Economic Evaluation of the Combined Use of Warfarin and Low-dose Aspirin Versus Warfarin Alone in Mechanical Valve Prostheses

Background

The use of combined therapy of antiplatelet and anticoagulant versus anticoagulant alone to reduce instances of thromboembolic events in patients with heart valve prostheses is an established standard of care in many countries but not in Egypt. A previous Markov model cost-effectiveness study on Egyptian patients aged 50–60 years demonstrated that the combined therapy reduces the overall treatment cost. However, due to the lack of actual real-world data on cost-effectiveness and the limitation of the Markov model study to 50- to 60-year-old patients, the Egyptian medical community is still questioning whether the added benefit is worth the cost.

Objective

To assess, from the perspective of the Egyptian health sector, the cost-effectiveness of the combined use of warfarin and low-dose aspirin (75 mg) versus that of warfarin alone in patients with mechanical heart valve prostheses who began therapy between the age of 15 and 50 years.

Methods

An economic evaluation was conducted alongside a randomized, controlled trial to assess the cost-effectiveness of the combined therapy in patients with mechanical valve prostheses. A total of 316 patients aged between 15 and 50 years were included in the study and randomly assigned to a group treated with both warfarin and aspirin or a group treated with warfarin alone.

Results

The patients in the combined therapy group exhibited a significantly longer duration of protection against the first event. Fewer primary events were observed in the patients treated with warfarin plus aspirin than in those treated with warfarin alone (1.4 %/year, vs. 4.8 %/year), and a higher mean quality-adjusted life-years (QALYs) value over 4 years was obtained for the group treated with warfarin plus aspirin (difference 0.058; 95 % CI 0.013–0.118), although this difference did not reach a conventional level of statistical significance. The total costs over a 4-year period were lower with the combined therapy (difference ?US$244; 95 % CI ?US$483.1 to ?US$3.8), which yielded an incremental cost-effectiveness ratio of ?US$4206 per QALY gained. Thus, the combined therapy was dominant. All costs were reported in US dollars (USD) for the financial year 2014.

Conclusions

The results of this analysis indicate that from the perspective of the Egyptian health sector, the addition of aspirin to the typical warfarin therapy is more effective and less costly for patients with mechanical valve prostheses than treatment with warfarin alone. This combined strategy could be adopted to prevent the complications of mechanical valve prostheses. Our study adds to the body of evidence supporting the option of warfarin-plus-aspirin therapy for patients with mechanical valve prostheses.

     

Socioeconomic costs of rheumatic diseases. Implications for technology assessment

OBJECTIVES: To study the socioeconomic impact of rheumatic illness in Sweden and to discuss the consequences for technology assessment studies. METHODS: A cost-of-illness study based on data from official statistics and treatment studies. RESULTS: The total socioeconomic cost was 52 billion Swedish kronor (SEK) in 1994. The imbalance between direct (10% of total) and indirect costs (90 effectiveness of the healthcare sector, the need for new treatment methods, appropriate information systems, and technology assessment studies as well as the institutional arrangements for rehabilitation and basic medical research. CONCLUSIONS: A discussion of solutions for financial cooperation between county councils and regional social insurance offices should be considered. The new biotechnological pharmaceuticals will increase the cost for drugs in health care about 20 times, but the total socioeconomic cost for society may remain at the same level due to a decrease of inpatient costs and indirect costs for loss of production as well as a decrease of transfer payments from social insurance. It is unavoidable that the new pharmaceuticals require priority discussions and active resource allocation in health care and in other sectors of society.     

Socioeconomic Status of Newborns and Hospital Efficiency: Implications for Hospital Payment Methods

ObjectivesStudies have shown a consistent impact of socioeconomic status at birth for both mother and child; however, no study has looked at its impact on hospital efficiency and financial balance at birth, which could be major if newborns from disadvantaged families have an average length of stay (LOS) longer than other newborns. Our objective was therefore to study the association between socioeconomic status and hospital efficiency and financial balance in that population.MethodsA study was carried out using exhaustive national hospital discharge databases. All live births in a maternity hospital located in mainland France between 2012 and 2014 were included. Socioeconomic status was estimated with an ecological indicator and efficiency by variations in patient LOS compared with different mean national LOS. Financial balance was assessed at the admission level through the ratio of production costs and revenues and at the hospital level by the difference in aggregated revenues and production costs for said hospital. Multivariate regression models studied the association between those indicators and socioeconomic status.ResultsA total of 2 149 454 births were included. LOS was shorter than the national means for less disadvantaged patients and longer for the more disadvantaged patients, which increased when adjusted for gestational age, birth weight, and severity. A 1% increase in disadvantaged patients in a hospital’s case mix significantly increased the probability that the hospital would be in deficit by 2.6%.ConclusionsReforms should be made to hospital payment methods to take into account patient socioeconomic status so as to improve resource allocation efficiency.     

Medicaid and Long-Term Care for the Elderly: Implications of Restructuring

Because it absorbs about a third of Medicaid spending, long-term care would be affected by any major changes in the financing or structure of this federal–state program. Analysis of the implications for long-term care of the Medicaid restructuring proposals that Congress considered in the 1995–96 federal budget debate leads to this conclusion: the fiscal pressure and incentives that would be created by fixed dollar or block grants, or by limits on federal spending per beneficiary (per capita caps), when combined with enhanced state flexibility in program design, could significantly hinder service choice and quality, reduce access to care, and increase out-of-pocket payments by Medicaid beneficiaries or their families.     

Depression in Public Community Long-Term Care: Implications for Intervention Development

The objective of this paper is to increase understanding of geriatric depression in the public community long-term care system to guide intervention development. Protocols included screening 1,170 new clients of a public community long-term care agency and interviewing all clients with major, dysthymia, or subthreshold depression (n = 299) and a randomly selected subset of nondepressed older adults (n = 315) at baseline, 6-month, and 1 year. Six percent had major depression, one-half of a percent had dysthymia only, and another 19% had subthreshold depression. Over the year observation period, 40% were persistently depressed; 32% were assessed as depressed only at the first observation; and the remainder was intermittently depressed. There were high levels of comorbid medical, functional, and psychosocial conditions. Mental health service use was low, and clients reported attitudinal and other barriers to depression treatment. Findings suggest the need for universal screening for depression with some strategies for triaging the most severely and persistently depressed for treatment. Although there will be challenges to the development of depression interventions, the public community long-term care system has high potential to assist vulnerable older adults receive help with depression. Presented at Improving Chronic Care Quality Conference, Columbia, Missouri, September. 2004.     

Long-Term Care Use During the Last 2 Years of Life in Sweden: Implications for Policy to Address Increased Population Aging

ObjectivesTo map out the total use of long-term care (LTC; ie, home care or institutional care) during the last 2 years of life and to investigate to what extent gender differences in LTC use were explained by cohabitation status and age at death.DesignThe National Cause of Death Register was used to identify decedents. Use of LTC was based on the Social Services Register (SSR) and sociodemographic factors were provided by Statistics Sweden.Setting and ParticipantsAll persons living in Sweden who died in November 2015 aged ≥67 years (n = 5948).MethodsZero inflated negative binomial regression was used to estimate the relative impact of age, gender, and cohabitation status on the use of LTC.ResultsWomen used LTC to a larger extent [odds ratio (OR) 2.17, 95% confidence interval (CI) 1.92-2.50] and for a longer period [risk ratio (RR) 1.14, 95% CI 1.11-1.18] than men. When controlling for age at death and cohabitation status, gender differences in LTC attenuated (OR 1.47, 95% CI 1.28-1.72) and vanished in regard to the duration. In the controlled model, women used LTC for 15.6 months (95% CI 15.2-16.0) and men for 14.1 months (95% CI 13.7-14.5) out of 24 months. The length of stay in institutional care was 7.2 (95% CI 6.8-7.5) and 6.2 months (95% CI 5.8-6.6), respectively.Conclusions and ImplicationsA substantial part of women's greater use of LTC was due to their higher age at death and because they more often lived alone. Given that survival continues to increase, the association between older age at death and LTC use suggests that policy makers will have to deal with an increased pressure on the LTC sector. Yet, increased survival among men could imply that more women will have access to spousal caregivers, although very old couples may have limited capacity for extensive caregiving at the end of life.     

Warfarin necrosis.

Skin and subcutaneous tissue necrosis is a rare complication of warfarin therapy. Although the incidence is low, with increased use of warfarin family physicians need to be aware of this potentially catastrophic event. This article reviews the history of warfarin necrosis and discusses its clinical presentation. The histologic findings with necrosed lesions are described, with emphasis on the possible pathogenesis of this disorder. Treatment options based on existing clinical experience as outlined in the literature are discussed.     

Challenges in Tracking and Reporting Antibiotic Use in Long-Term Care

The contemporary long-term care provider and interdisciplinary team are well aware of the recent focus on antibiotic use in their settings. Regulatory changes implemented by Centers for Medicare and Medicaid Services beginning in 2016 have required long-term care settings to look at antibiotic use in a more comprehensive way and to align their programs with the Centers for Disease Control and Prevention's Core Elements for Antibiotic Stewardship for Nursing Homes. As long-term care settings have worked to develop antibiotic stewardship programs over the past several years, there have been many discoveries about the processes involved in gathering data about antibiotic use and associated attributes, including dose, duration of therapy, and indication for use. Attempts to align these attributes with appropriateness may require integration of data elements from pharmacy records and the individual resident's electronic medical record. In this article, we systematically discuss relevant antibiotic use metrics, sources of antibiotic use data, collecting and reporting antibiotic use data, concluding with implications for policy, practice, and research. Only by measuring antibiotic use can we start to assess the effectiveness of antibiotic stewardship program to induce meaningful change in the care of residents in long-term care.     

Lipid Emulsion Use in Pediatric Patients Requiring Long-Term Parenteral Nutrition

The ability to deliver nutrients via parenteral nutrition (PN) has markedly improved the prognosis of infants and children with intestinal failure. Technical refinements and advances in knowledge have led to the development of highly sophisticated PN solutions that are tailored to meet the needs of pediatric patients. However, children who require long-term PN have an increased risk of complications such as catheter-related sepsis, liver disease, and bone disease. Although the pathogenesis of intestinal failure associated liver disease (IFALD) is multifactorial, studies have identified a possible link between the dose of lipid emulsions based on soybean oil and cholestasis, shown to occur with a significantly higher frequency in patients receiving >1 g lipids/kg/d. Potential contributing factors include oxidative stress, high ω-6 polyunsaturated fatty acid (PUFA) and phytosterol content, and relatively low α-tocopherol levels. Lipid emulsions containing fish oil offer potential advantages compared with traditional emulsions with a high soybean oil content, such as decreased ω-6 and increased ω-3 PUFA concentrations, high concentrations of α-tocopherol, and reduced phytosterol content. Studies in PN-dependent children at risk for IFALD have shown that lipid emulsions containing fish oil reduce the risk of cholestasis and improve biochemical measures of hepatobiliary function compared with pure soybean oil emulsions. This review summarizes evidence regarding the role of lipid emulsions in the management of pediatric patients with intestinal failure requiring long-term PN, with a particular focus on the prevention and treatment of IFALD.     

Diminished Alternative Reinforcement as a Mechanism Underlying Socioeconomic Disparities in Adolescent Substance Use

ObjectiveThis study examined socioeconomic disparities in adolescent substance use utilizing a behavioral economic theoretical framework. We tested the hypothesis that teens of lower (vs. higher) socioeconomic status (SES) are vulnerable to substance use because they engage in fewer pleasurable substance-free activities that provide reinforcement and may deter substance use.MethodIn a cross-sectional correlational design, 9th grade students (N = 2839; mean age = 14.1 years) in Los Angeles, California, USA completed surveys in Fall 2013 measuring SES (i.e., parental education), alternative reinforcement (engagement in pleasurable substance-free activities, e.g., hobbies), substance use susceptibility, initiation, and frequency, and other factors.ResultsFor multi-substance composite outcomes, lower parental education was associated with greater likelihood of substance use initiation in the overall sample, frequency of use among lifetime substance users, and susceptibility to substance use in never users. Substance-specific analyses revealed that lower parental education was associated with higher likelihood of initiating cigarettes, alcohol, and marijuana use as well as greater susceptibility to use cigarettes in never smokers. Each inverse association between parental education and substance-related outcomes was statistically mediated by diminished alternative reinforcement; lower parental education was associated with lower engagement in alternative reinforcers, which, in turn, was associated with greater substance use susceptibility, initiation, and frequency.ConclusionThese results point to a behavioral economic interpretation for socioeconomic disparities in adolescent substance use. Replication and extension of these findings would suggest that prevention programs that increase access to and engagement in healthy and fun activities may reduce youth socioeconomic health disparities related to substance use.     

Nutritional Implications of Reduced-Fat Food Use by Free-Living Consumers

The nutritional implications of the purchase and consumption of reduced-fat foods at home were assessed in normal-weight, free-living consumers in a 6-week intervention study. Control (n=14) and experimental (n=15) subjects kept 4-day weighed food diaries to establish energy and macronutrient intake at baseline and experimental weeks 2, 4 and 6. The control group continued their habitual diet throughout the study whereas the experimental group used reduced-fat foodsad libitumin place of the traditionally high-fat counterparts that they usually consumed. All subjects purchased the majority of their groceries from the same food store and were reimbursed for a proportion of their grocery bill. Repeated-measures analysis of variance indicated that the experimental group, compared to the control group, significantly reduced their percentage of energy from fat (from 38·3±1·8 to 30·4±1·7), but increased the percentage of energy from protein (p=0·06) and carbohydrate (p=0·019) such that changes in total energy intake were not statistically significantly different between conditions. Nevertheless, the experimental group lost 1·1 kg (while the control group gained 0·4 kg) in the first 4 weeks of the study, consistent with the observed reduction in energy intake, though no further body weight changes were seen in week 6. This study suggests that although use of reduced-fat foods may have short-term effects on energy balance, long-term sustained reduction in energy intake may be limited if this dietary strategy is used in isolation.     

Long-Term Opioid Use and Dementia Risk in Patients With Chronic Pain

ObjectiveThis study aimed to investigate the association between long-term opioid use and the risk of dementia in patients with chronic pain.DesignA head-to-head propensity score–matched (PSM) comparative cohort study was conducted to examine the effect of long-term opioid use on dementia risk. A time-varying Cox regression analysis was performed to calculate adjusted hazard ratios (aHRs) with 95% CIs to identify independent predictors of dementia risk.Setting and ParticipantsThe study included 41,636 patients after PSM, with 20,968 in the opioid use group (≥180 defined daily doses per year) and 20,968 in the non–opioid use group.MethodsMultivariate Cox regression analysis was conducted to compare the dementia risk between the opioid use and non–opioid use groups. The incidence of dementia was calculated as the number of cases per 10,000 person-years for each group. Adjusted incidence ratios were determined to assess the dementia risk associated with opioid use.ResultsThe multivariate Cox regression analysis showed that the aHR for dementia risk in the opioid use group, compared with the non–opioid use group, was 1.86 (95% CI 1.25-2.09; P < .001). The incidence of dementia was higher among opioid users (44.09 per 10,000 person-years) compared with nonusers (38.85 per 10,000 person-years). The adjusted incidence ratio for dementia risk in the opioid use group, compared with the nonuse group, was 1.13 (95% CI: 1.07-1.21, P < .001).Conclusions and ImplicationsLong-term opioid use may be associated with an increased risk of dementia in patients with chronic pain. These findings highlight the need for cautious prescribing and monitoring of opioid use in this population, considering the potential long-term cognitive implications.     

Alcohol Use and Implications for Public Health: Patterns of Use in Four Communities

Background:

Alcohol is one of the leading causes of death and disability globally and in India. Information on quantum and pattern of consumption is crucial to formulate intervention programs.

Objectives:

To identify the extent and pattern of alcohol use in urban, rural, town and slum populations using a uniform methodology.

Materials and Methods:

Door-to-door survey was undertaken and simple random sampling methodology was adopted; households were the primary sampling unit. One respondent in each alcohol-user household was randomly chosen for detailed interview.

Results:

Overall, 13% of males and females consumed alcohol. Proportion of users was greater in town (15.7%) and among 26–45 years (67.4%). Whisky (49%) and arrack (35%) were the preferred types and the preferences differed between rural (arrack) and urban (beer) areas. Nearly half (45%) of rural population were very frequent users (consuming daily or every alternate-days) as against users in town (23%) or slum (20%). Two-thirds were long-term users and the proportions were greater in the rural and town areas. While, overall 17% of the users were heavy-users, frequent-heavy-drinking was more in slum and rural areas. Nearly two-thirds consumed alcohol in liquor-shops, restaurants, bars and pubs. Habituation and peer-pressure were the key reasons for alcohol use.

Conclusions:

The study documented alcohol use and patterns of use in four different communities particularly in transitional areas using similar methodology. Many of the patterns identified are detrimental to health both immediate and over the long period of time.     

Socioeconomic Pathogenicity

The following letter is directed to Gro Harlem Brundtland, former Prime Minister of Norway, who assumed the position of Director- General of the World Health Organization on July 21,1998.     

Disparities in Hormone Replacement Therapy Use by Socioeconomic Status in a Primary Care Population

The use of hormone replacement therapy (HRT) is a controversial decision for many women, yet few studies have evaluated the socio-demographic, psychological, and behavioral correlates of HRT use. This cross-sectional, mailed survey evaluated the associations of socioeconomic status, preventive health behaviors, knowledge and perceptions about HRT-related risks and benefits with HRT use among 428 women 50–70 years old in Vermont. The overall prevalence of HRT use was 40%. Women of moderate to high income were three times more likely than those of low income to use HRT. HRT use was significantly higher among women whose physician had encouraged use (58%) than among those who received ambivalent recommendations from their physicians (20%). Hysterectomy, higher income, younger age, regular adherence to cervical cancer screening, and recommendation by a provider were significantly associated with HRT use in multivariate analyses. There were no differences in HRT use according to level of concern about heart disease, osteoporosis, or breast cancer. A recommendation by a health care provider is a powerful predictor of HRT use, but disparities in use exist by socioeconomic status. Future research should examine why lower income women are less likely to use HRT and whether the discrepancy is due to inconsistent recommendations by health care providers.