IBS civilian system only cases increased from 22.58 to 26.52 over 5 years, whereas the corresponding number of military system only cases increased from 22.06 to 27.87. Among CFS civilian system only cases, the average number of annual encounters increased from 24.51 (2006) to 29.86 (2010); in contrast, military system only encounters had a sporadic pattern throughout the period.
Costs
Total inflation-adjusted cost for all beneficiaries diag- nosed with FMS increased from
Table II shows the results of the cost trend rate model for FMS cases. Controlling for other factors, subgroups with the highest costs per person were in the age group 25 to 34; females, whose total costs were, on average,
Among IBS cases, total cost increased from
Controlling for other factors, total cost per person trend rate model for IBS cases found higher per person costs in the 45 to 64 age group compared to the reference 18 to 24 age group by
Likewise, we found a significant increase in CFS cost over time with total cost increasing from
After controlling for other factors, higher costs for CFS cases was associated with the 25 to 34 age group compared to the reference age group ( p = 0.018, 95% CI [
Pharmacy Costs
Figure 3 shows pharmacy costs over time by MUPS condi- tion, with vertical hatched lines indicating the dates of
Total pharmacy costs for IBS cases were
Total 2006 and 2010 pharmacy costs for individuals diagnosed with CFS were
DISCUSSION
Data based on DoD health care claims provide an opportunity to examine population-based prevalence, utilization, and costs of MUPS conditions where equal benefits and access to care extend to all beneficiaries. Although military-related and civilian populations have differences in health status, our findings indicate the prevalence rates of U.S. nonelderly adults diagnosed with FMS, IBS, and CFS are 0.7%, 0.12%, and 0.02%, respectively. Prevalence rates for conditions coded with same ICD-9 codes should remain stable over time unless there are changes in diagnostic classification, biomed- ical advances, health risks, or environmental exposures. Indeed, prevalence rates for IBS and CFS remained relatively stable compared to FMS. The 2007 uptick in FMS rates cannot be attributed to diagnostic classification given the 1990-1992 diagnostic criteria for FMS were not modified until 2010.35 Likewise, there have been no medical break- throughs on FMS etiology, nor known changes in risk factors. Since the contemporary term "fibromyalgia" first appeared in 1981,36 the only risk factors associated with FMS have been female sex and middle age. Hence, we strongly suspect that the rise in FMS prevalence between 2006 and 2008 is due to drug marketing activities between
It should be noted that published conflicts of interest are also apparent in Cochrane reviews of FMS drugs. For exam- ple, the four authors of a 2013 Cochrane review examining the evidence for anticonvulsant drug use in FMS42 (e.g., pregabalin) have conflicts of interest with
Utilization of ambulatory services by DoD beneficiaries diagnosed with FMS, IBS, and CFS are at least five times higher than utilization for all conditions in the insured U.S. population,46 and at least four times higher than TRICARE Prime beneficiaries with medical-surgical ambulatory encounters.47 Among FMS cases, we found higher health care utilization in civilian facilities compared to military facilities. This latter finding was expected given the higher numbers of women and non-active duty beneficiaries diag- nosed with FMS, the majority of whom do not use military facilities. The unrestricted use of health care afforded to
In DoD, FMS-related total costs increased 93.5% between 2005 and 2010; for the same period, the National Health Expenditure rate for the U.S. population increased 27.9%.48 The 2010 average pharmacy cost per beneficiary diagnosed with FMS was
Most of the increase for FMS pharmacy costs is due to the three
Independent of our study, beginning in 2007, the DoD Pharmacoeconomics Center tracked FMS-approved drugs for their level of effectiveness compared to equivalent drugs and associated costs. In 2010, DoD classified milnacipran as a nonformulary drug, and in 2012 pregabalin and duloxetine were classified as nonformulary52 with equivalent drugs being provisionally required in newly diagnosed FMS cases. The minimal increase in FMS-related pharmacy costs between 2009 and 2010 appears to be a direct consequence of DoD evaluation of FMS drugs and cost containment efforts. It remains to be seen, however, if the nonformulary classification of these drugs will impact the prevalence, health care utilization, and overall costs related to FMS sub- sequent to 2010. In a
Limitations
We did not consider FMS comorbidities, nor establish the date of first FMS diagnosis as done elsewhere.23,29 We also did not control for severity of illness, or restrict health care utilization to encounters where MUPS was theprimarydiagnosis.Wehadnoinformationonsystem capacity, referrals to medical specialists, reason for pre- scribed medications, patient outcomes, or out-of-pocket expenses. Also, the doubling of FMS total costs in mili- tary settings may be due to an unknown number of active duty personnel given the diagnostic code of ICD-9 729.1 for conditions related to soft tissue and muscle strain and trauma. Finally, we could not determine if non-Prime enrollees submitted health care claims as completely as Prime enrollees.
Conclusion
Our study appears to be the first to compare the preva- lence, health care utilization, and costs over time of indi- viduals diagnosed with FMS to those diagnosed with IBS and CFS, and the first to examine these MUPS conditions in a military-connected population. Consistent with the liter- ature, we found disproportionate rates among middle-aged females, and higher average costs for women. Active duty personnel also incurred greater costs once controlling for other factors. Although we cannot establish causality, our findings strongly suggest that the DoD beneficiary popu- lation and their health care providers are susceptible to
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*
[dagger]
[double dagger]
§Altarum Institute,
doi: 10.7205/MILMED-D-13-00419
| Copyright: | (c) 2014 Association of Military Surgeons of the United States |
| Wordcount: | 6169 |
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