Which Localizing Strategy is the Most Cost-Effective in Reoperative Primary Hyperparathyroidism?

INTRODUCTION: 2%-10% of patients with primary hyperparathyroidism (PHPT) who undergo parathyroidectomy develop persistent/recurrent disease. The aim of this study was to determine which preoperative localization method is most cost-effective in reoperative PHPT. METHODS: Clinical decision analytic models comparing cost-effectiveness of localizing studies in reoperative PHPT were constructed using TreeAge Pro. Cost and probability assumptions were varied via Probabilistic Sensitivity Analysis (PSA) to test the robustness of the base case models. RESULTS: Base case analysis of model 1 revealed ultrasound (US)-guided fine-needle aspiration with PTH assay as most cost-effective after localizing US. This was confirmed on PSA of model 1. Model 2 showed four-dimensional computed tomography (4D-CT) as most cost-effective after negative US. If not localized by US, on PSA, 4D-CT was the next most cost-effective test. CONCLUSIONS: US-guided FNA with PTH is the most cost-effective confirmatory test after US localization. 4D-CT should be considered as the next best test after negative US.

Commentary: Determining Economic Factors That Matter to People With Intellectual and Developmental Disabilities and Their Caregivers: A Process Framework.

BACKGROUND: The 2020-2029 strategic plan for the Patient-Centered Outcomes Research Trust Fund calls for addressing data infrastructure gaps that are critical for studying issues around intellectual and developmental disabilities (I/DD). Specifically, the plan calls for data collection on economic factors that affect person-centered approaches to health care decision-making. Among people with I/DD and their caregivers, such economic factors may include financial costs of care, decreased opportunities for leisure and recreation, income losses associated with caregiving, and foregone opportunities for skill acquisition or other human capital investments. OBJECTIVE: This commentary supports responsiveness to the Patient-Centered OutcomesResearch Trust Fund (PCORTF) calls by conceptualizing and operationalizing a framework for identifying preferences on economic factors that are relevant to people with I/DD and their caregivers. MAIN ARGUMENTS: The framework outlined in this commentary addresses barriers to data collection that hinder measure development in the study of I/DD. This work is significant and timely given the continued movement to integrate and maintain people with I/DD within communities and recent methodological advances for eliciting preferences among people with I/DD. RELEVANCE TO THE SPECIAL ISSUE: Readers will be introduced to a framework for building data capacity in the study of economic outcomes among a population that is a high research priority for federal funding agencies. This commentary aims to be useful to researchers in planning, developing, and initiating projects in this area.

Addressing racial inequality and its effects on vaccination rate: A trial comparing a pharmacist and peer educational program (MOTIVATE) in diverse older adults.

BACKGROUND: The mortality, morbidity, health care utilization, and cost attributable to vaccine-preventable diseases are substantial for those aged 50 years and older. Although vaccination is the most cost-effective strategy to prevent common infectious diseases in older adults, vaccination rates remain below US Centers for Disease Control and Prevention benchmarks, especially among racial minorities. Historical mistrust, structural racism within the US medical system, and misinformation contributed to lower immunization rates among minorities, especially Black Americans. To address the critical need to increase knowledge and trust in vaccination, 2 community-based educational interventions were tested: a pharmacist-led didactic session (PHARM) and a peer-led educational workshop (PEER). OBJECTIVE: To determine and compare the effectiveness and costs of PEER and PHARM community-based education models in improving knowledge and trust in vaccinations. METHODS: The Motivating Older adults to Trust Information about Vaccines And Their Effects (MOTIVATE) study was a cluster-randomized trial conducted in the greater Delaware Valley Region sites from 2017 to 2020. The included sites (7 senior centers, 3 housing units, 1 church, and 1 neighborhood family center) predominantly served Black communities. Participants were randomized to either PHARM or PEER sessions covering influenza, pneumococcal disease, herpes zoster, and beliefs related to vaccines. Peer leaders facilitated smaller workshops (5-10 participants), whereas pharmacists conducted larger didactic lectures with 15-43 participants. Outcomes were captured through a self-administered survey at baseline, postprogram, and 1 month after the program. Intervention costs were measured in 2017 US dollars. RESULTS: 287 participants were included. Their mean age was 74.5 years (SD = 8.94), 80.5% were women, 64.2% were Black, and 48.1% completed some college. Knowledge scores within groups for all 3 diseases significantly increased postprogram for both PEER and PHARM and were sustained at 1 month. Between-group knowledge differences were significant only for influenza (PEER participants had significantly larger improvement vs PHARM). Vaccination trust significantly increased in both groups. Total program costs were $11,411 for PEER and $5,104 for PHARM. CONCLUSIONS: Both interventions significantly improved knowledge and trust toward vaccination and retained their effect 1 month after the program. The 2 effective community-based education models should be expanded to ensure timely and trusted information is available to educate older adults about vaccine-preventable diseases. Further research is encouraged to assess the long-term cost-effectiveness of these models' utilization on a larger scale. DISCLOSURES: Dr Schafer is an employee of Merck; however, at the time of the project, he was a professor at Thomas Jefferson University. The other authors have no conflicts of interest to disclose. This study was supported in part by a research grant from the Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. The opinions expressed in this article are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. The sponsor played no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the article. Study Registration Number: NCT03239665.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia.

INTRODUCTION: Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD. METHODS: We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios. RESULTS: All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses. CONCLUSION: Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes.

Black individuals with diabetes have high rates of emergency department (ED) use. This randomized controlled trial compared the efficacy of Diabetes Interprofessional Team to Enhance Adherence to Medical Care (DM I-TEAM) versus Usual Medical Care (UMC) to reduce number of return ED visits/hospitalizations over 12 months in 200 Black individuals with diabetes after an ED visit. DM I-TEAM consisted of community health worker-delivered diabetes education and behavior activation, telehealth visits with a diabetes nurse educator and primary care physicians, and clinical pharmacist recommendations to reduce potentially inappropriate medications (PIMs). Secondary outcomes included glycemic control, PIMs use, diabetes self-management, diabetes self-efficacy, depression, and medical trust. Participants had a mean age of 64.9 years and 73.0% were women. The 2 treatment groups were similar in baseline characteristics. Sixty-eight (69.4%) DM I-TEAM participants and 69 (67.6%) UMC participants had at least 1 incident ED visit/hospitalization over 12 months. The adjusted incidence rate ratio for DM I-TEAM versus UMC was 1.11 (95% confidence interval 0.79-1.56; P = 0.54). DM I-TEAM participants attained significantly better diabetes self-management, diabetes self-efficacy, and institutional trust than UMC participants. There were no treatment group differences in hemoglobin A1c level nor PIMs use. Among Black individuals with diabetes, a novel culturally relevant intervention was no better than usual care at preventing return ED visits/hospitalizations over 1 year. Before reasonable clinical interventions such as DM I-TEAM can be effective, reducing system-level barriers to health, building community health care capacity, and designing interventions that better align with the everyday realities of patients' lives are necessary. clinicaltrials.gov NCT03393338.

Economic Analysis of the Tailored Activity Program: A Nonpharmacological Approach to Improve Quality of Life in People Living With Dementia and their Caregivers.

We investigated costs of delivering the Tailored Activity Program (TAP) and cost savings from two perspectives (health sector and societal) for people living with dementia (PLWD) and their caregivers (dyads) compared to attention control (AC) using data from a randomized controlled trial. The evaluation assessed intervention delivery costs and caregiver reported health care utilization. The total intervention cost of TAP was $1707/dyad versus $864/dyad for AC, and total costs over 6 months for TAP dyads as compared to AC were $1299 (CI: -$10,496, $7898) less from the healthcare perspective, and $761 (CI: -$10,133, $8611) less from the societal perspective. TAP cost savings are driven by lower use of healthcare services among participating dyads, but further analyses with larger samples is warranted to confirm its financial impact.

Manhattan Vision Screening and Follow-up Study (NYC-SIGHT): Baseline Results and Costs of a Cluster-Randomized Trial.

PURPOSE: To describe the 15-month baseline results and costs of the Manhattan Vision Screening and Follow-up Study, which aims to investigate whether innovative community-based eye health screening can improve early detection and management of glaucoma and other eye diseases among high-risk populations. DESIGN: Five-year prospective, cluster-randomized controlled trial. METHODS: Individuals aged 40+ years were recruited from public housing buildings in New York City for an eye health screening (visual acuity (VA) with correction, intraocular pressure measurements (IOP), and fundus photography). Participants with VA 20/40 or worse, IOP 23-29 mm Hg, or an unreadable fundus image failed the screening and were scheduled for an optometric examination at the same location; those with an abnormal image were referred to ophthalmology. A cost analysis was conducted alongside the study. RESULTS: A total of 708 participants were screened; mean age 68.6±11.9 years, female (65.1%), African American (51.8%) and Hispanic (42%). 78.4% (n = 555) failed the eye health screening; 35% (n= 250) had an abnormal image and were also referred to ophthalmology. 308 participants attended the optometric exam; 218 were referred to ophthalmology. Overall, 66.1% were referred to ophthalmology. The cost per participant to deliver the eye health screening and optometric examination was $180.88. The cost per case of eye disease detected was $273.64. CONCLUSIONS: This innovative study in public housing developments targeted high-risk populations, provided access to eye-care, and improved early detection of ocular diseases in New York City. The study has identified strategies to overcoming barriers to eye care to reduce eye health disparities.

Cost-Benefit Analysis of the COPE Program for Persons Living With Dementia: Toward a Payment Model.

BACKGROUND AND OBJECTIVES: There is a critical need for effective interventions to support quality of life for persons living with dementia and their caregivers. Growing evidence supports nonpharmacologic programs that provide care management, disease education, skills training, and support. This cost-benefit analysis examined whether the Care of Persons with Dementia in their Environments (COPE) program achieves cost savings when incorporated into Connecticut's home- and community-based services (HCBS), which are state- and Medicaid-funded. RESEARCH DESIGN AND METHODS: Findings are based on a pragmatic trial where persons living with dementia and their caregiver dyads were randomly assigned to COPE with HCBS, or HCBS alone. Cost measures included those relevant to HCBS decision makers: intervention delivery, health care utilization, caregiver time, formal care, and social services. Data sources included care management records and caregiver report. RESULTS: Per-dyad mean cost savings at 12 months were $2 354 for those who received COPE with a mean difference-in-difference of -$6 667 versus HCBS alone (95% CI: -$15 473, $2 734; not statistically significant). COPE costs would consume 5.6%-11.3% of Connecticut's HCBS annual spending limit, and HCBS cost-sharing requirements align with participants' willingness to pay for COPE. DISCUSSION AND IMPLICATIONS: COPE represents a potentially cost-saving dementia care service that could be financed through existing Connecticut HCBS. HCBS programs represent an important, sustainable payment model for delivering nonpharmacological dementia interventions such as COPE.

Economic implications of FDA platelet bacterial guidance compliance options: Comparison of single-step strategies.

BACKGROUND: Bloodborne pathogens pose a major safety risk in transfusion medicine. To mitigate the risk of bacterial contamination in platelet units, FDA issues updated guidance materials on various bacterial risk control strategies (BRCS). This analysis presents results of a budget impact model updated to include 5- and 7-day pathogen reduced (PR) and large volumed delayed sampling (LVDS) BRCS. STUDY DESIGN AND METHODS: Model base-case parameter inputs were based on scientific literature, a survey distributed to 27 US hospitals, and transfusion experts' opinion. The outputs include hospital budget and shelf-life impacts for 5- and 7-day LVDS, and 5- and 7-day PR units under three different scenarios: (1) 100% LVDS, (2) 100% PR, and (3) mix of 50% LVDS - and 50% PR. RESULTS: Total annual costs from the hospital perspective were highest for 100% LVDS platelets (US$2.325M) and lowest for 100% PR-7 units (US$2.170M). Net budget impact after offsetting annual costs by outpatient reimbursements was 5.5% lower for 5-day PR platelets as compared to 5-day LVDS (US$1.663 vs. US$1.760M). A mix of 7-day LVDS and 5-day PR platelets had net annual costs that were 1.3% lower than for 100% 7-day LVDS, but 1.3% higher than for 100% 5-day PR. 7-day PR platelets had the longest shelf life (4.63 days), while 5-day LVDS had the shortest (2.00 days). DISCUSSION: The model identifies opportunities to minimize transfusion center costs for 5- and 7-day platelets. Budget impact models such as this are important for understanding the financial implications of evolving FDA guidance and new platelet technologies.

Polypharmacy and Potentially Inappropriate Medication Use in Older Blacks with Diabetes Mellitus Presenting to the Emergency Department.

Background: Medication-related problems in older Blacks with diabetes mellitus (DM) are not well established. Objectives: To describe the frequency of medication-related problems in older Blacks with DM presenting to the emergency department (ED). Methods: The study was a cross-sectional analysis of baseline data from a randomized controlled trial evaluating Blacks aged ≥60 years of age presenting to the ED. Polypharmacy, potentially inappropriate medication (PIM) use, and anticholinergic score were evaluated. Results: Of 168 patients (median age = 68, range 60-92), most (n = 164, 98%) were taking ≥5 medications, and 67 (39.9%) were taking a PIM. A majority (n = 124, 74%) were taking a medication with an anticholinergic score ≥1. Number of medications was correlated with number of PIMs (r = .22, p = .004) and anticholinergic score (r = .50, p < .001). Conclusion: Polypharmacy and PIM use was common in older Blacks with DM.

Assessing the impact of medically tailored meals and medical nutrition therapy on type 2 diabetes: Protocol for Project MiNT.

BACKGROUND: Research has shown that among people with type 2 diabetes mellitus, reduction in hemoglobin A1c (HbA1c) prevents long term complications. Medically tailored meals (MTM) and telehealth-delivered medical nutrition therapy (tele-MNT) are promising strategies for patient-centered diabetes care. OBJECTIVES: Project MiNT will determine whether provision of MTM with and without the addition of telehealth-delivered medical nutrition therapy improves HbA1c and is cost effective for patients with type 2 diabetes mellitus. METHODS: Patients with poorly controlled type 2 diabetes mellitus (HbA1c >8%) will be recruited from Jefferson Health. Eligible patients will be randomized to one of three arms: 1) usual care, 2) 12 weeks of home-delivered MTM, or 3) MTM + 12 months of tele-MNT. All participants (n = 600) will complete three follow-up assessments at 3, 6, and 12 months. The primary outcome is change in HbA1c at 6 months. Secondary outcomes include change in HbA1c at 3 and 12 months and cost-effectiveness of the intervention at 6 and 12 months. Conclusion Findings from Project MiNT will inform MTM coverage and financing decisions, how to structure services for scalability and system-wide integration, and the role of these services in reducing health disparities.

Manhattan Vision Screening and Follow-Up Study in Vulnerable Populations: 1-Month Feasibility Results.

Purpose/Aim: In the United States, high rates of vision impairment and eye disease disproportionately impact those who lack access to eye care, specifically vulnerable populations. The objective of our study was to test instruments, implement protocols, and collect preliminary data for a larger 5-year study, which aims to improve detection of eye diseases and follow-up eye care in vulnerable populations using community health workers (CHW) and patient navigators. In the study, trained CHWs conducted vision screening and patient navigators scheduled on-site eye exams and arranged appointments for those referred to ophthalmology to improve adherence to follow-up eye care.Materials and Methods: Eligible individuals age 40-and-older were recruited from the Riverstone Senior Center in Upper Manhattan, New York City. Participants underwent on-site vision screening (visual acuity with correction, intraocular pressure measurements, and fundus photography). Individuals who failed the vision screening were scheduled with an on-site optometrist for an eye exam; those with ocular pathologies were referred to an ophthalmologist. Participants were also administered the National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ-8) and Stopping Elderly Accidents, Deaths, and Injuries (STEADI) test by community health workers.Results:Participants (n = 42) were predominantly older adults, with a mean age of 70.0 ± 9.8, female (61.9%), and Hispanic (78.6%). Most individuals (78.6%, n = 33) failed vision screening. Of those who failed, 84.8% (n = 28) attended the on-site eye exam with the optometrist. Ocular diagnoses: refractive error 13/28 (46.4%), glaucoma/glaucoma suspect 9/28 (32.1%), cataract 7/28 (25.0%), retina abnormalities 6/28 (21.4%); 13 people required eyeglasses.Conclusion: This study demonstrates the feasibility of using CHWs and patient navigators for reducing barriers to vision screening and optometrist-based eye exams in vulnerable populations, ultimately improving early detection of eye disease and linking individuals to additional eye care appointments. The full five-year study aims to further examine these outcomes.

A longitudinal evaluation of family caregivers' willingness to pay for an in-home nonpharmacologic intervention for people living with dementia: results from a randomized trial.

OBJECTIVE: To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD). DESIGN: Randomized clinical trial. SETTING: Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC. PARTICIPANTS: 250 dyads. INTERVENTION: Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use. MEASUREMENT: At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence. RESULTS: At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: -$5.00, $25.47) and $7.15 (95%CI: -$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was -12% (95%CI: -28%, -5%) and -7% (95%CI:-25%, -11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: -$2.57, $28.17). CONCLUSIONS: Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

Impact of body mass index on survival and serious adverse events in advanced non-small cell lung cancer treated with bevacizumab: a meta-analysis of randomized clinical trials.

PURPOSE: Lung cancer accounts for 28% of all cancer deaths, more deaths than any other cancer in the United States. The influence of body composition has been evaluated in several studies, specifically, the influence of obesity on lung cancer survival. Outcomes have been mixed, with some studies demonstrating a paradoxical beneficial effect in early lung cancer where survival is improved in obese patients. The study aim was to evaluate the impact of obesity on overall survival (OS), progression free survival (PFS), and occurrence of serious adverse events (SAE) in clinical trials evaluating bevacizumab for advanced non-small cell lung cancer (NSCLC). METHODS: We performed a post hoc analysis combining available individual level data from bevacizumab randomized clinical trials available through the Clinical Study Data Request database. The primary outcome measured in our analysis was the influence of bevacizumab on OS stratified by body mass index (BMI). In addition to OS, both PFS and the occurrence of SAE requiring therapy interruption were evaluated. All endpoints were evaluated in patients who were obese (BMI ≥30.0 kg/m2) compared with non-obese (BMI <30.0 kg/m2). As a sensitivity analysis, endpoints were also evaluated in patients who were overweight (BMI ≥25.0 kg/m2) compared with non-overweight (BMI <25.0 kg/m2). In addition to analysis of each individual study, a meta-analysis was performed in order to calculate pooled hazard ratios (HR). Hazard ratios for both OS and PFS were calculated using multivariable Cox proportional hazards models. Odds ratios for SAE were calculated using multivariable logistic regression. The validity of the regression models was tested using a log-log plot and overall fit using the goodness of fit test. RESULTS: After adjusting for covariates using a Cox proportional hazards model and combining the resulting adjusted hazard ratios using meta-analysis, there was no significant difference between obese and non-obese groups for OS or PFS. In addition, when treatment discontinuation due to an adverse event was assessed, none of the trials showed a significant difference between the obese and non-obese groups. CONCLUSION: In this analysis of clinical trial data, obesity was not associated with worse survival versus non-obese individuals in advanced NSCLC. In addition, serious adverse events were similar between patients with and without obesity.

Economic Analyses of Pathogen-Reduction Technologies in Blood Transfusion: A Systematic Literature Review.

BACKGROUND: Technologies used in the processing of whole blood and blood component products, including pathogen reduction, are continuously being adopted into blood transfusion workflows to improve process efficiencies. However, the economic implications of these technologies are not well understood. With the advent of these new technologies and regulatory guidance on bacterial risk-control strategies, an updated systematic literature review on this topic was warranted. OBJECTIVE: The objective of this systematic literature review was to summarize the current literature on the economic analyses of pathogen-reduction technologies (PRTs). METHODS: A systematic literature review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to identify newly published articles in PubMed, MEDLINE Complete, and EconLit from 1 January 2000 to 17 July 2019 related to economic evaluations of PRTs. Only full-text studies in humans published in English were included in the review. Both budget-impact and cost-effectiveness studies were included; common outcomes included cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS: The initial searches identified 433 original abstracts, of which 16 articles were included in the final data extraction and reporting. Seven articles presented cost-effectiveness analyses and nine assessed budget impact. The introduction of PRT increased overall costs, and ICER values ranged widely across cost-effectiveness studies, from below $US150,000/QALY to upwards of $US20,000,000/QALY. This wide range of results was due to a multitude of factors, including comparator selection, target patient population, and scenario analyses included. CONCLUSIONS: Overall, the results of economic evaluations of bacterial risk-control strategies, regardless of mechanism, were highly dependent on the current screening protocols in place. The optimization of blood transfusion safety may not result in decisions made at the willingness-to-pay thresholds commonly seen in pharmaceutical evaluations. Given the critical public health role of blood products, and the potential safety benefits introduced by advancements, it is important to continue building this body of evidence with more transparency and data source heterogeneity. This updated literature review provides global context when making local decisions for the coverage of new and emerging bacterial risk-control strategies.

Reducing the Costs of an Eye Care Adherence Program for Underserved Children Referred Through Inner-City Vision Screenings.

PURPOSE: We previously reported costs and outcomes of the Children's Eye Care Adherence Program (CECAP1), a social worker intervention designed to improve adherence to eye care for underserved children in urban Philadelphia. Using cost findings from CECAP1, we revised the intervention to reduce costs. The aim of this study was to evaluate costs and effectiveness of the revised intervention (CECAP2). DESIGN: Retrospective cohort study. METHODS: Records of children needing ophthalmic follow-up after 2 community-based vision screening programs were reviewed. We modified CECAP1 to prioritize children more likely to visit, decreased phone calls and scheduling attempts, better documented children already followed by other doctors, and constricted our geographic catchment area for better accessibility. Cost was calculated using time spent executing CECAP2 by our salaried social worker. Effectiveness was defined as the percentage of patients completing at least 1 follow-up visit within the recommended time frame. RESULTS: Of 462 children referred to CECAP2 from our in-school and on-campus screening programs, 242 (52.4%) completed subsequent recommended eye examinations, a proportion identical to our prior report (52.3%). Social worker time per patient was 0.8 hours; a significant reduction from the previous 2.6 hours (P < .01). Cost per patient was $32.73; a significant reduction compared to the previous $77.20 (P < .01). CONCLUSIONS: Programmatic changes to reduce social worker intervention time and target potential patients by likelihood to attend along with constriction of the catchment area led to reduced costs by more than 50%, without impairing CECAP effectiveness.