Cost-benefit analysis with return on investment of clinical pharmacists in the Military Health System.

BACKGROUND: The Defense Health Agency comprises more than 700 military medical, dental, and veterinary facilities and provides care to more than 9.6 million beneficiaries. As medication experts, pharmacists identify opportunities to optimize medication therapy, reduce cost, and increase readiness to support the Defense Health Agency's mission. The Tripler Pilot Project and the Army Polypharmacy Program were used to establish a staffing model of 1 clinical pharmacist for every 6,500 enrolled beneficiaries. No large-scale cost-benefit study within the military health care system has been done, which documents the number of clinical interventions and uses established cost-avoidance (CA) data, to determine the cost-benefit and return on investment (ROI) for clinical pharmacists working in the medical treatment facilities. OBJECTIVE: To validate the patient-centered medical home staffing model across the military health care system using the Tripler Pilot Project results to provide a cost-benefit analysis with an ROI. The secondary goal is to describe the interventions, staffing levels, and US Department of Defense-specific requirements impacting the provision of clinical pharmacy. METHODS: A retrospective analysis of 3 years of encounters by clinical pharmacists in which an intervention was documented in the Tri-Service Workflow (TSWF) form as part of the electronic health record was completed. The analysis used 6 steps to assign CA intervention types and to prevent duplication and overestimation of the ROI. The absolute number of clinical pharmacists was determined using workload criteria defined as at least 20 encounters per month for at least 3 months of each calendar year. The number of clinical pharmacist full-time employees (FTEs) was determined by dividing the number of total active months by 12 months. Attrition was calculated comparing the presence of a unique provider identification between calendar years. The ROI range was calculated by dividing the CA by the total cost of clinical pharmacists using the variables' raw and extrapolated CA based on percentage of documentation template usage and the active clinical pharmacist calculation (absolute and FTE-based). RESULTS: Between January 1, 2017, and December 31, 2019, a total of 1,069,846 encounters by clinical pharmacists were documented in the electronic health record. The TSWF Alternative Input Method form was used by pharmacists to document 616,942 encounters. Forty-three percent of TSWF documented encounters had at least 1 CA intervention. The absolute number of clinical pharmacists associated with a documented encounter in any medical treatment facility ranged from 404 in 2017 to 374 in 2018 and the clinical pharmacist FTEs ranged from 324 in 2017 to 314 in 2019. Annual attrition rates for clinical pharmacists ranged from 15% to 20% (58 to 81 clinical pharmacists) annually. The total CA range was $329,166,543-$534,014,494. The ROI range was between $2 and $4 per dollar spent. CONCLUSIONS: This analysis demonstrated that ambulatory care clinical pharmacists in the Military Health System bring value through a positive ROI. Our study also identified a potential shortage of clinical pharmacists within the Air Force and Navy branches impacting medication management. This can have a negative impact on the readiness of service members, one of the leading priorities of the US Department of Defense.

Best Evidence to Best Practice: Implementing an Innovative Model of Nutrition Care for Patients with Head and Neck Cancer Improves Outcomes.

Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despite publication of nutrition care evidence-based guidelines (EBGs), evidence-practice gaps exist. This study aimed to implement and evaluate the integration of a patient-centred, best-practice dietetic model of care into an HNC multidisciplinary team (MDT) to minimise the detrimental sequelae of malnutrition. A mixed-methods, pre-post study design was used to deliver key interventions underpinned by evidence-based implementation strategies to address identified barriers and facilitators to change at individual, team and system levels. A data audit of medical records established baseline adherence to EBGs and clinical parameters prior to implementation in a prospective cohort. Key interventions included a weekly Supportive Care-Led Pre-Treatment Clinic and a Nutrition Care Dashboard highlighting nutrition outcome data integrated into MDT meetings. Focus groups provided team-level evaluation of the new model of care. Economic analysis determined system-level impact. The baseline clinical audit (n = 98) revealed barriers including reactive nutrition care, lack of familiarity with EBGs or awareness of intensive nutrition care needs as well as infrastructure and dietetic resource limitations. Post-implementation data (n = 34) demonstrated improved process and clinical outcomes: pre-treatment dietitian assessment; use of a validated nutrition assessment tool before, during and after treatment. Patients receiving the new model of care were significantly more likely to complete prescribed radiotherapy and systemic therapy. Differences in mean percentage weight change were clinically relevant. At the system level, the new model of care avoided 3.92 unplanned admissions and related costs of $AUD121K per annum. Focus groups confirmed clear support at the multidisciplinary team level for continuing the new model of care. Implementing an evidence-based nutrition model of care in patients with HNC is feasible and can improve outcomes. Benefits of this model of care may be transferrable to other patient groups within cancer settings.

Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy.

OBJECTIVE: To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts. MATERIALS AND METHODS: Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate. RESULTS: Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non-readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%. CONCLUSION: Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.

Optimising patient care in medical radiation services through health economics: an introduction.

The role of health economics in optimising patient care in medical radiation clinical settings is of increasing importance in ensuring efficient and effective service delivery. This commentary introduces health economics to medical radiation professionals by outlining the main analysis types utilised, highlighted by examples in the literature. The purpose is to provide an over-arching framework and starting point for incorporating health economics into medical radiation research study protocols.

The patient-centered oncology care on health care utilization and cost: A systematic review and meta-analysis.

BACKGROUND: Optimal cancer care entails coordination among multiple providers and continued follow-up and surveillance over time. The patient-centered care brings opportunities to improve the delivery of cancer care. The adoption of patient-centered oncology care (PCOC) is in its infancy. Evidence synthesis on the model's effectiveness is scant. PURPOSES: This is the first systemic review and meta-analysis on associations of PCOC with cancer patients' adverse health care utilization, cost, patient satisfaction, and quality of care. METHODS: Our study was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. Quality appraisal was performed using Downs and Black's quality checklist. Study-level effect sizes of adverse health care utilization were computed using Cohen's d and summarized using forest plots. Funnel plots were constructed to examine publication bias. RESULTS: Of 334 studies that were reviewed, 10 met eligibility criteria and were included into the final analysis. Many included studies implemented almost all six of patient-centered care core attributes, plus three additional attributes that specifically addressed cancer patients' needs, including triage pathways, standardized and evidence-based symptom management, as well as support patient navigation. PCOC patients had lower utilization of inpatient care (standardized means difference [SMD] = -0.027, p = .049). Overall positive effect of PCOC on emergency department use was small and not significant (SMD = -0.023, p = .103). With regard to cost and quality of care, our narrative summaries showed an overall positive direction, though we found limitations in individual study quality that precluded a meta-analysis. PUBLIC IMPLICATION: The results showed that it is possible to utilize patient-centered model to support best practice of cancer care. Early evidence shows that the PCOC model has potential to improve health care utilization, cost, and quality of care, but limited numbers of included articles and heterogeneity of those studies implied that more rigorous research is expected to further investigate the model's effects.

Simulated Costs of the ASCO Patient-Centered Oncology Payment Model in Medicare Beneficiaries With Newly Diagnosed Advanced Ovarian Cancer.

PURPOSE: Efforts to curb the rising costs of cancer care while improving quality include alternative payment models (APMs), which offer incentives to reduce avoidable spending and provide high-quality and cost-efficient care. The impact of proposed APMs has not been quantified in real-world practice. In this study, we evaluated ASCO's Patient-Centered Oncology Payment (PCOP) model in existing fee-for-service (FFS) Medicare beneficiaries to understand the magnitude of potential cost savings. MATERIALS AND METHODS: SEER-Medicare data were used to identify women with advanced ovarian cancer diagnosed between 2000 and 2012 who either (1) underwent primary debulking surgery followed by chemotherapy or (2) received neoadjuvant chemotherapy followed by surgery. Medicare payments in each cohort were used to compare FFS and PCOP and to estimate the potential for cost savings across health care services received, including outpatient emergency department visits, hospitalizations, and imaging. RESULTS: Three thousand seven hundred seventy-seven primary debulking surgery and 866 neoadjuvant chemotherapy patients were included in the study, with mean total costs of $75,433 and $95,138 in 2016 US$, respectively Most costs were related to chemotherapy or hospitalization. Additional PCOP-related payments would be offset if hospitalizations could be reduced by 11.6% or imaging claims by 88%. CONCLUSION: APMs have the potential to reduce costs of current FFS reimbursement via either a large reduction in imaging or a modest reduction in hospitalizations during treatment of ovarian cancer. PCOP is a reasonable payment structure for oncologists if the additional payments can provide the necessary resources to invest in improved coordination of care.

As Value Assessment Frameworks Evolve, Are They Finally Ready for Prime Time?

BACKGROUND: Value assessment frameworks have emerged as tools to assist healthcare decision makers in the United States in assessing the relative value of healthcare services and treatments. As more healthcare decision makers in the United States-including state government agencies, pharmacy benefit managers, employers, and health plans-publicly consider the adoption of value frameworks, it is increasingly important to critically evaluate their ability to accurately measure value and reliably inform decision making. OBJECTIVE: To examine the evolution of the value assessment landscape in the past two years, including new entrants and updated frameworks, and assess if these changes successfully advance the field of value assessment. METHODS: We analyzed the progress of the three currently active value assessment frameworks developed by the Institute for Clinical and Economic Review, the Innovation and Value Initiative, and the National Comprehensive Cancer Network, against six key areas of concern. RESULTS: Value assessment frameworks are moving closer to meeting the challenge of accurately measuring value and reliably informing healthcare decisions. Each of the six concerns has been addressed in some way by at least one framework. CONCLUSIONS: Although value assessments are potential inputs that can be considered for healthcare decision making, none of them should be the sole input for these decisions. Considering the limitations, they should, at most, be only one of many tools in the toolbox.

Value-based medicine and palliative care: how do they converge?

Introduction: Sick persons need doctors who understand their pathology, know how to treat their problem, and accompany them through their illness. This study aimed to synthesize the state of knowledge regarding the concept of value-based medicine (VBM) through an integrative literature review, and establish how VBM can be applied in palliative care. Areas covered: An integrative review was conducted with the keywords 'value-based medicine,' 'patient-centered care,' and 'medicina baseada em valor' (Portuguese for VBM) in PubMed and Virtual Health Library, identifying 17,189 articles in total. Of these, 10 articles met the eligibility criteria. VBM combines the highest level of technical-scientific data with patients' values. It is defined as the combination of evidence-based medicine, patient-centered care, and cost-effectiveness. Patients' values are a set of preferences, concerns, and expectations that contribute toward accommodating their needs in the treatment clinic. Expert opinion: Like VBM, palliative care focuses on patients' values and quality of life, respecting natural limits. The early development of a care plan with active participation of the patient in the face of life-threatening diseases should be encouraged and can bring peace and comfort in a person's final moments.

Anti-TNF biosimilars in Crohn's Disease: a patient-centric interdisciplinary approach.

Introduction: The purpose of this review is to highlight the role of biosimilars in early treatment in IBD and introduce ways to facilitate a patient-centric switching process through multidisciplinary approach. Areas covered: We summarize existing scientific literature related to the role of biosimilars in inflammatory bowel disease in terms of early treatment and cost-saving and implementing switching process. Expert opinion: Use of anti-TNF biosimilars in patients has the potential for large drug-acquisition cost-saving, which can be reinvested into early treatment. Managed switched programs for adalimumab can add further benefits in the future.

Economic burden of incident interstitial lung disease (ILD) and the impact of comorbidity on costs of care.

INTRODUCTION: Evidence about the economic burden related to interstitial lung diseases (ILDs) and the cost-driving factors is sparse. In the knowledge that distinct comorbidities affect the clinical course of ILDs, our study investigates their impact on costs of care within first year after diagnosis. METHODS: Using claims data of individuals diagnosed with Idiopathic Interstitial Pneumonia (IIP) (n = 14 453) or sarcoidosis (n = 9106) between 2010 and 2013, we calculated total and ILD-associated mean annual per capita costs adjusted by age, sex and comorbidity burden via Generalized Linear Gamma models. Then, we assessed the cost impact of chronic obstructive pulmonary disease (COPD), diabetes, coronary artery disease, depression, gastro-esophageal reflux disease, pulmonary hypertension (PH), obstructive sleep apnoea syndrome (OSAS) and lung cancer using the model-based parameter estimates. RESULTS: Total mean annual per capita costs were €11 131 in the pooled cohort, €12 111 in IIP and €8793 in sarcoidosis, each with a 1/3 share of ILD-associated cost. Most comorbidities had a significant cost-driving effect, which was most pronounced for lung cancer in total (1.989 pooled, 2.491 sarcoidosis, 1.696 IIP) and for PH in ILD-associated costs (2.606 pooled, 2.347 IIP, 3.648 sarcoidosis). The lung-associated comorbidities COPD, PH, OSAS more strongly affected ILD-associated than total costs. CONCLUSION: Comorbidities increase the already substantial costs of care in ILDs. To support patient-centred ILD care, not only highly cost-driving conditions that are inherent with high mortality themselves require systematic management. Moreover, conditions that are more rather restricting the patient's activities of daily living should be addressed - despite a low-cost impact.

Cost-effective care in eosinophilic esophagitis.

OBJECTIVE: To examine costs related to eosinophilic esophagitis (EoE), understand the source of these costs, discuss a possible approach for cost-effective care in EoE, and identify areas for future research in this topic. DATA SOURCES/STUDY SELECTIONS: Narrative review of the literature from 1977 (first description of EoE) to March 2019, focusing on costs and cost-effectiveness analyses in EoE. RESULTS: High costs in EoE can be related to diagnostic delays, requirement for upper endoscopy with biopsy for diagnosis and monitoring of disease activity, expensive medications currently used off-label, increased food costs related to dietary elimination treatment, frequent doctor visits with subspecialists, and complications or disease exacerbations. Provision of cost-effective care in EoE is an understudied area, and a patient-centric approach is key. There are multiple areas in which future research can make an impact. These include determining predictors of treatment response, minimally or noninvasive methods to monitor disease activity, and validation of the use of multidisciplinary care. CONCLUSION: Eosinophilic esophagitis (EoE) is considered to be a rare disease, but the costs of care and burden of disease attributed to EoE are substantial. However, few studies examine either the costs related to EoE or the approach to cost-effective care for the EoE patient. To provide cost-effective care, a patient-centric approach and shared decision-making model are optimal. In addition, a rational strategy for EoE diagnosis and initial treatment, effective maintenance therapy for disease control and ideally to prevent complications, and appropriate long-term monitoring are all required.

A sustainable business model for comprehensive medication management in a patient-centered medical home.

OBJECTIVES: To develop a sustainable business model for pharmacist-provided comprehensive medication management services in a patient-centered medical home. Secondarily, to evaluate the impact that the pharmacist had on clinical (glycosylated hemoglobin [A1C], low-density lipoprotein [LDL], and blood pressure) and economic (physician productivity and cost avoidance) outcomes. PRACTICE DESCRIPTION: This pilot project took place at the Palmetto Primary Care Physicians Trident office in North Charleston, South Carolina, from October 2013 to September 2014. At the time, the practice employed 5 physicians and 2 nurse practitioners and served more than 20,000 patients. PRACTICE INNOVATION: The pharmacist targeted patients with diabetes, lipid disorders, hypertension, congestive heart failure, obesity, polypharmacy, and treatment regimen nonadherence for his comprehensive medication management services. The pharmacist was available for immediate consultation or referrals by appointment 5 days per week. Services provided by the pharmacist were billed as medication therapy management or "incident to" physician evaluation and management services codes. EVALUATION: Number of patients seen per day, revenue collected from services rendered by the pharmacist, physician productivity and payment, cost avoidance, and health quality metrics (A1C, LDL, and blood pressure) were measured to determine the financial sustainability and clinical impact of the project. RESULTS AND IMPLICATIONS: The pharmacist was able to see an average of 11 patients per day, which was 72% of his capacity. The practice collected about $7400 per month for services rendered by the pharmacist. The average daily payment for services rendered by the physicians in the practice increased by 20.6%. More than 70% of uncontrolled patients had an improvement in clinical outcomes, such as A1C, LDL, and blood pressure. CONCLUSION: This project demonstrates the sustainable business model for embedding a pharmacist into a patient-centered medical home.

Continuing barriers to care of Wilms tumor in a low-income country.

BACKGROUND/OBJECTIVE: This study evaluates the outcome of Wilms tumor (WT) following introduction of multidisciplinary team management and patient treatment stratification by tumor histology in two referral centers in southeastern Nigeria. METHODS: We analyzed histologically confirmed WT cases managed from January 2008 to June 2017. RESULTS: There were 45 patients, peak age incidence of 2 to 5 years who presented after mean symptom duration of 4.9 months (range, 1-12 months), with mean tumor weight of 1040 g (range, 350-4200 g). Overall, 14 (31.1%) had unfavorable histology of WT. A total of 22 (48.9%) patients received preoperative chemotherapy, 43 (95.6%) received postoperative chemotherapy based on stage of disease and histopathology, but none received adequate radiotherapy. Of these, 19 (44.2%) patients complied with chemotherapy regimen, 15 (33.3%) were lost to follow-up and 12 (26.7%) cases relapsed. With 30 cases available for evaluation and mean follow-up duration of 23 months (range, 6-80 months), the overall 5-year survival is 53.3% (16 cases). Survival in children who complied with postoperative chemotherapy was 73.7%, and abandonment-sensitive survival was 35.6%. Persisting challenges were late presentation, poor compliance to treatment, and lack of radiotherapy treatment. CONCLUSION: Multidisciplinary team management and chemotherapy based on tumor histology might have resulted in slight improvement of outcome since our last report. However, to ensure survival that may approach global benchmarks, there is need for public health measures to improve time to diagnosis, and improvement of facilities and healthcare funding to ensure compliance to all phases of standard therapy.

Economic evaluation of a person-centred care intervention in head and neck oncology: results from a randomized controlled trial.

PURPOSE: Head and neck cancer and its treatment deteriorate quality of life, but symptoms improve with person-centred care. We examined the cost-effectiveness of a person-centred care intervention versus standard medical care. METHODS: In this randomized clinical trial of a person-centred intervention, patients were planned for outpatient oncology treatment in a Swedish university hospital between 2012 and 2014 and were followed during 1 year. Annual healthcare costs were identified from medical records and administrative register data. Productivity costs were calculated from reported sick leave. Health-related quality of life was collected using the EuroQol Group's five-dimension health state questionnaire. RESULTS: Characteristics were similar between 53 patients in the intervention group and 39 control patients. The average total cost was Euro (EUR) 55,544 (95% confidence interval: EUR 48,474-62,614) in the intervention group and EUR 57,443 (EUR 48,607-66,279) among controls, with similar health-related quality of life. CONCLUSIONS: This person-centred intervention did not result in increased costs and dominated the standard medical care. TRIAL REGISTRATION: ClinicalTrials.gov (registration number: NCT02982746).

Patient-Centered Medical Homes in Community Oncology Practices: Changes in Spending and Care Quality Associated With the COME HOME Experience.

PURPOSE: We examined whether the Community Oncology Medical Home (COME HOME) program, a medical home program implemented in seven community oncology practices, was associated with changes in spending and care quality. PATIENTS AND METHODS: We compared outcomes from elderly fee-for-service Medicare beneficiaries diagnosed between 2011 and 2015 with breast, lung, colorectal, thyroid, or pancreatic cancer, lymphoma, or melanoma and served by COME HOME practices before and after program implementation versus similar beneficiaries served by other geographically proximate oncologists. Difference-in-differences analysis compared changes in outcomes for COME HOME patients versus concurrent controls. Propensity score matching and regression methods were adjusted for clinical and sociodemographic differences. Our primary outcome was 6-month medical spending per beneficiary. Secondary outcomes included 6-month out-of-pocket spending, inpatient and ambulatory care-sensitive hospitalizations, readmissions, length of stay, and emergency department and evaluation and management visits. RESULTS: Before COME HOME, 6-month medical spending was $2,975 higher for the study group compared with controls (95% CI, $1,635 to $4,315; P < .001) and increasing at a similar rate. After intervention, this difference was reduced to $318 (95% CI, -$1,105 to $1,741; P = .661), a significant change of -$2,657 (95% CI, -$4,631 to -$683; P = .008) or 8.1% savings relative to 6-month average spending ($32,866). COME HOME was also associated with significantly reduced (10.2 %) emergency department visits per 1,000 patients per 6-month period ( P = .024). There were no statistically significant differences in other outcomes. CONCLUSION: COME HOME was associated with reduced Medicare spending and improved emergency department use. The patient-centered medical home model holds promise for oncology practices, but improvements were not uniform.