Determinants of the Cost-Effectiveness of Telemedicine: Systematic Screening and Quantitative Analysis of the Literature.

Background and Objectives: Telemedicine holds the promise of increasing access-to-care at a lower cost. Yet, for years, the evidence of telemedicine's cost-effectiveness was scarce. Faced with a rapidly expanding literature, we conduct both manual and systematic selection of the literature, and analyzed the data to determine: (1) the characteristics of economic evaluations of telemedicine, and (2) the determinants of economically efficient telemedicine interventions. Methods: We reviewed all published economic evaluations of telemedicine in Cochrane, Embase, and Pubmed from 2008 to 2018. Articles were screened by two researchers first on title and abstract (Stage 1), then on full article (Stage 2), (protocol available on PROSPERO, ref. CRD42019143032). We proposed an alternative method for screening articles using machine learning based on textual classification and compared these two approaches. We constructed an exclusive dataset on the characteristics of the selected articles and enriched it using OECD data at the country level. We identified the determinants of efficient telemedicine interventions using multiple logit models. Results and Conclusion: We included 156 articles out of 2,639. Most economic studies of our sample regard telemonitoring. A majority (73.7%) of studies found that telemedicine intervention is efficient, regardless of the medical domain. Articles with higher standards of economic evaluation (cost-effectiveness analysis, randomized trials with high sample size) were less likely to report an efficient intervention. We found no effect of the publication year, signifying that the nature of the evidence has not changed over time.

Assessing real-world effectiveness of therapies: what is the impact of incretin-based treatments on hospital use for patients with type 2 diabetes?

BACKGROUND: Managing type 2 diabetes represents a major public health concern due to its important and increasing prevalence. Our study investigates the impact of taking incretin-based medication on the risk of being hospitalized and the length of hospital stay for individuals with type 2 diabetes. METHOD: We use claim panel data from 2011 to 2015 and provide difference-in-differences (DID) estimations combined with matching techniques to better ensure the treatment and control groups' comparability. Our propensity score selects individuals according to their probability of taking an incretin-based treatment in 2013 (N = 2,116). The treatment group includes individuals benefiting from incretin-based treatments from 2013 to 2015 and is compared to individuals not benefiting from such a treatment but having a similar probability of taking it. RESULTS: After controlling for health-related and socio-economic variables, we show that benefiting from an incretin-based treatment does not significantly impact the probability of being hospitalized but does significantly decrease the annual number of days spent in the hospital by a factor rate of 0.621 compared with the length of hospital stays for patients not benefiting from such a treatment. CONCLUSION: These findings highlight the potential implications for our health care system in case of widespread use of these drugs among patients with severe diabetes.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient-physician relationship?

CONTEXT: Potentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people. OBJECTIVE: To determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient-physician relationship. METHODS: Our dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient-physician relationship. RESULTS: 17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient-physician relationship. CONCLUSION: Our study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.

Do older adults know the purpose of their medications? A survey among community-dwelling people.

PURPOSE: This study assessed the level of knowledge among community-dwelling older individuals about the purpose of medications and the characteristics that influenced that knowledge. We focused on drugs frequently used and/or often involved in iatrogenic events. METHODS: This cross-sectional survey included 2690 community-dwelling older adults, aged 68 years and above, who reported using at least one drug of interest, in the canton of Vaud, Switzerland. Participants reported drugs that they currently used and described their purpose. A good knowledge level was defined as knowledge of the exact purpose or identification of the anatomical system or organ targeted by the drug. We performed a multivariate logistic regression analysis to identify factors associated with a good knowledge level for all drugs of interest. Sampling weights were employed to provide representative estimates. RESULTS: On average, patients had good knowledge of 80.6% of the drugs reported. The highest knowledge levels were demonstrated for non-steroidal antiinflammatory drugs, antidiabetics, analgesics, and endocrinological drugs and the lowest for platelet aggregation inhibitors, minerals, anticoagulants, and other narrow therapeutic index drugs. Overall, 66% of participants had good knowledge of the purpose of all the drugs of interest. Polypharmacy and receiving help with drug management were negatively associated with good knowledge (adjusted OR4-5 drugs 0.45; 95% CI 0.29-0.71, adjusted OR≥ 6 drugs 0.20; 95% CI 0.13-0.31, and adjusted ORhelp 0.42; 95% CI 0.18-0.99). CONCLUSION: This study showed that education about drugs was lacking among patients that received multiple drugs, particularly patients that used anticoagulants and antiplatelet inhibitors.

Effects of a long-term exercise programme on functional ability in people with dementia living in nursing homes: Research protocol of the LEDEN study, a cluster randomised controlled trial.

BACKGROUND: Exercise may lead to improvements on functional ability, physical function, and neuropsychiatric symptoms (particularly depression) in people with dementia (PWD). However, high-quality randomised controlled trial (RCT), controlling for the socialisation aspect of group-based exercise interventions, and designed to delay the declines on the functional ability of PWD in the nursing home (NH) setting is almost inexistent. This article describes the protocol of the LEDEN study, an exercise RCT for PWD living in NHs. METHODS/DESIGN: LEDEN is a cluster-randomised controlled pilot trial composed of two research arms: exercise training (experimental group) and social/recreational activity (control group). Both interventions will be provided twice a week, for 60 min, during the 6-month intervention. The total duration of the study is 12 months, being six months of intervention plus six months of observational follow-up. Eight French NHs volunteered to participate in LEDEN; they have been randomised to either exercise intervention or social/recreational intervention in a 1:1 ratio. RESULTS: The primary objective is to investigate the effects of exercise, compared to a social/recreational intervention, on the ability of PWD living in NHs to perform activities of daily living (ADL). Secondary objectives are related with the cost-effectiveness of the interventions, and the effects of the interventions on patients' physical function, neuropsychiatric symptoms, pain, nutritional status, and the incidence of falls and fractures. DISCUSSION: LEDEN will provide the preliminary evidence needed to inform the development of larger and more complex interventions using exercise or non-exercise social interventions.

Are public subsidies effective to reduce emergency care? Evidence from the PLASA study.

Elderly people facing dependence are exposed to the financial risk of long lasting care expenditures. This risk is high for people facing cognitive, functional and behavioral problems. In the short-term, dependent elderly people face increased non-medical care expenditures. In the long-term, they face increased medical care expenditures, which are driven by emergency care events such as: emergency hospitalization, emergency medical visits, and emergency institutionalizations. In France, providing public financial assistance has been shown to improve dependent people's access to non-medical care services. However, the impact of public financial assistance on emergency care use has not been explored yet. Our study aims at determining whether financial assistance on non-medical care provision decreases the probability of emergency care rates using data of 1131 French patients diagnosed with Alzheimer's disease, collected between 2003 and 2007. Using instrumental variables to deal with the presence of a potential endogeneity bias, we find that beneficiaries of long-term care subsidies have a significantly lower rate of emergency care than non-beneficiaries. Failing to control for endogeneity problems would lead to misestimate the impact of long-term care subsidies on emergency care rates. Finding that home care subsidies has a protective effect for emergency care confirmed the efficacy of this public policy tool.

Evaluation of full costs of care for patients with Alzheimer's disease in France: the predominant role of informal care.

OBJECTIVE: It is crucial that the cost of Alzheimer's disease be evaluated, from a societal perspective, since the number of patients is expected to increase dramatically in the coming decades. This assessment of the full cost of care for community-dwelling patients with Alzheimer's disease in France also addresses the factors associated with informal care, its predominant component. DATA AND METHODS: From 2009 to 2010, 57 patient/informal caregiver pairs were interviewed using the Resource Utilization in Dementia questionnaire, adapted to provide a micro-costing approach of the overall care process. Both the opportunity cost method and the proxy good method were used to value informal care. Ordinary least square regression was performed to determine factors associated with informal care. RESULTS: Average total monthly costs were €2450 with the proxy good method and €3102 with the opportunity cost method. Living with the patient, severity of dementia and hours spent on formal care were significantly associated with informal care time. POLICY IMPLICATIONS: Since French allowance cannot cover all formal and informal non-medical costs, the choice for policy makers is either to spend more on formal care or to develop family care by investing in supportive programmes for informal caregivers.

The influence of waiting times on cost-effectiveness: a case study of colorectal cancer mass screening.

When a cost-effectiveness analysis is implemented, the health-care system is usually assumed to adjust smoothly to the proposed new strategy. However, technological innovations in health care may often induce friction in the organization of care supply, implying the congestion of services and subsequent waiting times. Our objective here is to measure how these short run rigidities can challenge cost-effectiveness recommendations favorable to an innovative mass screening test for colorectal cancer. Using Markov modeling, we compare the standard Guaiac fecal occult blood test (gFOBT) with an innovative screening test for colorectal cancer, namely the immunological fecal occult blood test (iFOBT). Waiting time can occur between a positive screening test and the subsequent confirmation colonoscopy. Five scenarios are considered for iFOBT: no further waiting time compared with gFOBT, twice as much waiting time for a period of 5 or 10 years, and twice as much waiting time for a period of 5 or 10 years combined with a 25% decrease in participation to confirmation colonoscopies. According to our modeling, compared with gFOBT, iFOBT would approximately double colonoscopy demand. Probabilistic sensitivity analysis enables concluding that the waiting time significantly increases the uncertainty surrounding recommendations favorable to iFOBT if it induces a decrease in the adherence rate for confirmation colonoscopy.

Incremental net benefit and acceptability of alternative health policies: a case study of mass screening for colorectal cancer.

The incremental net benefit (INB) and the related acceptability curves for public health programs provide valuable tools for decision making. We proposed to apply them to the assessment of mass screening of colorectal cancer. The now standard guaiac fecal occult blood test (FOBT) is already implemented in several countries. We considered the innovative immunological FOBT and computed tomography colonography (CTC) as competing screening technologies. Using biennial guaiac FOBT as the reference strategy, we estimated the cost-effectiveness of the following alternatives: biennial immunological FOBT, CTC every 5 years (strategy CTC5), and CTC every 10 years (strategy CTC10). Over a 30-year horizon and from the perspective of a third-party payer, we developed a Markov model on a hypothetical cohort of 100,000 subjects at average risk of colorectal cancer. Close expected net benefits between immunological FOBT and CTC5 induced uncertainty in the choice of the optimal strategy. Probabilistic sensibility analysis then suggested that below a willingness to pay (WTP) per life-years gained (LYG) of 8,587 €/LYG, CTC10 was optimal, while CTC5 would be preferred beyond a WTP of 8,587 €/LYG.

Cost-effectiveness of colorectal cancer screening with computed tomography colonography or fecal blood tests.

OBJECTIVE: To assess the cost-effectiveness of colorectal cancer screening using computed tomography colonography (CTC) and immunological fecal occult blood test (iFOBT). METHODS: CTC and iFOBT strategies were compared with Nn screening or guaiac FOBT (gFOBT) using Markov modeling. CTC was proposed at 50, 60, and 70 years, whereas gFOBT and iFOBT were performed every 2 years beginning at 50 years until 74 years of age with a 30-year time horizon. We calculated incremental cost-effectiveness ratios and efficiency ratios (ERs). Then, we performed univariate and probabilistic sensitivity analyses. RESULTS: With gFOBT as reference, colorectal cancer prevention rate was 18% for CTC and 11% for iFOBT. The incremental cost-effectiveness ratio of CTC and iFOBT were respectively 3204 and 5458 euro per life years gained (LYG), the ER for CTC was 0.22 and the ER for iFOBT was 2.08 colonoscopies per LYG. Cost-effectiveness results were sensitive to CTC cost. In the probabilistic sensitivity analysis, compared with CTC, iFOBT strategy was cost-effective for 84.6% of simulations when we assumed a willingness to pay (WTP) of 20,000 euro/LYG. CONCLUSION: CTC requires substantially less colonoscopies than iFOBT and is cost-effective for low values of WTP. However, iFOBT is the preferred screening strategy for a WTP greater than 6207 euro/LYG.

Cost-effectiveness of colorectal cancer screening with computed tomography colonography according to a polyp size threshold for polypectomy.

OBJECTIVE: Computed tomography colonography (CTC) has an acceptable accuracy in detecting colonic lesions, especially for polyps at least 6 mm. The aim of this analysis is to determine the cost-effectiveness of population-based screening for colorectal cancer (CRC) using CTC with a polyp size threshold. METHODS: The cost-effectiveness ratios of CTC performed at 50, 60 and 70 years old, without (PL strategy) or with (TS strategy) polyp size threshold were compared using a Markov process. Incremental cost-effectiveness ratios (ICER) were calculated per life-years gained (LYG) for a time horizon of 30 years. RESULTS: The ICER of PL and TS strategies were 12 042 and 2765 euro/LYG associated to CRC prevention rates of 37.9 and 36.5%. The ICER of PL and TS strategies dropped to 9687 and 1857 euro/LYG when advanced adenoma (AA) prevalence increased from 6.9 to 8.6% for male participants and 3.8-4.9% for female participants or to 9482 and 2067 euro/LYG when adenoma and AA annual recurrence rates dropped to 3.2 and 0.25%. The ICER for PL and TS strategies decreased to 7947 and 954 euro/LYG or when only two CTC were performed at 50 and 60-years-old. Conversely, the ICER did not significantly change when varying population participation rate or accuracy of CTC. CONCLUSION: CTC with a 6 mm threshold for polypectomy is associated to a substantial cost reduction without significant loss of efficacy. Cost-effectiveness depends more on the AA prevalence or transition rate to CRC than on CTC accuracy or screening compliance.