What is the cost-effectiveness of menu calorie labelling on reducing obesity-associated cancer burdens? An economic evaluation of a federal policy intervention among 235 million adults in the USA.

OBJECTIVE: To assess the impact of menu calorie labelling on reducing obesity-associated cancer burdens in the USA. DESIGN: Cost-effectiveness analysis using a Markov cohort state-transition model. SETTING: Policy intervention. PARTICIPANTS: A modelled population of 235 million adults aged ≥20 years in 2015-2016. INTERVENTIONS: The impact of menu calorie labelling on reducing 13 obesity-associated cancers among US adults over a lifetime was evaluated for: (1) effects on consumer behaviours; and (2) additional effects on industry reformulation. The model integrated nationally representative demographics, calorie intake from restaurants, cancer statistics and estimates on associations of policy with calorie intake, dietary change with body mass index (BMI) change, BMI with cancer rates, and policy and healthcare costs from published literature. MAIN OUTCOME MEASURES: Averted new cancer cases and cancer deaths and net costs (in 2015 US$) among the total population and demographic subgroups were determined. Incremental cost-effectiveness ratios from societal and healthcare perspectives were assessed and compared with the threshold of US$150 000 per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs). RESULTS: Considering consumer behaviour alone, this policy was associated with 28 000 (95% UI 16 300 to 39 100) new cancer cases and 16 700 (9610 to 23 600) cancer deaths averted, 111 000 (64 800 to 158 000) QALYs gained, and US$1480 (884 to 2080) million saved in cancer-related medical costs among US adults. The policy was associated with net cost savings of US$1460 (864 to 2060) million and US$1350 (486 to 2260) million from healthcare and societal perspectives, respectively. Additional industry reformulation would substantially increase policy impact. Greater health gains and cost savings were predicted among young adults, Hispanic and non-Hispanic Black individuals. CONCLUSIONS: Study findings suggest that menu calorie labelling is associated with lower obesity-related cancer burdens and reduced healthcare costs. Policymakers may prioritise nutrition policies for cancer prevention in the USA.

Cost-effectiveness Analysis of Nutrition Facts Added-Sugar Labeling and Obesity-Associated Cancer Rates in the US.

Importance: Obesity-associated cancer burdens are increasing in the US. Nutrition policies, such as the Nutrition Facts added-sugar labeling, may reduce obesity-associated cancer rates. Objective: To evaluate the cost-effectiveness of Nutrition Facts added-sugar labeling and obesity-associated cancer rates in the US. Design, Setting, and Participants: A probabilistic cohort state-transition model was used to conduct an economic evaluation of added-sugar labeling and 13 obesity-associated cancers among 235 million adults aged 20 years or older by age, sex, and race/ethnicity over a median follow-up of 34.4 years. Policy associations were considered in 2 scenarios: with consumer behaviors and with additional industry reformulation. The model integrated nationally representative population demographics, diet, and cancer statistics; associations of policy intervention with diet, diet change and body mass index, and body mass index with cancer risk; and policy and health-related costs from established sources. Data were analyzed from January 8, 2019, to May 6, 2020. Main Outcomes and Measures: Net costs and incremental cost-effectiveness ratio were estimated from societal and health care perspectives. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs). Results: Based on consumer behaviors, the policy was associated with a reduction of 30 000 (95% UI, 21 600-39 300) new cancer cases and 17 100 (95% UI, 12 400-22 700) cancer deaths, a gain of 116 000 (95% UI, 83 800-153 000) quality-adjusted life-years, and a saving of $1600 million (95% UI, $1190 million-$2030 million) in medical costs associated with cancer care among US adults over a lifetime. The policy was associated with a savings of $704 million (95% UI, $44.5 million-$1450 million) from the societal perspective and $1590 million (95% UI, $1180 million-$2020 million) from the health care perspective. Additional industry reformulation to reduce added-sugar amounts in packaged foods and beverages would double the impact. Greater health gains and cost savings were expected among young adults, women, and non-Hispanic Black individuals than other population subgroups. Conclusions and Relevance: These findings suggest that the added-sugar labeling is associated with reduced costs and lower rates of obesity-associated cancers. Policymakers may consider and prioritize nutrition policies for cancer prevention in the US.

Cost-effectiveness of a Nutrition Education Curriculum Intervention in Elementary Schools.

OBJECTIVE: To estimate the long-term cost-effectiveness of an obesity prevention nutrition education curriculum (Food, Health, & Choices) as delivered to all New York City fifth-grade public school students over 1 year. METHODS: This study is a standard cost-effectiveness analysis from a societal perspective, with a 3% discount rate and a no-intervention comparator, as recommended by the US Panel on Cost-effectiveness in Health and Medicine. Costs of implementation, administration, and future obesity-related medical costs were included. Effectiveness was based on a cluster-randomized, controlled trial in 20 public schools during the 2012-2013 school year and linked to published estimates of childhood-to-adulthood body mass index trajectories using a decision analytic model. RESULTS: The Food, Health, & Choices intervention was estimated to cost $8,537,900 and result in 289 fewer males and 350 fewer females becoming obese (0.8% of New York City fifth-grade public school students), saving 1,599 quality-adjusted life-years (QALYs) and $8,098,600 in direct medical costs. Food, Health, & Choices is predicted to be cost-effective at $275/QALY (95% confidence interval, -$2,576/QALY to $2,084/QALY) with estimates up to $6,029/QALY in sensitivity analyses. CONCLUSIONS AND IMPLICATIONS: This cost-effectiveness model suggests that a nutrition education curriculum in public schools is effective and cost-effective in reducing childhood obesity, consistent with the authors' hypothesis and previous literature. Future research should assess the feasibility and sustainability of scale-up.

Why the Neighborhood Social Environment Is Critical in Obesity Prevention.

The continuing obesity epidemic in the USA calls for the examination of antecedents to the well-known risk factors of physical activity and diet. The neighborhood built environment has been extensively studied in relation to obesity noting an increased risk of development and prevalence of obesity in relation to numerous built environment characteristics (lack of green spaces, higher number of fast food restaurants, low walkability indices). The neighborhood social environment, however, has been less extensively studied but is perhaps an equally important component of the neighborhood environment. The neighborhood social environment, particularly constructs of social capital, collective efficacy, and crime, is associated with obesity among both adults and children. Several studies have identified physical activity as a potential pathway of the neighborhood social environment and obesity association. Further work on social networks and norms and residential segregation, as well as the examination of dietary behaviors and mental health as potential mediating pathways, is necessary. Given the existing evidence, intervening on the neighborhood social environment may prove to be an effective target for the prevention on obesity. Intervention studies that promote healthy behaviors and prevent obesity while addressing aspects of the neighborhood social environment are necessary to better identify targets for obesity prevention.

Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation.

BACKGROUND: Obesity is associated with adverse outcomes and increased costs after total knee arthroplasty. Bariatric surgery is an effective treatment for morbid obesity, but its cost-effectiveness for weight loss prior to total knee arthroplasty is unknown. The purpose of this study was to evaluate the cost-effectiveness of bariatric surgery prior to total knee arthroplasty for patients in whom medical treatment of obesity and knee osteoarthritis had failed. METHODS: A state-transition Markov model was constructed to compare the cost-utility of two treatment protocols for patients with morbid obesity and end-stage knee osteoarthritis: (1) immediate total knee arthroplasty and (2) bariatric surgery two years prior to the total knee arthroplasty. The probability of transition for each health state and its utility were derived from the literature. Costs, expressed in 2012 United States dollars, were estimated with use of administrative and claims data. Costs and utilities were discounted at 3% annually, and effectiveness was expressed in quality-adjusted life-years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed, using $100,000 per QALY as the threshold willingness to pay. RESULTS: Morbidly obese patients undergoing total knee arthroplasty alone had lower QALYs gained than patients who underwent bariatric surgery two years prior to the total knee arthroplasty. The ICER between these two procedures was approximately $13,910 per QALY, well below the threshold willingness to pay. Results were stable across broad value ranges for independent variables. Probabilistic sensitivity analysis found that the median ICER was $14,023 per QALY (95% confidence interval, $4875 to $51,210 per QALY). CONCLUSIONS: This model supports bariatric surgery prior to total knee arthroplasty as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis who are indicated for total knee arthroplasty. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013.

Efforts to expand Medicaid while controlling spending must be informed by a deeper understanding of the extent to which the high medical costs associated with severe obesity (having a body mass index of [Formula: see text] or higher) determine spending at the state level. Our analysis of population-representative data indicates that in 2013, severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. Approximately 11 percent of the cost of severe obesity was paid for by Medicaid, 30 percent by Medicare and other federal health programs, 27 percent by private health plans, and 30 percent out of pocket. Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations' access to cost-effective treatment for severe obesity should be part of each state's strategy to mitigate rising obesity-related health care costs.

Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement.

Policy makers seeking to reduce childhood obesity must prioritize investment in treatment and primary prevention. We estimated the cost-effectiveness of seven interventions high on the obesity policy agenda: a sugar-sweetened beverage excise tax; elimination of the tax subsidy for advertising unhealthy food to children; restaurant menu calorie labeling; nutrition standards for school meals; nutrition standards for all other food and beverages sold in schools; improved early care and education; and increased access to adolescent bariatric surgery. We used systematic reviews and a microsimulation model of national implementation of the interventions over the period 2015-25 to estimate their impact on obesity prevalence and their cost-effectiveness for reducing the body mass index of individuals. In our model, three of the seven interventions--excise tax, elimination of the tax deduction, and nutrition standards for food and beverages sold in schools outside of meals--saved more in health care costs than they cost to implement. Each of the three interventions prevented 129,000-576,000 cases of childhood obesity in 2025. Adolescent bariatric surgery had a negligible impact on obesity prevalence. Our results highlight the importance of primary prevention for policy makers aiming to reduce childhood obesity.

Strategies for Primary Prevention of Coronary Heart Disease Based on Risk Stratification by the ACC/AHA Lipid Guidelines, ATP III Guidelines, Coronary Calcium Scoring, and C-Reactive Protein, and a Global Treat-All Strategy: A Comparative--Effectiveness Modeling Study.

BACKGROUND: Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown. METHODS: We constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45-75 and women 55-75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe. RESULTS: Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event. CONCLUSIONS: Despite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers.

Economic and Survival Implications of Use of Electric Power Morcellation for Hysterectomy for Presumed Benign Gynecologic Disease.

BACKGROUND: Electric power morcellation during laparoscopic hysterectomy allows some women to undergo minimally invasive surgery but may disrupt underlying occult malignancies and increase the risk of tumor dissemination. METHODS: We developed a state transition Markov cohort simulation model of the risks and benefits of hysterectomy (abdominal, laparoscopic, and laparoscopic with electric power morcellation) for women with presumed benign gynecologic disease. The model considered perioperative morbidity, mortality, risk of cancer and dissemination, and outcomes in women with an underlying malignancy. We explored the effectiveness from a societal perspective stratified by age (<40, 40-49, 50-59, and ≥60 years). RESULTS: Under all scenarios, modeled laparoscopic hysterectomy without morcellation was the most beneficial strategy. Laparoscopic hysterectomy with morcellation was associated with 80.83 more intraoperative complications, 199.64 fewer perioperative complications, and 241.80 fewer readmissions than abdominal hysterectomy per 10 000 women. Per 10 000 women younger than age 40 years, laparoscopic hysterectomy with morcellation was associated with 1.57 more cases of disseminated cancer and 0.97 fewer deaths than abdominal hysterectomy. The excess cases of disseminated cancer per 10 000 women with morcellation compared with abdominal hysterectomy increased with age to 47.54 per 10 000 in women age 60 years and older. Compared with abdominal hysterectomy, this resulted in 0.30 (age 40-49 years), 5.07 (age 50-59 years), and 18.14 (age 60 years and older) excess deaths per 10 000 women in the respective age groups. CONCLUSION: Laparoscopic hysterectomy without morcellation is the most beneficial approach of the three methods of hysterectomy studied. In older women, the risks of electric power morcellation may outweigh the benefits of minimally invasive hysterectomy.

Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common among young athletes. Biomechanical studies have led to the development of training programs to improve neuromuscular control and reduce ACL injury rates as well as screening tools to identify athletes at higher risk for ACL injury. The purpose of this study was to evaluate the cost-effectiveness of these training methods and screening strategies for preventing ACL injuries. METHODS: A decision-analysis model was created to evaluate three strategies for a population of young athletes participating in organized sports: (1) no training or screening, (2) universal neuromuscular training, and (3) universal screening, with neuromuscular training for identified high-risk athletes only. Risk of injury, risk reduction from training, and sensitivity and specificity of screening were based on published data from clinical trials. Costs of training and screening programs were estimated on the basis of the literature. Sensitivity analyses were performed on key model parameters to evaluate their effect on base case conclusions. RESULTS: Universal neuromuscular training of all athletes was the dominant strategy, with better outcomes and lower costs compared with screening. On average, the implementation of a universal training program would save $100 per player per season, and would reduce the incidence of ACL injury from 3% to 1.1% per season. Screening was not cost-effective within the range of reported sensitivity and specificity values. CONCLUSIONS AND CLINICAL RELEVANCE: Given its low cost and ease of implementation, neuromuscular training of all young athletes represents a cost-effective strategy for reducing costs and morbidity from ACL injuries. While continued innovations on inexpensive and accurate screening methods to identify high-risk athletes remain of interest, improving existing training protocols and implementing neuromuscular training into routine training for all young athletes is warranted.

Cost-effectiveness of chemoprevention with proton pump inhibitors in Barrett's esophagus.

BACKGROUND: Proton pump inhibitors (PPIs) may reduce the risk of esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus. PPIs are prescribed for virtually all patients with Barrett's esophagus, irrespective of the presence of reflux symptoms, and represent a de facto chemopreventive agent in this population. However, long-term PPI use has been associated with several adverse effects, and the cost-effectiveness of chemoprevention with PPIs has not been evaluated. AIM: The purpose of this study was to assess the cost-effectiveness of PPIs for the prevention of EAC in Barrett's esophagus without reflux. METHODS: We designed a state-transition Markov microsimulation model of a hypothetical cohort of 50-year-old white men with Barrett's esophagus. We modeled chemoprevention with PPIs or no chemoprevention, with endoscopic surveillance for all treatment arms. Outcome measures were life-years, quality-adjusted life years (QALYs), incident EAC cases and deaths, costs, and incremental cost-effectiveness ratios. RESULTS: Assuming 50% reduction in EAC, chemoprevention with PPIs was a cost-effective strategy compared to no chemoprevention. In our model, administration of PPIs cost $23,000 per patient and resulted in a gain of 0.32 QALYs for an incremental cost-effectiveness ratio of $12,000/QALY. In sensitivity analyses, PPIs would be cost-effective at $50,000/QALY if they reduce EAC risk by at least 19%. CONCLUSIONS: Chemoprevention with PPIs in patients with Barrett's esophagus without reflux is cost-effective if PPIs reduce EAC by a minimum of 19%. The identification of subgroups of Barrett's esophagus patients at increased risk for progression would lead to more cost-effective strategies for the prevention of esophageal adenocarcinoma.

Cost-effectiveness of QuantiFERON testing before initiation of biological therapy in inflammatory bowel disease.

BACKGROUND: Anti-tumor necrosis factor α drugs are known to reactivate latent tuberculosis (TB). Current guidelines recommend screening for latent tuberculosis infection, with either tuberculin skin test (TST) or interferon gamma release assays such as QuantiFERON-TB Gold (QFT-G). Given the high rates of anergy to TST among immunosuppressed inflammatory bowel disease (IBD) patients, there is considerable interest in evaluating the superiority of interferon gamma release assays over TST in this patient population to diagnose latent tuberculosis infection. We compared the performance of TST and QFT-G for screening latent TB among immunosuppressed IBD patients based on prevalence, mortality risk from reactivation TB, and costs. METHODS: A decision analytical model was constructed to compare 1-year outcomes and costs of using TST or interferon gamma release assay in an immunosuppressed IBD population. RESULTS: Under the base case scenario, for every 1000 patients screened, the QFT-G strategy resulted in 0.53 deaths from reactivation TB compared with 1.92 deaths using TST. The QFT-G strategy results in 1.85 reactivation TB versus 6.7 reactivation TB using TST. The model was not sensitive to background prevalence of latent TB. The cost of QFT-G would have to be more than double for the TST strategy to become more cost effective. QFT-G also remains the cost-effective option unless the sensitivity of the TST improves by 400%. CONCLUSIONS: Under a broad range of parameter values, the QFT-G strategy dominates the TST strategy in cost-effectiveness. Consideration should be given to QFT-G as the preferred method of identifying latent TB in all immunosuppressed IBD patients.

Derivation of background mortality by smoking and obesity in cancer simulation models.

BACKGROUND: Simulation models designed to evaluate cancer prevention strategies make assumptions on background mortality-the competing risk of death from causes other than the cancer being studied. Researchers often use the U.S. life tables and assume homogeneous other-cause mortality rates. However, this can lead to bias because common risk factors such as smoking and obesity also predispose individuals for deaths from other causes such as cardiovascular disease. METHODS: We obtained calendar year-, age-, and sex-specific other-cause mortality rates by removing deaths due to a specific cancer from U.S. all-cause life tables. Prevalence across 12 risk factor groups (3 smoking [never, past, and current smoker] and 4 body mass index [BMI] categories [<25, 25-30, 30-35, 35+ kg/m(2)]) were estimated from national surveys (National Health and Nutrition Examination Surveys [NHANES] 1971-2004). Using NHANES linked mortality data, we estimated hazard ratios for death by BMI/smoking using a Poisson regression model. Finally, we combined these results to create 12 sets of BMI and smoking-specific other-cause life tables for U.S. adults aged 40 years and older that can be used in simulation models of lung, colorectal, or breast cancer. RESULTS: We found substantial differences in background mortality when accounting for BMI and smoking. Ignoring the heterogeneity in background mortality in cancer simulation models can lead to underestimation of competing risk of deaths for higher-risk individuals (e.g., male, 60-year old, white obese smokers) by as high as 45%. CONCLUSION: Not properly accounting for competing risks of death may introduce bias when using simulation modeling to evaluate population health strategies for prevention, screening, or treatment. Further research is warranted on how these biases may affect cancer-screening strategies targeted at high-risk individuals.

Disparities in youth physical activity in the United States: 2003-2006.

PURPOSE: This study aimed to examine changes in physical activity among children and adolescents, by race/ethnicity, in the United States from 2003-2004 to 2005-2006. METHODS: Secondary analysis of the objectively measured accelerometer data among children and adolescents 6-19 yr: 2003-2004 (n = 1665) and 2005-2006 (n = 1716) from the nationally representative National Health and Nutrition Examination Survey 2003-2004 and 2005-2006. We estimated regression coefficients for change between the two periods by age group, accounting for sampling design and adjusting for age, sex, race/ethnicity, and number of hours monitored. We tested for differences in mean accelerometer counts per minute and minutes per day of moderate and vigorous physical activity trends by race/ethnicity and gender. RESULTS: Physical activity decreased with age, boys were more active than girls, and non-Hispanic black children were more active than non-Hispanic whites (all P < 0.01). Overall mean accelerometer counts increased from 2003-2004 to 2005-2006 for children ages 6-11 yr (+31.6 counts per minute; 95% confidence interval = 0.51-62.6) but not among adolescents ages 12-19 yr. There was an increase over time in mean accelerometer counts among 6- to 11-yr-old non-Hispanic white children (+52.4 counts per minute, P = 0.007; 95% confidence interval = 15.7-89) but a decrease among non-Hispanic black and Mexican American children. No changes over the period in moderate and vigorous physical activity were found in either age group. CONCLUSIONS: The lack of improvement in physical activity among all children and adolescents and a potentially emerging race-ethnic disparity indicate a need for further research on potential mechanisms underlying these differences. Effective interventions to improve physical activity opportunities and attenuate the decline in activity levels as children enter adolescence are needed.

The impact of obesity on the rise in esophageal adenocarcinoma incidence: estimates from a disease simulation model.

BACKGROUND: The United States has experienced an alarming and unexplained increase in the incidence of esophageal adenocarcinoma (EAC) since the 1970s. A concurrent increase in obesity has led some to suggest a relationship between the two trends. We explore the extent of this relationship. METHODS: Using a previously validated disease simulation model of white males in the United States, we estimated EAC incidence 1973 to 2005 given constant obesity prevalence and low population progression rates consistent with the early 1970s. Introducing only the observed, rising obesity prevalence, we calculated the incremental incidence caused by obesity. We compared these with EAC incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry to determine obesity's contribution to the rise therein. Incidences were converted to absolute numbers of cases using U.S. population data. RESULTS: Using constant obesity prevalence, we projected a total of 30,555 EAC cases cumulatively over 1973 to 2005 and 1,151 in 2005 alone. Incorporating the observed obesity trend resulted in 35,767 cumulative EACs and 1,608 in 2005. Estimates derived from SEER data showed 111,223 cumulative and 7,173 cases in 2005. We conclude that the rise in obesity accounted for 6.5% of the increase in EAC cases that occurred from 1973 to 2005 and 7.6% in the year 2005. CONCLUSION: Using published OR for EAC among obese individuals, we found that only a small percentage of the rise in EAC incidence is attributable to secular trends in obesity. IMPACT: Other factors, alone and in combination, should be explored as causes of the EAC epidemic.

Health and economic burden of the projected obesity trends in the USA and the UK.

Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations--the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6-8·5 million cases of diabetes, 5·7-7·3 million cases of heart disease and stroke, 492,000-669,000 additional cases of cancer, and 26-55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year in the USA and by £1·9-2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

A minimally invasive approach is more cost-effective than a traditional sternotomy approach for mitral valve surgery.

OBJECTIVE: The aim of this study was to compare the cost and effectiveness of a minimally invasive (MI) versus traditional sternotomy (ST) approach for mitral valve surgery (MVS). METHODS: From January 1, 2003, to December 31, 2008, a total of 847 patients underwent isolated MVS at our institution. Propensity matching on 22 clinical variables was carried out to generate a study cohort of 434 patients (217 matched pairs). Direct and indirect costs from the hospital perspective were retrospectively obtained from our finance department. Total hospital costs were further stratified into 13 standardized institutional billing categories. In addition, data on morbidity, mortality, discharge location, hospital readmissions within 1 year, and freedom from reoperation were obtained. RESULTS: Compared with ST, MIMVS was associated with a $9054 ± $3302 lower mean total hospital cost (P = .006), driven largely by a reduction in direct (P = .003) versus indirect costs (P = .06). Among the 13 billing categories, MIMVS was associated with a significant reduction in costs of cardiac imaging (P = .004), laboratory tests (P = .005), boarding and nursing (P = .001), and radiology (P = .002). More patients in the ST group required intubation for more than 72 hours (P = .019); however, there were no differences in morbidity or long-term survival (P = .334). A higher proportion of MI patients were discharged home with no nursing services (P = .018), and a higher proportion of ST patients required readmission within 1 year (P = .023). There were no differences in freedom from reoperation between groups (P = .574). CONCLUSIONS: With equivalent efficacy across a range of measures and lower costs compared with ST, MIMVS represents a cost-saving strategy for MVS.

Effectiveness and cost-effectiveness of blood pressure screening in adolescents in the United States.

OBJECTIVE: To compare the long-term effectiveness and cost-effectiveness of 3 approaches to managing elevated blood pressure (BP) in adolescents in the United States: no intervention, "screen-and-treat," and population-wide strategies to lower the entire BP distribution. STUDY DESIGN: We used a simulation model to combine several data sources to project the lifetime costs and cardiovascular outcomes for a cohort of 15-year-old U.S. adolescents under different BP approaches and conducted cost-effectiveness analysis. We obtained BP distributions from the National Health and Nutrition Examination Survey 1999-2004 and used childhood-to-adult longitudinal correlation analyses to simulate the tracking of BP. We then used the coronary heart disease policy model to estimate lifetime coronary heart disease events, costs, and quality-adjusted life years (QALY). RESULTS: Among screen-and-treat strategies, finding and treating the adolescents at highest risk (eg, left ventricular hypertrophy) was most cost-effective ($18000/QALY [boys] and $47000/QALY [girls]). However, all screen-and-treat strategies were dominated by population-wide strategies such as salt reduction (cost-saving [boys] and $650/QALY [girls]) and increasing physical education ($11000/QALY [boys] and $35000/QALY [girls]). CONCLUSIONS: Routine adolescents BP screening is moderately effective, but population-based BP interventions with broader reach could potentially be less costly and more effective for early cardiovascular disease prevention and should be implemented in parallel.

Future cardiovascular disease in china: markov model and risk factor scenario projections from the coronary heart disease policy model-china.

BACKGROUND: The relative effects of individual and combined risk factor trends on future cardiovascular disease in China have not been quantified in detail. METHODS AND RESULTS: Future risk factor trends in China were projected based on prior trends. Cardiovascular disease (coronary heart disease and stroke) in adults ages 35 to 84 years was projected from 2010 to 2030 using the Coronary Heart Disease Policy Model-China, a Markov computer simulation model. With risk factor levels held constant, projected annual cardiovascular events increased by >50% between 2010 and 2030 based on population aging and growth alone. Projected trends in blood pressure, total cholesterol, diabetes (increases), and active smoking (decline) would increase annual cardiovascular disease events by an additional 23%, an increase of approximately 21.3 million cardiovascular events and 7.7 million cardiovascular deaths over 2010 to 2030. Aggressively reducing active smoking in Chinese men to 20% prevalence in 2020 and 10% prevalence in 2030 or reducing mean systolic blood pressure by 3.8 mm Hg in men and women would counteract adverse trends in other risk factors by preventing cardiovascular events and 2.9 to 5.7 million total deaths over 2 decades. CONCLUSIONS: Aging and population growth will increase cardiovascular disease by more than a half over the coming 20 years, and projected unfavorable trends in blood pressure, total cholesterol, diabetes, and body mass index may accelerate the epidemic. National policy aimed at controlling blood pressure, smoking, and other risk factors would counteract the expected future cardiovascular disease epidemic in China.