Economic Burden of Acute Gastroenteritis among Members of Integrated Healthcare Delivery System, United States, 2014-2016.

We conducted a large surveillance study among members of an integrated healthcare delivery system in Pacific Northwest of the United States to estimate medical costs attributable to medically attended acute gastroenteritis (MAAGE) on the day care was sought and during 30-day follow-up. We used multivariable regression to compare costs of MAAGE and non-MAAGE cases matched on age, gender, and index time. Differences accounted for confounders, including race, ethnicity, and history of chronic underlying conditions. Analyses included 73,140 MAAGE episodes from adults and 18,617 from children who were Kaiser Permanente Northwest members during 2014-2016. Total costs were higher for MAAGE cases relative to non-MAAGE comparators as were costs on the day care was sought and costs during follow-up. Costs of MAAGE are substantial relative to the cost of usual-care medical services, and much of the burden accrues during short-term follow-up.

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care.

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

Should major trauma fractures be part of a fracture liaison service's remit: a cost-benefit estimate.

The refracture rate after major trauma is approximately half (57%) the refracture rate after a minimal trauma injury. Extending Fracture Liaison Service activity to include major trauma patients creates significant additional direct cost, but remains essentially cost neutral if notional savings through refracture risk reduction are taken into account. PURPOSE: To compare the 3-year refracture rate following minimal trauma (MT) and non-minimal trauma (non-MT) injuries and evaluate the cost of extending fracture liaison service (FLS) operations to non-MT presentations. METHODS: Patients aged 50, or above presenting to the John Hunter Hospital with a fracture in calendar year 2018 were identified through the Integrated Patient Management System (IPMS) of the Hunter New England Health Service's (HNEHS), and re-presentation to any HNEHS facility over the following 3 years monitored. The refracture rate of MT and non-MT presentations was compared and analysed using Cox proportional hazards regression models. The cost of including non-MT patients was estimated through the use of a previously conducted micro-costing analysis. The operational fidelity of the FLS to the previous estimate was confirmed by comparing the 3-year refracture rate of MT presentations in the two studies. RESULTS: The 3-year refracture rate following a MT injury was 8% and after non-MT injury 4.5%. Extension of FLS activities to include non-MT patients in 2022 would have cost an additional $198,326 AUD with a notional loss/saving of $ - 26,625/ + 26,913 AUD through refracture risk reduction. No clinically available characteristic at presentation predictive of increased refracture risk was identified. CONCLUSION: The 3-year refracture after a non-MT injury is about half (57%) that of the refracture rate after a MT injury. Extending FLS activity to non-MT patients incurs a significant additional direct cost but remains cost neutral if notional savings gained through reduction in refracture risk are taken into account.

Costs and Productivity Benefits of the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks Act Scribes Trial.

OBJECTIVES: To improve access, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 mandated a 2-year study of medical scribes in Veterans Health Administration specialty clinics and emergency departments. Medical scribes are employed in clinical settings with the goals of increasing provider productivity and satisfaction by minimizing physicians' documentation burden. Our objective is to quantify the economic outcomes of the MISSION Act scribes trial. METHODS: A cluster-randomized trial was designed with 12 Department of Veterans Affairs (VA) medical centers randomized into the intervention. We estimated the total cost of the trial, cost per scribe-year, and projected cost of hiring additional physicians to achieve the observed scribe productivity benefits in relative value units and visits per full-time-equivalent over the 2-year intervention period (June 30, 2020 to July 1, 2022). RESULTS: The estimated cost of the trial was $4.6 million, below the Congressional Budget Office estimate of $5 million. A full-time scribe-year cost approximately $74 600 through contracting and $62 900 through VA hiring. Randomization into the trial led to an approximate 30% increase in productivity in cardiology and 20% in orthopedics. The projected incremental cost of using additional physicians instead of scribes to achieve the same productivity benefits was nearly $1.7 million more, or 75% higher, than the observed cost of scribes in cardiology and orthopedics. CONCLUSIONS: As the largest randomized trial of scribes to date, the MISSION Act scribes trial provides important evidence on the costs and benefits of scribes. Improving productivity enhances access and scribes may give VA a new tool to improve productivity in specialty care at a lower cost than hiring additional providers.

Assessing the cost-effectiveness of integrated case management of Neglected Tropical Diseases in Liberia.

BACKGROUND: In 2017, Liberia became one of the first countries in the African region to develop and implement a national strategy for integrated case management of Neglected Tropical Diseases (CM-NTDs), specifically Buruli ulcer, leprosy, lymphatic filariasis morbidities, and yaws. Implementing this plan moves the NTD program from many countries' fragmented (vertical) disease management. This study explores to what extent an integrated approach offers a cost-effective investment for national health systems. METHODS: This study is a mixed-method economic evaluation that explores the cost-effectiveness of the integrated CM-NTDs approach compared to the fragmented (vertical) disease management. Primary data were collected from two integrated intervention counties and two non-intervention counties to determine the relative cost-effectiveness of the integrated program model vs. fragmented (vertical) care. Data was sourced from the NTDs program annual budgets and financial reports for integrated CM-NTDs and Mass Drug Administration (MDA) to determine cost drivers and effectiveness. RESULTS: The total cost incurred by the integrated CM-NTD approach from 2017 to 2019 was US$ 789,856.30, with the highest percentage of costs for program staffing and motivation (41.8%), followed by operating costs (24.8%). In the two counties implementing fragmented (vertical) disease management, approximately US$ 325,000 was spent on the diagnosis of 84 persons and the treatment of twenty-four persons suffering from NTDs. While 2.5 times as much was spent in integrated counties, 9-10 times more patients were diagnosed and treated. CONCLUSIONS: The cost of a patient being diagnosed under the fragmented (vertical) implementation is five times higher than integrated CM-NTDs, and providing treatment is ten times as costly. Findings indicate that the integrated CM-NTDs strategy has achieved its primary objective of improved access to NTD services. The success of implementing an integrated CM-NTDs approach in Liberia, presented in this paper, demonstrates that NTD integration is a cost-minimizing solution.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

The value of the modern vascular surgeon to the health care system: A report from the Society for Vascular Surgery Valuation Work Group.

Vascular surgeons provide an important service to the health care system. They are capable of treating a wide range of disease processes that affect both the venous and arterial systems. Their presence broadens the complexity and diversity of services that a health care system can offer both in the outpatient setting and in the inpatient setting. Because of their ability to control hemorrhage, they are critical to a safe operating room environment. The vascular surgery service line has a positive impact on hospital margin through both the direct vascular profit and loss and the indirect result of assisting other surgical and medical services in providing care. The financial benefits of a vascular service line will hold true for a wide range of alternative payment models, such as bundled payments or capitation. To fully leverage a modern vascular surgeon's skill set, significant investment is required from the health care system that is, however, associated with substantial return on the investment.

Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach.

BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Analyzing Cost-Effectiveness of Allocating Neurointerventionist for Drive and Retrieve System for Patients with Acute Ischemic Stroke.

OBJECTIVES: There are regional disparities in implementation rates of endovascular thrombectomy due to time and resource constraints such as endovascular thrombectomy specialists. In Hokkaido, Japan, Drive and Retrieve System (DRS), where endovascular thrombectomy specialists perform early endovascular thrombectomies by traveling from the facilities where they normally work to facilities closer to the patient. This study analyzed the cost-effectiveness of allocating a endovascular thrombectomy specialist for DRS to treat stroke patients. MATERIALS AND METHODS: he number of ischemic stroke patients expected to receive endovascular thrombectomy in Hokkaido in 2015 was estimated. It was assumed that an additional neutointerventionist was allocated for DRS. The analysis was performed from the government's perspective, which includes medical and nursing-care costs, and the personnel cost for endovascular thrombectomy specialist. The analysis was conducted comparing the current scenario, where patients received endovascular thrombectomy in facilities where endovascular thrombectomy specialists normally work, with the scenario with DRS within 60 min drive distance. Patient transport time was analyzed using geographic information system, and patient severity was estimated from the transport time. The primary outcome was incremental cost-effectiveness ratio (ICER) in each medical area which was calculated from the incremental costs and the incremental quality-adjusted life years (QALYs), estimated from patient severity using published literature. The entire process was repeated 100 times. RESULTS: DRS was most cost-effective in Kamikawachubu area, where the ICER was $14,173±16,802/QALY, significantly lower than the threshold that the Japanese guideline suggested. CONCLUSIONS: Since DRS was cost-effective in Kamikawachubu area, the area should be prioritized when a endovascular thrombectomy specialist for DRS is allocated as a policy.

Telestroke Across the Continuum of Care: Lessons from the COVID-19 Pandemic.

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Expedited and Comprehensive Management of Low-Risk TIA Patients in the Emergency Department is Safe and Less Costly.

OBJECTIVES: Transient ischemic attack (TIA) can be a warning sign of an impending stroke. The objective of our study is to assess the feasibility, safety, and cost savings of a comprehensive TIA protocol in the emergency room for low-risk TIA patients. MATERIALS AND METHODS: This is a retrospective, single-center cohort study performed at an academic comprehensive stroke center. We implemented an emergency department-based TIA protocol pathway for low-risk TIA patients (defined as ABCD2 score < 4 and without significant vessel stenosis) who were able to undergo vascular imaging and a brain MRI in the emergency room. Patients were set up with rapid outpatient follow-up in our stroke clinic and scheduled for an outpatient echocardiogram, if indicated. We compared this cohort to TIA patients admitted prior to the implementation of the TIA protocol who would have qualified. Outcomes of interest included length of stay, hospital cost, radiographic and echocardiogram findings, recurrent neurovascular events within 30 days, and final diagnosis. RESULTS: A total of 138 patients were assessed (65 patients in the pre-pathway cohort, 73 in the expedited, post-TIA pathway implementation cohort). Average time from MRI order to MRI end was 6.4 h compared to 2.3 h in the pre- and post-pathway cohorts, respectively (p < 0.0001). The average length of stay for the pre-pathway group was 28.8 h in the pre-pathway cohort compared to 7.7 h in the post-pathway cohort (p < 0.0001). There were no differences in neuroimaging or echocardiographic findings. There were no differences in the 30 days re-presentation for stroke or TIA or mortality between the two groups. The direct cost per TIA admission was $2,944.50 compared to $1,610.50 for TIA patients triaged through the pathway at our institution. CONCLUSIONS: This study demonstrates the feasibility, safety, and cost-savings of a comprehensive, emergency department-based TIA protocol. Further study is needed to confirm overall benefit of an expedited approach to TIA patient management and guide clinical practice recommendations.

Understanding parent preferences for NHS paediatric allergy services.

OBJECTIVES: To understand parent preferences for NHS paediatric allergy services. DESIGN: A stated preference study (discrete choice experiment). SETTING: West Midlands, UK. PARTICIPANTS: A sample of parents of children aged 16 years or younger recruited from the general population through a third party company approved by the University of Birmingham. INTERVENTION: An online questionnaire with 18 choice questions describing two hypothetical paediatric allergy specialist clinics described in terms of the clinician, information provision, additional facilities, waiting times and out of pocket expenses. Main outcome measures Preference and willingness to pay estimates for each of the specified attributes. RESULTS: Parents strongly preferred that their children be reviewed by consultants or specialist nurses formally trained in allergy compared with consultants with no formal allergy training [Willingness to pay (WTP) estimates for nurse specialist £150.9 (138.8-163.2), trained allergy consultants £218.7 (205.7-231.9), compared with consultants without formal training]. They were willing to wait longer to see trained practitioners. Parents also expressed a strong preference for improving online information regarding allergies [WTP for written information £18.4 (6.1-30.6) and £72.6 for improved online information (59.9-85.3), compared with verbal information]. Specialist clinics with additional dietician and eczema support were also preferred [WTP £29.9 (19.8-40.1), compared with no additional support]. CONCLUSIONS: Parents showed strong preference for formally trained practitioners in specialist allergy clinics. Access to improved online allergy information and additional facilities within allergy clinics were also preferred. These findings have implications for future commissioning of paediatric allergy services in the UK.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg.

BACKGROUND: Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied. METHODS: In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients. INCLUSION CRITERIA: age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy. EXCLUSION CRITERIA: pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods. DISCUSSION: NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Analysis of Outpatient Telemedicine Reimbursement in an Integrated Healthcare System.

BACKGROUND: Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery. METHODS: Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients. RESULTS: Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of $120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit. CONCLUSIONS: These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients.

Communities, health-care organizations and the contingencies and contradictions of engagement: A case study from Chile.

CONTEXT: Despite a growing interest in service-user involvement in mental health services, the interaction between health institutions and local groups is only beginning to receive attention, particularly in global south settings. OBJECTIVE: Looking at a participatory initiative in Chile, this study explores how, under unfavourable administrative conditions, health organizations approach and work with communities. METHODS: We interviewed policy-makers (5), local professionals (10), service users and community representatives (6) linked to a concrete participatory initiative. Participant observation in relevant meetings helped to enrich the interpretations. Thematic analysis was applied to interview transcripts and field notes. FINDINGS: The findings present a sequence of actions starting with the creation of a network of community-based groups. A set of problems ensued, related to the group's diversity, internal representation, decision-making and funding processes. In response, processionals implemented simultaneously bureaucratic and democratic adjustments, developing a vision of community that ignored the particularities-including the motivations-of local groups. DISCUSSION AND CONCLUSION: Based on these findings, we argue that participatory initiatives should be studied as on-going achievements shaped by broad policy orientations and local configurations of interest. In the process, they produce ad hoc forms of knowledge and visions of community that provide orientation to the agents involved.

Profit distribution and managers' behaviour in vertical integrated medical delivery systems - an experimental economics study.

BACKGROUND: The vertical integration of medical delivery systems (VIMDSs) is a reform direction both in China and worldwide. We conducted a controlled economic experiment to explore decision-making by managers of medical institutions with respect to profits and what influences the distribution mechanism in VIMDSs. METHODS: Students and hospital staff were recruited to make choices regarding the role of directors of institutions. z-Tree software was used to design the experimental program. Ninety-six subjects participated in the experiment. We gathered 479 valid contracts. RESULTS: Of the subjects, 66.39% chose flexible contracts. The median of the bidding distribution rate to community health service centres of all auctions was 18.50%. The final distribution rate was approximately 3 percentage points higher than the bidding distribution rate. The median effort level was 9.00. There was a significant correlation between the improvement rate and the choice of effort level (P<0.05) in flexible contracts. CONCLUSIONS: Hospital managers have a preference for flexible contracts because of uncertainty in the medical system. A community health service centre director may behave perfunctorily by engaging in shading in the integration. Flexible contracts and sharing rates beyond the participants' expectations motivate managers to engage in more cooperative behaviours.

Effectiveness and cost-effectiveness of treatment with additional enrollment to a homeopathic integrated care contract in Germany.

BACKGROUND: A number of German statutory health insurance companies are offering integrated care contracts for homeopathy (ICCHs) that cover the reimbursement of homeopathic treatment. The effectiveness and cost-effectiveness of these contracts are highly debated. METHODS: To evaluate the effectiveness and cost-effectiveness of treatment after an additional enrollment in an ICCH, a comparative, prospective, observational study was conducted in which participants in the ICCH (HOM group) were compared with matched (on diagnosis, sex and age) insured individuals (CON group) who received usual care alone. Those insured with either migraine or headache, allergic rhinitis, asthma, atopic dermatitis and depression were included. Primary effectiveness outcomes were the baseline adjusted scores of diagnosis-specific questionnaires (e.g. RQLQ, AQLQ, DLQI, BDI-II) after 6 months. Primary cost-effectiveness endpoints were the baseline adjusted total costs from an insurer perspective in relation to the achieved quality-adjusted life years (QALYs). Costs were derived from health claims data and QALYs were calculated based on SF-12 data. RESULTS: Data from 2524 participants (1543 HOM group) were analyzed. The primary effectiveness outcomes after six months were statistically significant in favor of the HOM group for migraine or headache (Δ = difference between groups, days with headache: - 0.9, p = 0.042), asthma (Δ-AQLQ(S): + 0.4, p = 0.014), atopic dermatitis (Δ-DLQI: - 5.6, p ≤ 0.001) and depression (Δ-BDI-II: - 5.6, p ≤ 0.001). BDI-II differences reached the minimal clinically important difference. For all diagnoses, the adjusted mean total costs over 12 months were higher in the HOM group from an insurer perspective, with migraine or headache, atopic dermatitis and depression suggesting cost-effectiveness in terms of additional costs per QALY gained. CONCLUSION: After an additional enrollment in the ICCH, the treatment of participants with depression showed minimally clinically relevant improvements. From an insurer perspective, treatment with an ICCH enrollment resulted in higher costs over all diagnoses but seemed to be cost-effective for migraine or headache, atopic dermatitis and depression according to international used threshold values. Based on the study design and further limitations, our findings should be considered cautiously and no conclusions regarding the effectiveness of specific treatment components can be made. Further research is needed to overcome limitations of this study and to confirm our findings. TRIAL REGISTRATION: clinicaltrials.gov , NCT01854580. Registered 15 March 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01854580.

Integrating Formal Technology Assessment into an Integrated Healthcare Delivery System: Smart Innovation.

OBJECTIVES: We designed, developed, and implemented a new hospital-based health technology assessment (HB-HTA) program called Smart Innovation. Smart Innovation is a decision framework that reviews and makes technology adoption decisions. Smart Innovation was meant to replace the fragmented and complex process of procurement and adoption decisions at our institution. Because use of new medical technologies accounts for approximately 50 percent of the growth in healthcare spending, hospitals and integrated delivery systems are working to develop better processes and methods to sharpen their approach to adoption and management of high cost medical innovations. METHODS: The program has streamlined the decision-making process and added a robust evidence review for new medical technologies, aiming to balance efficiency with rigorous evidence standards. To promote system-wide adoption, the program engaged a broad representation of leaders, physicians, and administrators to gain support. RESULTS: To date, Smart Innovation has conducted eleven HB-HTAs and made clinician-led adoption decisions that have resulted in over $5 million dollars in cost avoidance. These are comprised of five laboratory tests, three software-assisted systems, two surgical devices, and one capital purchase. CONCLUSIONS: Smart Innovation has achieved cost savings, avoided uncertain or low-value technologies, and assisted in the implementation of new technologies that have strong evidence. The keys to its success have been the program's collaborative and efficient decision-making systems, partnerships with clinicians, executive support, and proactive role with vendors.

Return on Investment of the Primary Health Care Integrated Geriatric Services Initiative Implementation.

BACKGROUND: Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities. AIM OF THE STUDY: We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread. METHODS: We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 \sim = USD 0.75) using the Canadian Consumer Price Index. RESULTS: The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The PHC IGSI is cost-effective in Alberta. IMPLICATIONS FOR HEALTH POLICY: The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted. IMPLICATIONS FOR FURTHER RESEARCH: Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.

Modeling the Health and Budgetary Impacts of a Team-based Hypertension Care Intervention That Includes Pharmacists.

OBJECTIVE: The objective of this study was to assess the potential health and budgetary impacts of implementing a pharmacist-involved team-based hypertension management model in the United States. RESEARCH DESIGN: In 2017, we evaluated a pharmacist-involved team-based care intervention among 3 targeted groups using a microsimulation model designed to estimate cardiovascular event incidence and associated health care spending in a cross-section of individuals representative of the US population: implementing it among patients with: (1) newly diagnosed hypertension; (2) persistently (≥1 year) uncontrolled blood pressure (BP); or (3) treated, yet persistently uncontrolled BP-and report outcomes over 5 and 20 years. We describe the spending thresholds for each intervention strategy to achieve budget neutrality in 5 years from a payer's perspective. RESULTS: Offering this intervention could prevent 22.9-36.8 million person-years of uncontrolled BP and 77,200-230,900 heart attacks and strokes in 5 years (83.8-174.8 million and 393,200-922,900 in 20 years, respectively). Health and economic benefits strongly favored groups 2 and 3. Assuming an intervention cost of $525 per enrollee, the intervention generates 5-year budgetary cost-savings only for Medicare among groups 2 and 3. To achieve budget neutrality in 5 years across all groups, intervention costs per person need to be around $35 for Medicaid, $180 for private insurance, and $335 for Medicare enrollees. CONCLUSIONS: Adopting a pharmacist-involved team-based hypertension model could substantially improve BP control and cardiovascular outcomes in the United States. Net cost-savings among groups 2 and 3 make a compelling case for Medicare, but favorable economics may also be possible for private insurers, particularly if innovations could moderately lower the cost of delivering an effective intervention.