A Break-Even Analysis for Dementia Care Collaboration: Partners in Dementia Care

Background

Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the “Partners in Dementia Care” (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care.

Objective

We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care.

Design

This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers.

Participants

Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165).

Interventions

PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer’s Association chapters.

Main Measures

We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans’ cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period.

Key Results

Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost.

Conclusions

These analyses show that PDC meets veterans’ needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer’s Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.KEY WORDS: costs and cost analysis, dementia, veterans     

Cost effectiveness of ‘on demand’ HIV pre-exposure prophylaxis for non-injection drug-using men who have sex with men in Canada

BACKGROUND:

Recent trials report the efficacy of continuous tenofovir-based pre-exposure prophylaxis (PrEP) for prevention of HIV infection. The cost effectiveness of ‘on demand’ PrEP for non-injection drug-using men who have sex with men at high risk of HIV acquisition has not been evaluated.

OBJECTIVE:

To conduct an economic evaluation of the societal costs of HIV in Canada and evaluate the potential benefits of this PrEP strategy.

METHODS:

Direct HIV costs comprised outpatient, inpatient and emergency department costs, psychosocial costs and antiretroviral costs. Resource consumption estimates were derived from the Centre Hospitalier de l’Université de Montréal HIV cohort. Estimates of indirect costs included employment rate and work absenteeism. Costs for ‘on demand’ PrEP were modelled after an ongoing clinical trial. Cost-effectiveness analysis compared costs of ‘on demand’ PrEP to prevent one infection with lifetime costs of one HIV infection. Benefits were presented in terms of life-years and quality-adjusted life-years.

RESULTS:

The average annual direct cost of one HIV infection was $16,109 in the least expensive antiretroviral regimen scenario and $24,056 in the most expensive scenario. The total indirect cost was $11,550 per year. Total costs for the first year of HIV infection ranged from $27,410 to $35,358. Undiscounted lifetime costs ranged from $1,439,984 ($662,295 discounted at 3% and $448,901 at 5%) to $1,482,502 ($690,075 at 3% and $485,806 at 5%). The annual cost of PrEP was $12,001 per participant, and $621,390 per infection prevented. The PrEP strategy was cost-saving in all scenarios for undiscounted and 3% discounting rates. At 5% discounting rates, the strategy is largely cost-effective: according to least and most expensive scenarios, incremental cost-effectiveness ratios ranged from $60,311 to $47,407 per quality-adjusted life-year.

CONCLUSION:

This ‘on demand’ PrEP strategy ranges from cost-saving to largely cost-effective. The authors believe it represents an important public health strategy for the prevention of HIV transmission.     

Association Between Receipt of Brief Alcohol Intervention and Quality of Care among Veteran Outpatients with Unhealthy Alcohol Use

BACKGROUND

Brief alcohol intervention, including advice to reduce or abstain from drinking, is widely recommended for general medical outpatients with unhealthy alcohol use, but it is challenging to implement. Among other implementation challenges, providers report reluctance to deliver such interventions, citing concerns about negatively affecting their patient relationships.

OBJECTIVE

The purpose of this study was to determine whether patient-reported receipt of brief intervention was associated with patient-reported indicators of high-quality care among veteran outpatients with unhealthy alcohol use.

DESIGN

Cross-sectional secondary data analysis was performed using the Veterans Health Administration (VA) Survey of Healthcare Experiences of Patients (SHEP).

PARTICIPANTS

The study included veteran outpatients who (1) responded to the outpatient long-form SHEP (2009–2011), (2) screened positive for unhealthy alcohol use (Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) questionnaire score ≥ 3 for women, ≥ 4 for men), and (3) responded to questions assessing receipt of brief intervention and quality of care.

MAIN MEASURES

We used logistic regression models to estimate the adjusted predicted prevalence of reporting two indicators of high-quality care—patient ratings of their VA provider and of overall VA healthcare (range 0–10, dichotomized as ≥ 9 indicating high quality)—for both patients who did and did not report receipt of brief intervention (receiving alcohol-related advice from a provider) within the previous year.

KEY RESULTS

Among 10,612 eligible veterans, 43.8 % reported having received brief intervention, and 84.2 % and 79.1 % rated their quality of care as high from their provider and the VA healthcare system, respectively. In adjusted analyses, compared to veterans who reported receiving no brief intervention, a higher proportion of veterans reporting receipt of brief intervention rated the quality of healthcare from their provider (86.9 % vs. 82.0 %, p < 0.01) and the VA overall (82.7 % vs. 75.9 %, p < 0.01) as high.

CONCLUSIONS

In this cross-sectional analysis of veterans with unhealthy alcohol use, a higher proportion of those who reported receipt of brief intervention reported receiving high-quality care compared to those who reported having received no such intervention. These findings do not support provider concerns that delivering brief intervention adversely affects patients’ perceptions of care.KEY WORDS: Alcoholism and addictive behavior, Quality assessment, Veterans, Patient satisfaction     

Incidence of cardiovascular diseases and associated risk factors among subjects with type 2 diabetes – An 11-year follow up study

Aims

This study was planned to assess the development of cardiovascular disease (CVD) events over an 11-year period and to identify the associated risk factors that could predict the onset of CVD among subjects with type 2 diabetes.

Methods

Retrospective data of 249 patients (M:F 149:100) with type 2 diabetes, from a cohort of 7800 patients, attending a tertiary care center for diabetes from January 2000 to December 2011 were retrieved and analyzed for this study. Sociodemographic and habitual risk factors, baseline diabetes duration, HbA1c and time of onset of CVD and its risk factors were collected from case records. Person-years method was used to calculate incident rate of CVD. Binary logistic regression analyses were done to identify predictors associated with CVD and its risk factors.

Results

Incidence of CVD among subjects with diabetes was 5.6 cases/1000 person-years. Nearly 60% developed hypertension and dyslipidemia or both during the 11-year period. The most common complication was neuropathy (14.4%). Smoking [OR (95%CI)] [9.26 (1.6–54.9)] (p = 0.014) and heavy alcohol consumption [8.7 (1.1–69.8)] (p = 0.04) were significantly associated with CVD. Higher BMI was significantly associated with hypertension and dyslipidemia [2.4 (1.3–4.3)] (p = 0.003).

Conclusions

Smoking and heavy alcohol consumption were significantly associated with CVD, and increased BMI was significantly associated with hypertension and dyslipidemia among subjects with type 2 diabetes in this study population. These findings emphasize the need for early identification and modification of risk factors associated with CVD events in patients with diabetes.     

Patient Sharing Among Physicians and Costs of Care: A Network Analytic Approach to Care Coordination Using Claims Data

BACKGROUND

Improving care coordination is a national priority and a key focus of health care reforms. However, its measurement and ultimate achievement is challenging.

OBJECTIVE

To test whether patients whose providers frequently share patients with one another—what we term ‘care density’—tend to have lower costs of care and likelihood of hospitalization.

DESIGN

Cohort study

PARTICIPANTS

9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes who received care during 2009. Patients were enrolled in five large, private insurance plans across the US covering employer-sponsored and Medicare Advantage enrollees

MAIN MEASURES

Costs of care, rates of hospitalizations

KEY RESULTS

The average total annual health care cost for patients with CHF was $29,456, and $14,921 for those with diabetes. In risk adjusted analyses, patients with the highest tertile of care density, indicating the highest level of overlap among a patient’s providers, had lower total costs compared to patients in the lowest tertile ($3,310 lower for CHF and $1,502 lower for diabetes, p < 0.001). Lower inpatient costs and rates of hospitalization were found for patients with CHF and diabetes with the highest care density. Additionally, lower outpatient costs and higher pharmacy costs were found for patients with diabetes with the highest care density.

CONCLUSION

Patients treated by sets of physicians who share high numbers of patients tend to have lower costs. Future work is necessary to validate care density as a tool to evaluate care coordination and track the performance of health care systems.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2104-7) contains supplementary material, which is available to authorized users.KEY WORDS: care coordination, performance measure, provider social networks, care density     

Cardiovascular,diabetes, and cancer strips: evidences,mechanisms, and classifications

Objectives

To report and name firstly that there are cardiovascular disease (CVD), diabetes mellitus (DM) and cancers (CDC) strips; and disclose their mechanisms, classifications, and clinical significances.

Study design

Narrative and systematic review study and interpretive analysis.

Methods

Data sources and study selection: to collect and present related evidences on CDC strips from evidence-based, open-access, both Chinese- and English-language literatures in recent 10 years on clinical trials from PubMed according to keywords “CVD, DM and cancers” as well as authors’ extensive clinical experience with the treatment of more than fifty thousands of patients with CVD, diabetes and cancers over the past decades, and analyze their related mechanisms and categories which based on authors’ previous works. Data extraction: data were mainly extracted from 48 articles which are listed in the reference section of this review. Qualitative, quantitative and mixed data were included, narratively and systematically reviewed.

Results

With several conceptual and technical breakthrough, authors present related evidences on CDC strips, these are, CVD and DM, DM and cancers, cancers and CVD linked, respectively; And “Bad SEED” +/– “bad soil” theory or doctrine may explain this phenomenon due to “internal environmental injure, abnormal or unbalance” in human body resulting from the role of risk factors (RFs) related multi-pathways and multi-targets, which including organ & tissue (e.g., vascular-specific), cell and gene-based mechanisms. Their classifications include main strips/type B, and Branches/type A as showed by tables and figures in this article.

Conclusions

There are CDC strips and related mechanisms and classifications. CDC strips may help us to understand, prevent, and control related common non-communicable diseases (NCDs) as well as these high risk strips.     

The Relationship Between Food Insecurity and Depression,Diabetes Distress and Medication Adherence Among Low-Income Patients with Poorly-Controlled Diabetes

BACKGROUND

Food insecurity— lack of dependable access to adequate food—may play a role in poor diabetes control.

OBJECTIVE

We aimed to determine the relationship between food security status and depression, diabetes distress, medication adherence and glycemic control.

DESIGN

Secondary analysis of baseline data from Peer Support for Achieving Independence in Diabetes, a randomized controlled trial that enrolled patients from November 2011 to October 2013.

PARTICIPANTS

Participants had poorly controlled type 2 diabetes (A1c ≥ 8.0 % on eligibility screen), household income < 250 % of the federal poverty level, were 30–70 years old, and were recruited from a large public hospital, a VA medical center and a community-health center in King County, Washington.

MAIN MEASURES

We measured food insecurity determined by the Department of Agriculture’s 6-Item Food Security Module. Depression, diabetes distress and medication adherence measured by PHQ-8, Diabetes Distress Scale and Morisky Medication Adherence Scale, respectively. Diet was assessed through Summary of Diabetes Self-Care Activities and Starting the Conversation tool. Incidence of hypoglycemic episodes was by patient report. Glycemic control was assessed with glycosylated hemoglobin (A1c) values from fingerstick blood sample.

KEY RESULTS

The prevalence of food insecurity was 47.4 %. Chi-square tests revealed participants with food insecurity were more likely to be depressed (40.7 % vs. 15.4 %, p < 0.001), report diabetes distress (55.2 % vs. 33.8 %, p < 0.001) and have low medication adherence (52.9 % vs. 37.2 %, p = 0.02). Based on linear regression modeling, those with food insecurity had significantly higher mean A1c levels (β = 0.51; p = 0.02) after adjusting for sex, age, race/ethnicity, language, education, marital status, BMI, insulin use, depression, diabetes distress and low medication adherence.

CONCLUSIONS

Almost half of participants had food insecurity. Food insecurity was associated with depression, diabetes distress, low medication adherence and worse glycemic control. Even with adjustment, people with food insecurity had higher mean A1c levels than their food-secure counterparts, suggesting there may be other mediating factors, such as diet, that explain the relationship between food security status and diabetes control.KEY WORDS: food insecurity, diabetes, glycemic control     

Adherence to Metformin,Statins, and ACE/ARBs Within the Diabetes Health Plan (DHP)

Background

Reducing patient cost-sharing and engaging patients in disease management activities have been shown to increase uptake of evidence-based care.

Objective

To evaluate the effect of employer purchase of a disease-specific plan with reduced cost-sharing and disease management (the Diabetes Health Plan/DHP) on medication adherence among eligible employees and dependents.

Design

Employer-level “intent to treat” cohort study, including data from eligible employees and their dependents with diabetes, regardless of whether they were enrolled in the DHP.

Setting

Employers that contracted with a large national health plan administrator in 2009, 2010, and/or 2011.

Participants

Ten employers that purchased the DHP and 191 employers that did not (controls). Inverse probability weighting (IPW) estimation was used to adjust for inter-group differences.

Intervention

The DHP includes free or low-cost medications and physician visits. Enrollment strategies and specific benefit designs are determined by the employer and vary in practice. DHP participants are notified up front that they must engage in their own health care (e.g., receiving diabetes-related screening) in order to remain enrolled.

Main Outcome Measure

Mean employee adherence to metformin, statins, and ACE/ARBs at the employer level at one year post-DHP implementation, as measured by the proportion of days covered (PDC).

Results

Baseline adherence to the three medications was similar across DHP and control employers, ranging from 64 to 69 %. In the first year after DHP implementation, predicted employer-level adherence for metformin (+4.9 percentage points, p = 0.017), statins (+4.8, p = 0.019), and ACE/ARBs (+4.4, p = 0.02) was higher with DHP purchase.

Limitations

Non-randomized, observational study.

Conclusions

The Diabetes Health Plan, an innovative health plan that combines reduced cost-sharing and disease management with an up-front requirement of enrollee participation in his or her own health care, is associated with a modest improvement in medication adherence at 12 months.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3284-8) contains supplementary material, which is available to authorized users.Type 2 diabetes is highly prevalent in the United States, and leads to reduced functional status and disabling complications for many patients. The total economic cost of diabetes in 2012 has been estimated at $245 billion, which is an increase of 41 % since 2007.¹ This cost includes $176 billion in direct medical care, as well as $69 billion in decreased productivity such as absenteeism, reduced work performance, and reduced labor force participation.¹ Importantly, greater adherence to diabetes-related medications has been shown to decrease hospitalizations and emergency department use and to reduce costs of care.^2–4 Given these issues, employers have a strong interest in trying alternative approaches to providing medical care for their employees with diabetes.The Diabetes Health Plan (DHP) is an example of a novel health benefit design that became available to public and private employers in 2009. The DHP is the first disease-specific health plan in the United States for patients with diabetes and pre-diabetes, and offers features such as reduced cost-sharing for medications and office visits and free or low-cost resources for disease management. The DHP was actuarially designed to provide an estimated annual out-of-pocket savings of $150–$500 per participant.⁵As some employers purchased the DHP, while other similar employers did not, there is a unique opportunity to conduct a rigorous evaluation of a real-world intervention. In the current study, we examined the impact of the DHP on adherence to three evidence-based medications covered by the DHP (metformin, statins, ACE/ARBs) over 12 months. We also examined adherence to two unrelated medications that were not covered by the DHP (thyroxine, montelukast) in order to test whether our findings were related to the DHP. We chose to conduct employer-level analyses in order to provide information to guide the critical decision faced by employers in terms of which health plans to offer to their employees. With the employer as the unit of analysis, we predicted the average medication adherence across all DHP-eligible employees and dependents with diabetes whose employers had purchased the DHP, regardless of whether these patients actually enrolled in the plan.     

Cost comparison of linezolid versus vancomycin for treatment of complicated skin and skin-structure infection caused by methicillin-resistant Staphylococcus aureus in Quebec

BACKGROUND:

In Canada, complicated skin and skin-structure infection (cSSSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is usually treated with antibiotics in hospital, with a follow-up course at home for stable patients. The cost implications of using intravenous and oral linezolid instead of intravenous vancomycin in Canadian clinical practice have not been examined.

OBJECTIVES:

To evaluate the potential treatment cost impact for the Quebec health care system of linezolid versus vancomycin for MRSA-related cSSSI therapy, using a net impact analysis approach.

METHODS:

Health care resource use associated with linezolid and vancomycin therapy was estimated for patients in Quebec, based on expert opinion. Costs were assigned to health care resources (antibiotics, medical supplies, laboratory testing and health care professional time) based on unit prices. The base-case analysis assumed 14 days of antibiotic treatment for both agents; five days in hospital followed by nine days at home. Therapy duration, length of inpatient treatment and discharge rates were varied in sensitivity analyses.

RESULTS:

Antibiotic costs were higher for linezolid than for vancomycin, for both inpatient ($874 versus $144, respectively) and outpatient therapy ($1,356 versus $1,242, respectively). Compared with vancomycin, lower costs for antibiotic preparation, administration and monitoring of linezolid offset drug acquisition costs. Total treatment costs were $3,850 for linezolid versus $5,189 for vancomycin. Results were sensitive to the number of treatment days spent at home and the discharge rate.

CONCLUSION:

Using linezolid instead of vancomycin to treat MRSA-related cSSSI, for hospital and home courses combined, may reduce health care resource utilization and costs in Quebec.     

Clinical and Economic Outcomes Associated with Medication Errors in Kidney Transplantation

Background and objectives

Modern immunosuppressant regimens have significantly decreased acute rejection rates, but may have increased the risk of graft loss driven by adverse drug reactions (ADRs) and medication errors (MEs). The objectives of this study were to determine the incidence and risk factors for MEs and ADRs and determine the association between transplant outcomes and these events.

Design, setting, participants, & measurements

This was a post hoc analysis of a prospective, randomized trial that included patients aged>18 years that received a solitary renal transplant at an academic medical center recruited between March 2009 and July 2011. Patients were divided into groups based on developing a clinical significant ME (CSME), defined as a significant ME that contributed to a hospital admission.

Results

The mean study follow-up was 2.5±0.7 years. There were a total of 233 MEs and 327 ADRs in the 200 patients included in the analysis, with 64% of the cohort experiencing at least one ME and 87% experiencing an ADR; 23 patients (12%) experienced a CSME. Patients that experienced CSMEs had a trend toward more post-transplant readmissions (median 1 [interquartile range (IQR), 0–5] versus 0 [0–2]; P=0.06), higher costs for readmissions (median $18,091 [IQR, $3023–$56,268] versus $0 [$0–$15,991]; P<0.01), and overall length of stay (median 5.0 days [IQR, 2.0–14.0] versus 0.0 days [IQR, 0.0–5.5]; P<0.01) after the CSME event. CSME patients were also more likely to experience graft failure (22% versus 10%; P=0.05).

Conclusions

Significant MEs commonly occur in renal transplant recipients and are associated with an increased risk of deleterious clinical outcomes, including subsequent hospital days, costs, and graft loss.     

Arginine-directed glycation and decreased HDL plasma concentration and functionality

Background/Objectives:

Decreased plasma concentration of high-density lipoprotein cholesterol (HDL-C) is a risk factor linked to increased risk of cardiovascular disease (CVD). Decreased anti-atherogenic properties of HDL are also implicated in increased CVD risk. The cause is unknown but has been linked to impaired glucose tolerance. The aim of this study was to quantify the modification of HDL by methylglyoxal and related dicarbonyls in healthy people and patients with type 2 diabetes characterise structural, functional and physiological consequences of the modification and predict the importance in high CVD risk groups.

Subjects/Methods:

Major fractions of HDL, HDL2 and HDL3 were isolated from healthy human subjects and patients with type 2 diabetes and fractions modified by methylglyoxal and related dicarbonyl metabolites quantified. HDL2 and HDL3 were glycated by methylglyoxal to minimum extent in vitro and molecular, functional and physiological characteristics were determined. A one-compartment model of HDL plasma clearance was produced including formation and clearance of dicarbonyl-modified HDL.

Results:

HDL modified by methylglyoxal and related dicarbonyl metabolites accounted for 2.6% HDL and increased to 4.5% in patients with type 2 diabetes mellitus (T2DM). HDL2 and HDL3 were modified by methylglyoxal to similar extents in vitro. Methylglyoxal modification induced re-structuring of the HDL particles, decreasing stability and plasma half-life in vivo. It occurred at sites of apolipoprotein A-1 in HDL linked to membrane fusion, intramolecular bonding and ligand binding. Kinetic modelling of methylglyoxal modification of HDL predicted a negative correlation of plasma HDL-C with methylglyoxal-modified HDL. This was validated clinically. It also predicted that dicarbonyl modification produces 2–6% decrease in total plasma HDL and 5–13% decrease in functional HDL clinically.

Conclusions:

These results suggest that methylglyoxal modification of HDL accelerates its degradation and impairs its functionality in vivo, likely contributing to increased risk of CVD—particularly in high CVD risk groups.     

Folic Acid Therapy and Cardiovascular Disease in ESRD or Advanced Chronic Kidney Disease: A Meta-Analysis

Summary

Background and objectives

The efficacy of folic acid therapy to lower homocysteine (Hcy) levels in an effort to reduce cardiovascular disease (CVD) risk in patients with ESRD or advanced chronic kidney disease (ACKD; creatinine clearance, <30 ml/min) remains inconclusive. We conducted a meta-analysis of relevant randomized trials to further examine this issue.

Design, setting, participants, & measurements

This meta-analysis included 3886 patients with ESRD/ACKD from seven qualified randomized trials using folic acid therapy and with CVD reported as one of the end points.

Results

When pooling the seven trials, folic acid therapy reduced the risk of CVD by 15% (RR, 0.85; 95% CI, 0.76 to 0.96; P = 0.009). A greater beneficial effect was observed among those trials with a treatment duration >24 months (RR, 0.84; 95% CI, 0.72 to 0.98; P = 0.02), a decrease in Hcy level >20% (RR, 0.83; 95% CI, 0.73 to 0.95; P = 0.007), and no or partial folic acid fortification (RR, 0.80; 95% CI, 0.65 to 0.99; P = 0.04). The beneficial effect also was seen when Hcy levels decreased >20%, even in the presence of folic acid fortification (RR, 0.85; 95% CI, 0.73 to 0.99; P = 0.04). In the corresponding comparison groups, the estimated RRs were attenuated and insignificant.

Conclusions

Folic acid therapy can reduce CVD risk in patients with ESRD/ACKD by 15%. A greater beneficial effect was observed among those trials with no or partial folic acid fortification or a decrease in Hcy level >20% regardless of folic acid fortification.     

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

Background and objectives

The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)—the largest non–fee-for-service health system in the United States.

Design, setting, participants, & measurements

The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m².

Results

The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m² increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001).

Conclusions

Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.     

Inflammatory bowel disease: A Canadian burden of illness review

BACKGROUND:

Inflammatory bowel diseases (IBD) – Crohn’s disease (CD) and ulcerative colitis (UC) – significantly impact quality of life and account for substantial costs to the health care system and society.

OBJECTIVE:

To conduct a comprehensive review and summary of the burden of IBD that encompasses the epidemiology, direct medical costs, indirect costs and humanistic impact of these diseases in Canada.

METHODS:

A literature search focused on Canadian data sources. Analyses were applied to the current 2012 Canadian population.

RESULTS:

There are approximately 233,000 Canadians living with IBD in 2012 (129,000 individuals with CD and 104,000 with UC), corresponding to a prevalence of 0.67%. Approximately 10,200 incident cases occur annually. IBD can be diagnosed at any age, with typical onset occurring in the second or third decade of life. There are approximately 5900 Canadian children <18 years of age with IBD. The economic costs of IBD are estimated to be $2.8 billion in 2012 (almost $12,000 per IBD patient). Direct medical costs exceed $1.2 billion per annum and are driven by cost of medications ($521 million), hospitalizations ($395 million) and physician visits ($132 million). Indirect costs (society and patient costs) total $1.6 billion and are dominated by long-term work losses of $979 million. Compared with the general population, the quality of life patients experience is low across all dimensions of health.

CONCLUSIONS:

The present review documents a high burden of illness from IBD due to its high prevalence in Canada combined with high per-patient costs. Canada has among the highest prevalence and incidence rates of IBD in the world. Individuals with IBD face challenges in the current environment including lack of awareness of IBD as a chronic disease, late or inappropriate diagnosis, inequitable access to health care services and expensive medications, diminished employment prospects and limited community-based support.     

Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis

Background

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative to conventional surgery (CS). We aimed to estimate the short-term cost-effectiveness of VATS vs. CS for clinical stage I non-small cell lung cancer (NSCLC-c-stage-I) patients from the payer’s perspective (National Health Insurance).

Methods

We identified NSCLC-c-stage-I patients diagnosed and received surgery within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was 1 year. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment.

Results

Our study population constituted 966 patients. The mean hospital stay [days, standard deviation (SD)] were 14.4 [7] and 16.1 (7.7) for VATS and CS respectively (P=0.002). The mean cost (2013 USD) and survival (year) was $22,316 vs. $21,976 and 0.98 vs. 0.974 for VATS vs. CS. The probability for VATS to be cost-effective (i.e., positive net benefit) was 0.49 & 0.56 at willingness-to-pay (WTP) 50,000 & 100,000 USD/life-year, respectively.

Conclusions

We provide the first empirical evidence that when compared to CS, VATS was potentially cost-effective in the short term (1 year) within the common WTP levels in Taiwan.     

The cost of lung cancer in Alberta

BACKGROUND:

Lung cancer is the leading cause of cancer morbidity and mortality. In addition, lung cancer has a significant economic impact on society.

OBJECTIVE:

To present an economic analysis of the actual care costs of lung cancer which will allow comparison with, and verification of, cost estimates that were developed through modelling and opinion.

METHODS:

A chart review was conducted of incident cases (circa 1998) of primary bronchogenic lung cancer. Cases were censored at two years from the date of diagnosis. Relevant clinical and health utilization data were collected. Health utilization data included hospital and institutional outpatient (ie, ambulatory clinic) costs. Cost estimates were derived for over 200 specific health services. The present analysis was performed from the economic perspective of the health care institution.

RESULTS:

A total of 13,389 health service events were captured with an estimated total cost of $8.4 million. Laboratory tests, diagnostic imaging and ambulatory visits constituted 86% of the service events while patient admissions and therapy constituted 76% of the costs. The vast majority of overall costs occurred just before, or within, three months of diagnosis. The median nonsmall cell lung cancer and small cell lung cancer case costs were $10,928 (range $9,234 to $11,047) and $15,350 (range $13,033 to $21,436), respectively.

CONCLUSION:

The results agree with the literature that the majority of lung cancer case costs are realized around the date of diagnosis (ie, early phase). The present study illustrates Canadian health care system lung cancer case costs based on actual care received versus hypothetical care algorithms.     

Mobile Health and Diabetes: Telemedicine Diabetes Consultations Are Cost-Effective,and Effects on Essential Diabetes Treatment Parameters Are Similar to Conventional Treatment: 7-Year Results from the Svendborg Telemedicine Diabetes Project

Background

The increasing number of patients with diabetes poses a major challenge for the health care system. One instrument to meet these challenges could be the use of telemedicine, which, at the same time, may reduce treatment costs. Since 2005, diabetes patients on the island of Aeroe have been offered expert diabetes care using teleconsultations. This article describes the impact of the telemedicine solution on essential diabetes treatment parameters, patient satisfaction, and cost-effectiveness.

Methods

Telemedicine consultations were conducted with the patient and nurse specialist placed in a consultation room of Aeroe Hospital in audiovisual contact with the physician situated at the hospital on the mainland. Consultations were supported by an electronic patient record and a Web-based quality-monitoring diabetes database.

Results

Inclusion criteria in this retrospective study were at least 6 months of telemedicine diabetes control with a minimum of two visits and two hemoglobin A1c (HbA1c) values. Results were compared with data from the Danish National Diabetes Registry (DVDD). Data are given in medians. In total, 23 type 1 diabetes mellitus (T1DM) patients, aged 65 (56–74) versus 48 years, diabetes duration 21.0 (10.7–31.3) versus 20.5 years, and 55 type 2 diabetes mellitus (T2DM) patients, aged 67 (64–70) versus 65 years, diabetes duration 14.0 (10.5–17.5) versus 11.7 years, were included. After teleconsultation, HbA1c in T1DM patients was 8.0% (7.4–8.6%) versus 7.9% [64 (57–71) versus 63 mmol/mol], not significant, and in T2DM patients was 7.4% (7.1–7.7%) versus 7.6% [57 (54–61) versus 60 mmol/mol], p <.05. Body mass index, blood pressure, and lipid values were comparable with the DVDD. Patient satisfaction was especially related to the major reduction in transportation time (7 h). Reductions in traveling costs and saved working days were the most important factors in making the telemedicine set-up economically efficient.

Conclusion

Telemedicine consultation for remote outpatient diabetes control is feasible, and the interdisciplinary interventions achieved high treatment quality results in essential diabetes treatment parameters. In addition, the telemedicine set-up was associated with improved cost-effectiveness and patient satisfaction.