Cost-effectiveness analysis of biologic sequential treatments for moderate-to-severe psoriasis: A Malaysian healthcare system perspective.

OBJECTIVE: In Malaysia, there is now a dearth of recommendations pertaining to the priority of biologic treatments for the effective management of psoriasis, given the multitude of available therapeutic alternatives. Present analysis reports results of a cost-effectiveness model that determines the most optimal arrangement of biologic treatments, with a particular focus of adding biosimilars to the existing treatment pathway for psoriasis in Malaysia. METHODS: A Markov model was developed to compare the cost effectiveness of various biologic sequential treatments in a hypothetical cohort of moderate to severe psoriasis patient in Malaysia over a lifetime horizon. The model simulated the progression of patients through three lines of active biologic therapy, before transitioning to best supportive care. Costs and effects were discounted annually at a rate of 3%. RESULTS: First line secukinumab has produced lowest incremental cost effectiveness ratios (ICERs) when compared to first line systemic [ICERs value; US$152,474 (first set analysis) and US$110,572 (second set analysis)] and first line phototherapy [ICERs value; US$147,057 (first set analysis) and US$107,616 (second set analysis)]. However, these values were slightly higher than the Malaysian based threshold of three times gross domestic product per capita, US$104,337. A 40% reduction in the unit costs of reference biologics renders most of the evaluated treatment sequences cost-effective. CONCLUSION: Adding biosimilar to the current treatment sequence could achieve cost savings ranging from 4.3% to 10.8% without significant loss of effectiveness. Given the significant impact of comorbidities and the resulting decline in quality of life among individuals with psoriasis, it may be justifiable to establish a threshold of up to US$184,000 per quality-adjusted life year (QALY) for the provision of therapies in the context of Malaysia.

Considering patient perspectives in economic evaluations of health interventions.

Current guidelines for evaluating the cost-effectiveness of health interventions commonly recommend the use of a payer and/or a societal perspective. This raises the concern that the resulting reimbursement decision may overlook the full spectrum of impacts and equity considerations. In this paper, we argue that a potential solution is to supplement a societal- or payer-perspective economic evaluation with an additional evaluation accounting for exclusively the patient perspective. We present five categories of health interventions for which a patient-perspective analysis may be informative including those (1) that cross the definitional boundary between drugs and non-drug technologies; (2) affect patient adherence to protocol; (3) represent revolutionary treatments for genetic disorders; (4) with an incremental cost-effectiveness ratio involving slightly less effective, but substantially less costly, than the current standard; and (5) have been previously approved for funding but now being targeted for potential delisting or disinvestment. Real-world examples are discussed in detail. Lived experience individuals were invited to provide vignettes. Discussions are provided regarding how to incorporate patient inputs to improve patient-centered decision-making.

Public-private partnership alternative for a national pharmacare program in Canada.

BACKGROUND: Recently, the government and an opposition party cut a deal that involved a promise to consider implementing a single-payer pharmacare scheme in Canada in exchange for supporting the current minority government. There have been political headwinds from the private extended health insurance industry, the provinces of Ontario and Quebec, as well as the pharmaceutical industry. We suggest a new multiple-payer of mixed-resort framework that achieves both the goal of universal coverage and preserves the private extended health insurance industry through a scheme based on the current coordination of benefits between private payers in this sector. METHODS: We employ game theory to better understand the dynamics within a market that involves multiple payers. In particular, we use the game of Collective Action to help illustrate the problems of free-ridership. RESULTS: An analysis of the dynamics of this market suggests that ex-ante agreements need to be struck between all payers in a multi-payer marketplace to achieve both stability and sustainability of such a framework. CONCLUSION: We show that universal coverage is still possible while leveraging the existing system of private extended health insurance so long as a well-established system for coordinating benefits between public and private payers is established. A stable public/private partnership can achieve universal coverage so long as a system for coordinating benefits is instituted. The proposed alternative will achieve the same goals, but maintain a niche for the private sector thereby maintaining therapeutic variety in the marketplace.

A Tale of Two Countries: Changes to Canadian and U.S. Senior Population Projections due to the Pandemic-Implications for Health Care Planning in Canada and Other Western Countries.

To examine COVID-19 mortality demographics to determine if there will be any substantive shifts in population forecasts that will impact health and long-term care planning for seniors in both countries. Demographic data from Statistics Canada and the U.S. Census Bureau to 2060 are adjusted for COVID-19 age-group-specific mortality and then projected forward in five-year increments. These projections are then annualized using a linear imputation between each projected value. Consideration is given to the seniors 65 + , 75 + and 85 + as well as dependency ratios of each age category. Forecasts suggest that the proportion of seniors in the population will roughly plateau in 2035 at approximately 21% (U.S.) and 24% (Canada)-with another uptick observed beginning in 2050 for those aged 75 + . Adjustments due to the pandemic have had little impact on these projections suggesting that-unless there is a major shift in the demographics of pandemic-related mortality-the resource planning implications will be largely inconsequential. Investments in resources to serve seniors need not be done with the intention to repurpose these assets before they are fully depleted. While the demonstrated demographic plateau is likely to hold steady, there is uncertainty around the expected rate of decline in the health of seniors. Depending on this trajectory, community-level social supports could play a large role in lengthening the duration of senior health and independence.

Personal Support Homes: An Innovative Approach to Reduce the Alternative Level of Care Population in Ontario Hospitals.

OBJECTIVE: This study investigates the viability of personal support homes - a policy concept that reduces alternative level of care (ALC) days in Ontario hospitals. It allows people to leverage their empty bedrooms to temporarily house patients awaiting hospital discharge. METHOD: Data from the Municipal Property Assessment Corporation are used to map geographic supply of empty bedrooms, and Ontario Ministry of Health administrative data are used to assess potential demand. RESULTS: By remunerating certified homeowners $120-150/day, this concept could help decrease ALC patient days by 20% and save the province $1.13-1.95 billion in foregone hospital construction along with relieving current system pressures. CONCLUSION: As part of a multifaceted policy solution to ALC, this concept is particularly suited for rural/remote locations where excess bedroom supply per capita is the highest.

Changing healthcare capital-to-labor ratios: evidence and implications for bending the cost curve in Canada and beyond.

Healthcare capital-to-labor ratios are examined for the 10 provincial single-payer health care plans across Canada. The data show an increasing trend-particularly during the period 1997-2009 during which the ratio as much as doubled from 3 to 6 %. Multivariate analyses indicate that every percentage point uptick in the rate of increase in this ratio is associated with an uptick in the rate of increase of real per capita provincial government healthcare expenditures by approximately $31 ([Formula: see text] 0.01). While the magnitude of this relationship is not large, it is still substantial enough to warrant notice: every percentage point decrease in the upward trend of the capital-to-labor ratio might be associated with a one percentage point decrease in the upward trend of per capita government healthcare expenditures. An uptick since 1997 in the rate of increase in per capita prescription drug expenditures is also associated with a decline in the trend of increasing per capita healthcare costs. While there has been some recent evidence of a slowing in the rate of health care expenditure increase, it is still unclear whether this reflects just a pause, after which the rate of increase will return to its baseline level, or a long-term shift; therefore, it is important to continue to explore various policy avenues to affect the rate of change going forward.

The effect of social capital on the use of general practitioners: a comparison of immigrants and non-immigrants in Ontario.

Social capital, a resource arising from the social interaction among individuals, may be a determinant of medical care use. This study explored the interaction between community- and individual-level social capital and immigrant status on the propensity and frequency of physician visits. The results showed that community social capital, as measured by the Petris Social Capital Index, was not significant in any of the analyses. However, a sense of belonging to the local community tended to decrease the number of doctor visits made by immigrants, while tangible social support increased and affection decreased the frequency of GP consultations by non-immigrants. Further research is required to determine which types of social capital affect utilization of different health services. These findings also highlight the importance of being aware of potential interactions between the formal and informal components of the healthcare system.

Social capital, community size and utilization of health services: a lagged analysis.

OBJECTIVES: We examine the relationship between social capital, community size and GP visits, and conceptualize social capital as a stock variable measured at a prior point in time. METHODS: Data from the 2002 Canadian Community Health Survey and the 2001 Canadian Census are merged with GP visit data from the Ontario Health Ministry. Negative binomial regression is used to measure the impact of community-level (CSC) and individual-level social capital (ISC) on GP visits. CSC is measured with the Petris Index using employment levels in religious and community-based organizations, and ISC is measured along multiple dimensions. RESULTS: The effect of social capital varies by community size. A one standard deviation increase in the Petris Index in larger communities (population>100,000) leads to a 2.6% decrease in GP visits with an annual offset in public spending of $66.4M. Tangible social support-a measure of ISC-also exhibited large effects on GP visits. In smaller communities (population 10,000-100,000), only increased ISC exhibited an impact on GP visits. Age had no effect on the association between social capital and GP visits. CONCLUSIONS: Each form of social capital likely operates through different mechanisms and impact differs by community size. Stronger CSC likely obviates some physician visits in larger communities that involve counseling/caring services while some forms of ISC may act similarly in smaller communities.

Cost-effectiveness analysis of implantable venous access device insertion using interventional radiologic versus conventional operating room methods in pediatric patients with cancer.

PURPOSE: Percutaneous image-guided techniques are associated with less tissue trauma and morbidity than open surgical techniques. Interventional radiology has received significant health care investment. The purpose was to determine the cost effectiveness of inserting implantable venous access devices (IVADs) by interventional radiologic means versus conventional operating room surgery in pediatric patients with cancer. MATERIALS AND METHODS: In a retrospective cohort analysis, patients presenting with a new tumor diagnosis and receiving a first-time IVAD in January to June 2000 (operative group; n = 30) and January to June 2004 (interventional group; n = 30) were included. A societal costing perspective was adopted. Costs included labor, materials, equipment, inpatient wards, parent travel, and parental productivity losses for 30 days after insertion. Severe complications related to IVAD insertion were microcosted. Costs related to cancer therapy were not included. Incremental cost-effectiveness analysis and sensitivity analysis were performed. RESULTS: Interventional patients were older (7.3 years vs 4.1 years; P = .01). There were no significant differences between groups in sex, American Society of Anesthesiologists score, or length of hospital stay. Interventional radiologic procedures were shorter (84.9 minutes vs 112.8 minutes; P = 0.01). Interventional radiologic insertion was slightly less costly than operative insertion (Can$622,860 and Can$627,005 per 30-patient group, respectively) and more effective in reducing the complication rate (two vs eight complications per group, respectively; P = .039). The results were sensitive to the cost of operating the operating room. CONCLUSIONS: Interventional radiology was slightly less costly than operative IVAD insertion and resulted in fewer serious complications. It should be considered for IVAD insertions in pediatric patients with cancer.

The effects of competition on community-based nursing wages.

In 1997, Ontario implemented a competitive bidding process for purchasing home care services, with the twin objectives of lowering costs and increasing service quality. The authors of this study performed regression analyses to ascertain the relationship between measures of competition, profit status of providers and nursing wages for community-based RNs and LPNs between 1995/1996 and 2000/2001. Using the Herfindahl-Hirschman Index as a measure of competition, we observed that only RN wages significantly increased as competition in home care increased. Furthermore, for-profit agencies paid significantly lower RN wages than their not-for-profit counterparts. By contrast, LPN wages declined over the sample period and did not differ markedly across provider types. The relative distribution of for-profit and not-for-profit agencies changed dramatically over the study period, with large increases in the number and volume of for-profit contracts. The results indicate that (a) greater competition in the home care sector resulted in upward pressure on RN wages independent of the profit status of the provider and (b) the increase appears to have been constrained by the increased presence of for-profit providers over the study period. The results highlight the role of profit status in provider behaviour, even in the context of publicly funded home care services. This finding has implications for both provider mix and the remuneration of nurses.

Critical care services in Ontario: a survey-based assessment of current and future resource needs.

PURPOSE: In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highest-level critical care beds and to determine the physician management models in critical care units in Ontario, Canada. METHODS: In June 2006, self-administered questionnaires were mailed to the Chief Executive Officers of all acute care hospitals, identified through the Ontario government's hospital database. The questionnaire solicited information on the number and type of critical care units, number of beds, technological resources and management of each unit. RESULTS: Responses were obtained from 174 (100%) hospitals, with 126 (73%) reporting one or more critical care units. We identified 213 critical care units in the province, representing 1789 critical care beds. Over half (59%) of these beds provided mechanical ventilation on a regular basis, representing a capacity of 14.9 critical care and 8.7 mechanically ventilated beds per 100,000 population. Sixty-three percent of units with capacity for mechanical ventilation involved an intensivist in admission and coordination of care. Based on current utilization, the demand for mechanically ventilated beds by 2026 is forecast to increase by 57% over levels available in 2006. Assuming 80% bed utilization, it is estimated that an additional 810 ventilated beds will be needed by 2026. CONCLUSION: Current utilization suggests a substantial increase in the need for the highest-level critical care beds over the next two decades. Our findings also indicate that non-intensivists direct care decisions in a large number of responding units. Unless major investments are made, significant improvements in efficiency will be required to maintain future access to these services.

A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis.

OBJECTIVE: To carry out a cost-effectiveness analysis of omitting chest radiography in the diagnosis of infant bronchiolitis. HYPOTHESIS: Omitting chest radiographs in the diagnosis of typical bronchiolitis was expected to reduce costs without adversely affecting the detection rate of alternate diseases. STUDY DESIGN: An economic evaluation was conducted using clinical and health resources. Emergency department (ED) physicians provided diagnoses pre- and post-radiography as well as a management plan. The primary outcome was the diagnostic accuracy (false-negative rate) of alternate diagnoses with and without X-ray. The incremental costs of omitting radiography in comparison to routine radiography per patient were assessed from a health system perspective. PATIENT SELECTION: We studied 265 infants, 2-23 months old, presenting at the ED with typical bronchiolitis. Patients with pre-existing conditions or radiographs were omitted from the study. METHODOLOGY: Expected costs to the health care system of including and excluding chest radiographs were compared, including costs associated with misdiagnosis. RESULTS: All alternate diagnoses (two cases) were missed by ED physicians pre- and post-radiography, resulting in a 100% false negative rate. The specificity in detecting alternate diseases was 96.6% pre-radiography and 88.6% post-radiography. Of the 17 cases of coexistent pneumonia, 88% were missed pre-radiography and 59% post-radiography, with respective false positive rates of 10.5% and 16.1%. Omission of routine chest radiograph saved CDN $59 per patient, primarily due to savings in radiography and hospitalization costs. The economic benefit persisted after the inpatient length of stay, ED overhead and radiograph costs were varied. CONCLUSION: For infants with typical bronchiolitis, omitting radiography is cost saving without compromising diagnostic accuracy of alternate diagnoses and of associated pneumonia.

Aging, social capital, and health care utilization in Canada.

This paper examines relationships between aging, social capital, and healthcare utilization. Cross-sectional data from the 2001 Canadian Community Health Survey and the Canadian Census are used to estimate a two-part model for both GP physicians (visits) and hospitalization (annual nights) focusing on the impact of community- (CSC) and individual-level social capital (ISC). Quantile regressions were also performed for GP visits. CSC is measured using the Petris Social Capital Index (PSCI) based on employment levels in religious and community-based organizations [NAICS 813XX] and ISC is based on self-reported connectedness to community. A higher CSC/lower ISC is associated with a lower propensity for GP visits/higher propensity for hospital utilization among seniors. The part-two (intensity model) results indicated that a one standard deviation increase (0.13%) in the PSCI index leads to an overall 5% decrease in GP visits and an annual offset in Canada of approximately $225 M. The ISC impact was smaller; however, neither measure was significant in the hospital intensity models. ISC mainly impacted the lower quantiles in which there was a positive association with GP utilization, while the impact of CSC was strongest in the middle quantiles. Each form of social capital likely operates through a different mechanism: ISC perhaps serves an enabling role by improving access (e.g. transportation services), while CSC serves to obviate some physician visits that may involve counseling/caring services most important to seniors. Policy implications of these results are discussed herein.

Simulation of a Hirschman-Herfindahl index without complete market share information.

This paper utilizes maximum likelihood methods to simulate a Hirschman-Herfindahl index (HHI) for markets in which complete market share information is unavailable or delayed. Many jurisdictions either may be unable to administratively collect data or experience delays in collection that make data regarding turbulent markets of limited use. With the development of this method, regulatory authorities monitoring health-care competition or health-care firms can now use market surveys--in which reliable recall is often limited to the largest three or four firms--to produce an on-the-spot measure of market concentration.

Future intentions of registered nurses employed in the western New York labor market: relationships among demographic, economic, and attitudinal factors.

Demographic, economic, and attitudinal factors may affect the work participation behavior of full and part-time RNs in hospital and non-hospital settings. The sample (N = 776) included randomly selected RNs from the 1997 registration lists of the New York State Department of Professional Licensing. Classical t-tests and chi-square tests were used to test for differences between hospital, non-hospital, full-time and part-time RNs. Only RNs employed in hospital settings were significantly less satisfied and less committed to their organization than were non-hospital based nurses; however these attitudes, frequently shown to be related to turnover behavior, did not result in intentions to leave. Differences in satisfaction and commitment across job settings begin to explain work participation behavior of nurses, as distinct from organizational behavior.