Analysis of the Effect of Age of

High Blood Cholesterol Diagnosis

and Other Factors on Total Yearly
Health Expenditures
Hannah Wikkeling
Enrique Guzmn
MPH 646:
Advanced Epidemiology with Statistical Software Applications
August 1, 2013
Purpose of Research
To determine if the age at which individuals
get diagnosed with high blood cholesterol
(HBC) affects their total health
expenditures for the year 2010.
Also, to explore if other factors such as sex,
race, family income, and education level
play a role in these expenditures?
Hypothesis
The later in life an individual receives a
high blood cholesterol diagnosis, the higher
the health care expenditures will be for the
year 2010.
o Preventative medicine
o More Advanced level of High Cholesterol
o Other co-morbidities affecting their health
Literature Review
! 1/6 adult Americans has HBC
BC:
o Waxy, fat-like substance that your body needs
o Excess BC in blood can build up on artery walls
o Over time, cholesterol deposits (plaque) can narrow
arteries and reduce blood flow
o When plaque totally blocks an artery carrying blood
to the heart, a heart attack occurs
Thus, HBC places individuals at risk for heart disease,
the leading cause of death in the United States.
(CDC, 2010)
Literature Review
(CDC, 2010)
(Los Olivos, 2011)
Low Density Lipoproteins (LDL)
o "Bad" Cholesterol
o Contributes to clogged arteries
o Optimal: <130 mg/dL
Very Low Density Lipoproteins (VLDL)
o Precursor to LDL
o Optimal: <32 mg/dL
High Density Lipoproteins (HDL)
o "Good" cholesterol
o Prevents arteries from clogging
o Optimal: >40 mg/dL
Literature Review
Total Cholesterol
o HDL + LDL + VLDL
o Optimal: <200 mg/dL
The average total cholesterol level for adult Americans
is about 200 mg/dL
o borderline high risk
71 million American adults (33.5%) have high LDL
An estimated 17% of adults in the US have elevated
levels of serum cholesterol, or hyperlipidemia
(CDC, 2012)
(Harvard MS, 2005)
(Wilson et al., 2009)
Literature Review
2008:
Of the top 10 most costly conditions, HBC is
the 9th most costly
o $38.5 billion
On average, the expenditures for adults age
18 and older with high cholesterol were
o $810 per person for males
o $933 per person for females
(Soni, 2011)
Literature Review
Previous research: Blacks and Hispanics have higher TBC and LDL
relative to Whites
A larger percentage of Hispanic men have high TBC (15.4%)
o non-Hispanic whites (11.4%)
o non-Hispanic black men (10.2%)
BC screening lowest among individuals:
o Aged 1844
o Who are Hispanic
o With lower levels of education
BC screening is significantly lower for persons originating from
Mexico (70.9%)
o US born individuals on average (80.1%)
o US born Hispanic persons (77.8%)
(Willson et al., 2010)
(Stimpson et al., 2012)
Literature Review
Males more likely to have HBC than females (25.1% v. 19.2%)
On average women have substantially higher HDL levels compared
to males (60.3 mg/dL v. 48.5 mg/dL)
(Crawford et al., 2010)
(Harvard Means Health Watch, 2010)
Literature Review
By analyzing the association between age of cholesterol
diagnosis and total health expenditures for the year 2010,
we are addressing a gap in the literature.
Currently, the literature does not provide a solid baseline
from which to determine an association between these to
variables.
This analysis will help provide that baseline in addition to
exploring associations with other explanatory variables
Data Source
Used the most complete source of data on healthcare cost and use and
health insurance coverage among individuals in the U.S.
The Medical Expenditure Panel Survey (MEPS)
Contains Nationally representative data
Agency for Healthcare Research and Quality (DHHS)
o Set of large-scale surveys of families and individuals
o Their medical providers
o Their Employers
Specific data collected by MEPS:
o health services used
o frequency of their use
o cost
o payment method
o extent of health insurance coverage
(MEPS, 2009)
Measured Variables
Key explanatory variable:
o Age of HBC Dx. (CHOLAGED)
Dependent variable:
o Total Health Expenditures for the year 2010
(TOTEXP10) ! TOTEXP10_THOUS
Additional explanatory variables:
o Race (RACE)
o Sex (SEX)
o Family Income (FAMINC) ! FAMINC_THOUS
o Educational level (EDUCYR)
Descriptive Statistics
Sex: Binary Variable
Race/Ethnicity: Categorical Variables
:
Original Sample Size: 32,846
Excluded from Analysis: 26,098
Individuals Meeting Criteria for Sample Analysis 6,388
Sample Size
Summary Statistics
Additional Explanatory Variables: Continuous Variables
Model Assumption
Inclusion criteria for analysis
Categorization of White race
Cholesterol Diagnosis criteria
Correlation of Total Health Care
Expenditure and Age of Diagnosis of High
Cholesterol with Regression Line
Correlation
Weak association between the age at which
individuals received a HBC diagnosis and
their total health expenditures in 2010
Single Linear Regression
Multiple Linear Regression
R
2
: Captures the degree of association among analyzed variables based on the total
sample variation in the TOTEXP10 (DV) explained by the other explanatory variable.
Weak association. Not very close to 1.
Adjusted R
2
: Not much different than R
2
. Its slightly smaller because several other
explanatory variables were used for this analysis. Thus, the regression analysis penalized
these additional explanatory variables by using DoF to estimate the error variance.
Potential for Heteroskedasticity
Heteroskedastic
Not football-shaped
Any given
observation will be
off the regression
line by varying
amounts
In order to correct for
heteroskedasticity,
the robust SEs
calculated
That way
observations will
cluster around the
regression line more
constantly
Ordinary Least Squares
Table 4: OLS Regression of Age of High Cholesterol Diagnosis and other
explanatory variables on Total Health Care Expenditures in 2010
Predictive Total Healthcare
Expenditures Values for 2010
General formula:
!= "
o
+ !
1
x
1
+ !
2
x
2
+ !
3
x
3
+ !
4
x
4
+ !
5
x
5

constant CHOLAGED EDUCYR FAMINC10_THOUS SEX RACE
Example 1
Age of HBC Dx.: 25 y.o.
Education Level: 13 years of education
Family Income: $58,000
Sex: Male
Race: Hispanic
!= "o + !
1
x
1
+ !
2
x
2
+ !
3
x
3
+ !
4
x
4
+ !
5
x
5

!= 5.0845 + (0.1024)(25) + (-0.0688)(13) + (-0.0146)(58) + (-0.2965)(1) + (-4.0441)(1)
!= 1.5627
All else equal, a Hispanic male individual who was diagnosed with HBC
at age 25, completed one year of college and whose annual family
income is $58,000, on average, will spend $1,562.70 on their total
healthcare expenditures for the year 2010.
Example 2
Age of HBC Dx.: 60 y.o.
Education Level: 13 years of education
Family Income: $58,000
Sex: Male
Race: Hispanic
!= "o + "
o
+ !
1
x
1
+ !
2
x
2
+ !
3
x
3
+ !
4
x
4
+ !
5
x
5

!= 5.0845 + (0.1024)(60) + (-0.0688)(13) + (-0.0146)(58) + (-0.2965)(1) + (-4.0441)(1)
!= 5.1467
All else equal, a Hispanic male individual who was was diagnosed with
HBC at age 60, completed one year of college and whose annual family
income is $58,000, on average, will spend $5,146.70 on their total
healthcare expenditures for the year 2010.
Example 3
Age of HBC Dx.: 30 y.o.
Education Level: 11 years of education
Family Income: $20,000
Sex: Female
Race: White
!= "o + "
o
+ !
1
x
1
+ !
2
x
2
+ !
3
x
3
+ !
4
x
4
+ !
5
x
5

!= 5.0845 + (0.1024)(30) + (-0.0688)(11) + (-0.0146)(20) + (0.2965)(1) + (-0.5760)(1)
!= 6.8282
All else equal, a White female individual who was diagnosed with HBC at
age 30, completed three years of HS and whose annual family income is
$20,000, on average, will spend $1,743.70 on their total healthcare
expenditures for the year 2010.
Example 4
Age of HBC Dx.: 70 y.o.
Education Level: 17 years of education
Family Income: $120,000
Sex: Female
Race: White
!= "o + "
o
+ !
1
x
1
+ !
2
x
2
+ !
3
x
3
+ !
4
x
4
+ !
5
x
5

!= 5.0845 + (0.1024)(70) + (-0.0688)(17) + (-0.0146)(120) + (0.2965)(1) + (-0.5760)(1)
!= 9.0514
All else equal, a White female individual who was diagnosed with HBC at
age 70, completed one year of graduate school and whose annual family
income is $120,000, on average, will spend $9,0514.70 on their total
healthcare expenditures for the year 2010.
Quadratic Nonlinearity
Nonlinear InteractionGender
Discussion
Results from sample analysis support our research
hypothesis!!!
A weak positive association was observed between the
age of HBC diagnosis and the total healthcare
expenditures for the year 2010
General trend based on regression analyses and
predicted values for various individuals shows that the
higher the age of HBC Dx., the higher the total
healthcare expenditures are for 2010
Discussion
Given that not a lot of research has been conducted to analyze the
association between our DV and our key explanatory variable, this
study can be used as a baseline for future studies to build on
Even though MEPS is a nationally representative sample, based on
this preliminary analysis, we cannot generalize the results from
this study to the general population.
Several assumptions were made for this analysis, like the criteria
for HBC diagnosis being unclear and the assumption that those who
were not diagnosed with HBC and were excluded from analysis
Future studies with more sophisticated methods to make statistical
corrections would be needed before making generalization to the
general population based on this sample
Discussion
Results from further studies can have profound
implications for future policy
o Can provide further support for preventative medicine
" Focus on 1 and 2 prevention vs. 3
" Ex.: Regulations requiring BC screening earlier in life
" Address disparities that exist between sexes, races,
educational levels, and family incomes
" Funding allocation to provide screening and increase
awareness about BC screening
" Can ultimately lead to significantly improved health
outcomes and decreased health expenditures
References
Agency for Healthcare Research and Quality . (2009, August 21). Medical Expenditure Panel
Survey . Retrieved July 29, 2013, from meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp
CDC - DHDSP - Facts About Cholesterol. (2012, October 16). Centers for Disease Control and
Prevention. Retrieved July 28, 2013, from http://www.cdc.gov/cholesterol/facts.htm
CDC - DHDSP - LDL and HDL. (2010, February 9). Centers for Disease Control and
Prevention. Retrieved July 28, 2013, from http://www.cdc.gov/cholesterol/ldl_hdl.htm
Crawford, A., Cote, C., Couto, J., Daskiran, M., Gunnarsson, C., Haas, K., & ... Schuette, R.
(2010). Prevalence of obesity, type II diabetes mellitus, hyperlipidemia, and hypertension in the
United States: findings from the GE Centricity Electronic Medical Record database. Population
Health Management,13(3), 151-161. doi:10.1089/pop.2009.0039 http://0-
search.ebscohost.com.ignacio.usfca.edu/login.aspx?
direct=true&db=ccm&AN=2010696048&site=eds-live&scope=site
Los Olivos Women's Medical Group - Los Gatos, CA (2011). Home Page. Retrieved July 28,
2013, from http://www.losolivos-obgyn.com/info/general_health/blood_tests/
cholesterol_information.pdf
References
Making sense of cholesterol tests The Family Health Guide. (February, 2005). Health
Information and Medical Information - Harvard Health Publications. Retrieved July 28,
2013, from http://www.health.harvard.edu/fhg/updates/update0205c.shtml
Mars vs. Venus: The Gender Gap in Health - Harvard Health Publications. Jan 2010. Health
Information and Medical Information - Harvard Health Publications. Retrieved July 29,
2013, from
http://www.health.harvard.edu/newsletters/Harvard_Mens_Health_Watch/2010/January/
mars-vs-venus-the-gender-gap-in-health
Making sense of cholesterol tests The Family Health Guide. (February, 2005). Health
Information and Medical Information - Harvard Health Publications. Retrieved July 28,
2013, from http://www.health.harvard.edu/fhg/updates/update0205c.shtml
Mars vs. Venus: The Gender Gap in Health - Harvard Health Publications. Jan 2010. Health
Information and Medical Information - Harvard Health Publications. Retrieved July 29,
2013, from
http://www.health.harvard.edu/newsletters/Harvard_Mens_Health_Watch/2010/January/
mars-vs-venus-the-gender-gap-in-health
References
Prevalence of cholesterol screening and high blood cholesterol among adults - United States,
2005, 2007, and 2009. (2012). MMWR: Morbidity & Mortality Weekly Report, 61697-702.
http://0-search.ebscohost.com.ignacio.usfca.edu/login.aspx?
direct=true&db=ccm&AN=2011678399&site=eds-live&scope=site
Stimpson J., et al. (2012). Persistent disparities in cholesterol screening among immigrants to
the United States. International Journal for Equity in Health, 11(1), 22-25. doi:
10.1186/1475-9276-11-22
Willson, M., Neumiller, J., Sclar, D., Robison, L., & Skaer, T. (2010). Ethnicity/race, use of
pharmacotherapy, scope of physician-ordered cholesterol screening, and provision of diet/
nutrition or exercise counseling during US office-based visits by patients with
hyperlipidemia. American Journal Of Cardiovascular Drugs, 10(2), 105-108. doi:
10.2165/11532820-000000000-00000 http://0-search.ebscohost.com.ignacio.usfca.edu/
login.aspx?direct=true&db=ccm&AN=2010635187&site=eds-live&scope=site