Author + information
- Geoffrey D. Barnes, MD, MSc and
- Elizabeth A. Jackson, MD, MPH∗ ()
- Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, University of Michigan Medical Center, Ann Arbor, Michigan
- ↵∗Reprint requests and correspondence:
Dr. Elizabeth A. Jackson, Division of Cardiovascular Medicine, University of Michigan Health System, 24 Frank Lloyd Wright Drive, Ann Arbor, Michigan 48106-0363.
Peripheral artery disease (PAD) is a significant public health concern with more than 200 million adults diagnosed with PAD globally (1). In the United States, the annual prevalence of PAD is estimated at 12.3% (on the basis of national insurance claims) or 8.5 million individuals age ≥40 years (1). PAD is associated with significant increased risk for mortality. An estimated $4.37 billion in health care expenditures related to PAD were spent in 2001 alone (2) and increases in health care utilization related to PAD during the past decade translate into even higher costs in recent years. One of the strongest risk factors for PAD is tobacco use, which carries a 3- to 4-fold increased risk for PAD, often presenting as severe disease (1).
Unlike PAD, rates of tobacco use have declined by 26% since the late 1990s; now smokers are estimated to make up 18% of the American population (1). Despite the declining numbers of adults who smoke, health care costs related to tobacco use are staggering. Annual tobacco-attributed costs are estimated at $133 billion to $176 billion for direct-medical costs and an additional $151 billion for lost productivity (1).
The paper by Duval et al. (3) in this issue of the Journal supports prior studies showing high health care utilization among PAD patients (2,4). The present study adds to our current understanding by discriminating health care costs for PAD patients who smoke compared to nonsmoking PAD patients (3). The authors used data from Minnesota’s Blue Cross Blue Shield claims database collected for 2011. Of the 22,203 patients with PAD, 1,995 (9.0%) were identified as tobacco users (lower than national estimates). One-half of all tobacco users experienced hospitalizations during the study period, a 35% higher rate compared to nontobacco users with PAD. Smokers with PAD were more frequently admitted to the hospital for atherosclerotic diagnoses, acute myocardial infarction, and coronary heart disease and also were found to have a higher short-term cost ($64,041 vs. $45,918) compared to nonsmokers. The authors concluded that tobacco use among PAD patients is associated with a significant increase in PAD-related hospitalizations, atherosclerotic procedures, and health care costs. The costs were on the basis of 1-year follow-up; thus it is likely the long-term costs for PAD smokers are also significantly higher compared to PAD nonsmokers.
The authors performed detailed and thorough analyses to identify the tobacco user and nonuser cohorts, yet (as the authors themselves acknowledge) underestimation of smoking status was most likely present given the use of claims data. Notwithstanding this limitation, the impact of smoking on the leading hospital discharge diagnoses was striking. The number 1 reason for hospitalization among tobacco users was atherosclerotic disease, whereas nonsmokers had 7 to 9 other more common diagnoses. As with any observational study, care must be taken not to confuse correlation with causation. Whereas prior studies have accounted for the costs associated with either PAD diagnosis or tobacco use, this study quantifies the costs when the 2 are combined. In doing so, this study raises the issue of financing effective tobacco cessation interventions.
For all patients, the U.S. Preventative Services Task Force recommends the use of the 5 A's when managing tobacco using patients: 1) assess behaviors, beliefs, and knowledge; 2) advise about health risks and the benefit of change; 3) agree on a collaborative set of goals; 4) assist with support and pharmacotherapy; and 5) arrange follow up (5,6). However, this assessment is not regularly used by clinicians (7,8). Currently an estimated one-half of all patients who smoke report that their physician did not counsel them regarding tobacco cessation. Improved utilization and efficacy of interventions are critical (1). Electronic medical record systems with prompts to record and treat tobacco abuse have been associated with increased use of tobacco cessation referral programs (9), and may improve rates of smoking cessation counseling by clinicians. Similarly, use of state-based phone and internet resources have been shown to improve 30-day tobacco abstinence rates (10), and can be used to provide targeted messages to specific populations such as those with PAD. Lastly, use of pharmacologic interventions, such as nicotine patches, have shown efficacy and should be considered as a critical tool for smoking cessation programs (11).
It remains simplistic to think that a magic bullet exists to treat all patients who use tobacco. In 2010, we described a 1-size-fits-all approach to tobacco cessation “both naïve and biologically implausible” (12). Assessing a patient’s willingness to quit, and any potential barriers they have, will help to personalize tobacco cessation assistance. Targeting interventions to specific populations, such as those with PAD, may enhance smoking cessation interventions. In a recent randomized trial of 124 PAD patients who smoked, abstinence from tobacco use was greatly improved at 12 months when a tailored PAD-specific intervention was delivered (13). Health care policies that improve access and reimbursement for nicotine replacement and counseling are needed, particularly for groups with high health care utilization (14). Financial incentives for tobacco cessation may also be part of the solution. Use of a rewards-based model over a deposit-based program showed abstinence rates up to 16% at 6 to 12 months (15,16).
On the basis of the results of the study by Duval et al.(3), it would seem logical to define PAD patients as a highest-risk group for adverse outcomes and thus increased health care costs; therefore making it an important population to target for nicotine replacement coverage and/or financial incentives for tobacco abstinence. This is especially paramount because the increased health care costs accrued by tobacco users are funded by the population at large. Therefore, all citizens have a vested interest in reducing this health care burden.
One might suggest that concluding that high costs related to smoking among PAD patients is obvious, but it is the magnitude of the cost compared to nonsmoking PAD patients over a relatively short time period that is an important message. This study highlights the urgent need for smoking cessation among PAD patients and getting patients to quit has the potential to greatly improve care whereas potentially saving significant health care dollars over the long term.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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