Creating Value Through Learning Health Systems: The Alberta Strategic Clinical Network Experience.

Design, implementation, and evaluation of effective multicomponent interventions typically take decades before value is realized even when value can be measured. Value-based health care, an approach to improving patient and health system outcomes, is a way of organizing health systems to transform outcomes and achieve the highest quality of care and the best possible outcomes with the lowest cost. We describe 2 case studies of value-based health care optimized through a learning health system framework that includes Strategic Clinical Networks. Both cases demonstrate the acceleration of evidence to practice through scientific, financial, structural administrative supports and partnerships. Clinical practice interventions in both cases, one in perioperative services and the other in neonatal intensive care, were implemented across multiple hospital sites. The practical application of using an innovation pipeline as a structural process is described and applied to these cases. A value for money improvement calculator using a benefits realization approach is presented as a mechanism/tool for attributing value to improvement initiatives that takes advantage of available system data, customizing and making the data usable for frontline managers and decision makers. Health care leaders will find value in the descriptions and practical information provided.

Value in Healthcare: Designing an Integrated Value-Based Healthcare System.

Value-based healthcare (VBHC) can be interpreted in many ways depending on one's jurisdiction. Often it is used synonymously with cost-effectiveness. In Alberta, VBHC might more appropriately be termed "values-based healthcare." This reflects our belief that a healthcare system should meet the needs and desires of its population and contribute to overall wellness. We therefore developed a framework based on the dimensions of quality, the Quadruple Aim and feasibility considerations, which enables us to assess and measure our system activities and initiatives to determine if they are in keeping with VBHC in the Alberta context.

Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application.

We present a conceptual approach to determine the optimal solution to delivering a health technology, consistent with the objective of maximizing patient outcomes subject to resources available to a publicly funded health system. The article addresses two key policy questions: 1) adding system values through appropriate planning of health services delivery and 2) considering the tradeoff between patient outcomes and costs to the health system through appropriate use of health technologies for conditions with time-dependent treatment outcomes. We develop a health technology optimization framework that considers geographical variation and searches for the best delivery method through a pairwise comparison of all possible strategies, factoring in controlled variables including disease epidemiology, time or distance to hospitals, available medical services, treatment eligibility, treatment efficacy, and costs. Taking variations of these factors into account would help support a more efficient allocation of health resources. Drawing identified strategies together then creates a map of optimal strategies. We apply the proposed method to a policy-relevant health technology assessment of endovascular therapy (EVT) for treating acute ischemic stroke. The best strategy for providing EVT relies on the geographical location of stroke onset and the decision maker's preference for either patient outcomes or economic efficiency. The proposed method produced an optimization map showing the optimal strategy for EVT delivery, which maximizes patient outcomes while minimizing health system costs. In the illustrative case study, there were no tradeoffs between health outcomes and costs, meaning that the delivery strategies that were clinically optimal for patients were also the most cost-effective. In conclusion, the health technology optimization approach is a useful tool for informing implementation decisions and coordinating the delivery of complex health services such as EVT.

Cost-Effectiveness Analysis of Total Hip Arthroplasty Performed by a Canadian Short-Stay Surgical Team in Ecuador.

BACKGROUND: Few charitable overseas surgical missions produce cost-effectiveness analyses of their work. METHODS: We compared the pre- and postoperative health status for 157 total hip arthroplasty (THA) patients operated on from 2007 to 2011 attended by an annual Canadian orthopedic mission to Ecuador to determine the quality-adjusted life years (QALYs) gained. The costs of each mission are known. The cost per surgery was divided by the average lifetime QALYs gained to estimate an incremental cost-effectiveness ratio (ICER) in Canadian dollars per QALY. RESULTS: The average lifetime QALYs (95% CI) gained were 1.46 (1.4-1.5), 2.5 (2.4-2.6), and 2.9 (2.7-3.1) for unilateral, bilateral, and staged (two THAs in different years) operations, respectively. The ICERs were $4,442 for unilateral, $2,939 for bilateral, and $4392 for staged procedures. Seventy percent of the mission budget was spent on the transport and accommodation of volunteers. CONCLUSION: THA by a Canadian short-stay surgical team was highly cost-effective, according to criteria from the National Institute for Health and Care Excellence and the World Health Organization. We encourage other international missions to provide similar cost-effectiveness data to enable better comparison between mission types and between mission and nonmission care.

Implementation of Enhanced Recovery After Surgery (ERAS) Across a Provincial Healthcare System: The ERAS Alberta Colorectal Surgery Experience.

BACKGROUND: Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system. METHODS: We compared pre- and post-guideline implementation in consecutive elective colorectal patients, ≥ 18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts. RESULTS: A total of 1333 patients (350 pre- and 983 post-ERAS) were analysed. Of this number, 55 % were males. Median overall guideline compliance was 39 % in pre- and 60 % in post-ERAS patients. Median LOS was 6 days for pre-ERAS compared to 4.5 days in post-ERAS patients with the longest implementation (p value <0.0001). Adjusted risk ratio (RR) was 1.71, 95 % CI 1.09-2.68 for 30-day readmission, comparing pre- to post-ERAS patients. The proportion of patients who developed at least one complication was significantly reduced, from pre- to post-ERAS, difference in proportions = 11.7 %, 95 % CI 2.5-21.0, p value: 0.0139. The net cost savings attributable to guideline implementation ranged between $2806 and $5898 USD per patient. CONCLUSION: The findings in our study have shown that ERAS colorectal guideline implementation within a healthcare system resulted in patient outcome improvements, similar to those obtained in smaller standalone implementations. There was a significant beneficial impact of ERAS on scarce health system resources.

An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta

BACKGROUND: In February 2013, Alberta Health Services established an Enhanced Recovery After Surgery (ERAS) implementation program for adopting the ERAS Society colorectal guidelines into 6 sites (initial phase) that perform more than 75% of all colorectal surgeries in the province. We conducted an economic evaluation of this initiative to not only determine its cost-effectiveness, but also to inform strategy for the spread and scale of ERAS to other surgical protocols and sites. METHODS: We assessed the impact of ERAS on patients’ health services utilization (HSU; length of stay [LOS], readmissions, emergency department visits, general practitioner and specialist visits) within 30 days of discharge by comparing pre- and post-ERAS groups using multilevel negative binomial regressions. We estimated the net health care costs/savings and the return on investment (ROI) associated with those impacts for post-ERAS patients using a decision analytic modelling technique. RESULTS: We included 331 pre- and 1295 post-ERAS patients in our analyses. ERAS was associated with a reduction in all HSU outcomes except visits to specialists. However, only the reduction in primary LOS was significant. The net health system savings were estimated at $2 290 000 (range $1 191 000–$3 391 000), or $1768 (range $920–$2619) per patient. The probability for the program to be cost-saving was 73%–83%. In terms of ROI, every $1 invested in ERAS would bring $3.8 (range $2.4–$5.1) in return. CONCLUSION: The initial phase of ERAS implementation for colorectal surgery in Alberta is cost-saving. The total savings has the potential to be more substantial when ERAS is spread for other surgical protocols and across additional sites.

Prevnar 7 Childhood Immunization Program and Serotype Replacement: Changes in Pneumococcal Incidence and Resulting Impact on Health Care Costs in Alberta (2003-2008).

OBJECTIVE: Acute respiratory tract infections caused by Streptococcus pneumoniae are a leading cause of morbidity and mortality in young children and the elderly. In 2002, Alberta introduced a pneumococcal universal immunization program for children, using Pfizer's Prevnar 7, a 7-valent pneumococcal conjugate vaccine (PCV7). In this study, we explored the impact of the immunization program on the burden of disease and related health care costs in Alberta, in the context of serotype replacement. METHODS: Using surveillance data from Alberta, we examined the change in costs averted as a result of a decline in invasive pneumococcal disease (IPD) cases caused by PCV7 serotypes, as well as the increase in costs due to serotype replacement. We also calculated the magnitude of positive externalities (indirect effects) in terms of costs averted. RESULTS: We found that following the introduction of PCV7 (2003-2008), the number of cases of IPD caused by vaccine serotypes declined significantly across all ages. Non-PCV7 IPD cases, on the other hand, increased. Net costs were averted as a result of the implementation of PCV7 universal vaccination in Alberta, after accounting for serotype replacement. CONCLUSION: On the basis of the analysis of serotype-specific pneumococcal data, the impact of the Prevnar public immunization program on direct health costs averted in Alberta as a result of reducing IPD cases caused by PCV7 strains amounted to $5.5 million (in 2008 Canadian dollars). However, the unintended effects of serotype replacement resulted in costs incurred of nearly $1.9 million. As a result, on net, the total cost savings for Alberta amounted to about $3.6 million. Irrespective of serotype replacement, the PCV7 immunization program has had a positive impact in terms of health benefits, which translates into health service costs averted.

An economic evaluation of the parent-child assistance program for preventing fetal alcohol spectrum disorder in Alberta, Canada.

Parent-Child Assistance Program (P-CAP) is a 3-year home visitation/harm reduction intervention to prevent alcohol exposed births, thereby births with fetal alcohol spectrum disorder, among high-risk women. This article used a decision analytic modeling technique to estimate the incremental cost-effectiveness ratio and the net monetary benefit of the P-CAP within the Alberta Fetal Alcohol Spectrum Disorder Service Networks in Canada. The results indicate that the P-CAP is cost-effective and support placing a high priority not only on reducing alcohol use during pregnancy, but also on providing effective contraceptive measures when a program is launched.

Medical tourism and bariatric surgery: who pays?

INTRODUCTION: The objective of this study was to determine the short-term cost impact that medical tourism for bariatric surgery has on a public healthcare system. Due to long wait times for bariatric surgery services, Canadians are venturing to private clinics in other provinces/countries. Postoperative care in this population not only burdens the provincial health system with intervention costs required for complicated patients, but may also impact resources allotted to patients in the public clinic. METHODS: A chart review was performed from January 2009 to June 2013, which identified 62 medical tourists requiring costly interventions related to bariatric surgery. Secondarily, a survey was conducted to estimate the frequency of bariatric medical tourists presenting to general surgeons in Alberta, necessary interventions, and associated costs. A threshold analysis was used to compare costs of medical tourism to those from our institution. RESULTS: A conservative cost estimate of $1.8 million CAD was calculated for all interventions in 62 medical tourists. The survey established that 25 Albertan general surgeons consulted 59 medical tourists per year: a cost of approximately $1 million CAD. Medical tourism was calculated to require a complication rate ≤ 28% (average intervention cost of $37,000 per patient) to equate the cost of locally conducted surgery: a rate less than the current supported evidence. Conducting 250 primary bariatric surgeries in Alberta is approximately $1.9 million less than the modeled cost of treating 250 medical tourists returning to Alberta. CONCLUSIONS: Medical tourism has a substantial impact on healthcare costs in Alberta. When compared to bariatric medical tourists, the complication rate for locally conducted surgery is less, and the cost of managing the complications is also much less. Therefore, we conclude that it is a better use of resources to conduct bariatric surgery for Albertan residents in Alberta than to fund patients to seek surgery out of province/country.

Should vitamin B12 tablets be included in more Canadian drug formularies? An economic model of the cost-saving potential from increased utilisation of oral versus intramuscular vitamin B12 maintenance therapy for Alberta seniors.

OBJECTIVE: The aim of this study was to estimate the cost-savings attainable if all patients aged ≥65 years in Alberta, Canada, currently on intramuscular therapy were switched to oral therapy, from the perspective of a provincial ministry of health. SETTING: Primary care setting in Alberta, Canada. PARTICIPANTS: Seniors of age 65 years and older currently receiving intramuscular vitamin B12 therapy. INTERVENTION: Oral vitamin B12 therapy at 1000 µg/day versus intramuscular therapy at 1000 µg/month. PRIMARY AND SECONDARY OUTCOME MEASURES: Cost saving from oral therapy over intramuscular therapy, from the perspective of the Alberta Ministry of Health, including drug costs, dispensing fees, injection administration fees, additional laboratory monitoring and physician visit fees. RESULTS: Over 5 years, if all Albertans aged 65 years and older who currently receive intramuscular B12 are switched to oral therapy, our model found that $C13 975 883 can be saved. Even if no additional physician visits are billed for among patients receiving intramuscular therapy, $C8 444 346 could be saved from reduced administration costs alone. CONCLUSIONS: Oral B12 therapy has been shown to be an effective therapeutic option for patients with vitamin B12 deficiency, yet only three provinces and the Non-Insured Health Benefits program include oral tablets on their formulary rather than the parenteral preparation. To ensure judicious use of limited health resources, clinicians and formulary committees are encouraged to adopt oral B12 therapy as a clinically and cost-effective first-line therapy for vitamin B12 deficiency.

Potential impacts of the Alberta fetal alcohol spectrum disorder service networks on secondary disabilities: a cost-benefit analysis.

OBJECTIVES: To estimate the break-even effectiveness of the Alberta Fetal Alcohol Spectrum Disorder (FASD) Service Networks in reducing occurrences of secondary disabilities associated with FASD. METHODS: The secondary disabilities addressed within this study include crime, homelessness, mental health problems, and school disruption (for children) or unemployment (for adults). We used a cost-benefit analysis approach where benefits of the service networks were the cost difference between the two approaches: having the 12 service networks and having no service network in place, across Alberta. We used a threshold analysis to estimate the break-even effectiveness (i.e. the effectiveness level at which the service networks became cost-saving). RESULTS: If no network was in place throughout the province, the secondary disabilities would cost $22.85 million (including $8.62 million for adults and $14.24 million for children) per year. Given the cost of network was $6.12 million per year, the break-even effectiveness was estimated at 28% (range: 25% to 32%). DISCUSSION: Although not all benefits associated with the service networks are included, such as the exclusion of the primary benefit to those experiencing FASD, the benefits to FASD caregivers, and the preventative benefits, the economic and social burden associated with secondary disabilities will "pay-off" if the effectiveness of the program in reducing secondary disabilities is 28%.

The economic impact of weight regain.

Background. Obesity is well known for being associated with significant economic repercussions. Bariatric surgery is the only evidence-based solution to this problem as well as a cost-effective method of addressing the concern. Numerous authors have calculated the cost effectiveness and cost savings of bariatric surgery; however, to date the economic impact of weight regain as a component of overall cost has not been addressed. Methods. The literature search was conducted to elucidate the direct costs of obesity and primary bariatric surgery, the rate of weight recidivism and surgical revision, and any costs therein. Results. The quoted cost of obesity in Canada was $2.0 billion-$6.7 billion in 2013 CAD. The median percentage of bariatric procedures that fail due to weight gain or insufficient weight loss is 20% (average: 21.1% ± 10.1%, range: 5.2-39, n = 10). Revision of primary surgeries on average ranges from 2.5% to 18.4%, and depending on the procedure accounts for an additional cost between $14,000 and $50,000 USD per patient. Discussion. There was a significant deficit of the literature pertaining to the cost of revision surgery as compared with primary bariatric surgery. As such, the cycle of weight recidivism and bariatric revisions has not as of yet been introduced into any previous cost analysis of bariatric surgery.

Does performance-based remuneration for individual health care practitioners affect patient care?: a systematic review.

BACKGROUND: Pay-for-performance (P4P) is increasingly touted as a means to improve health care quality. PURPOSE: To evaluate the effect of P4P remuneration targeting individual health care providers. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library, OpenSIGLE, Canadian Evaluation Society Unpublished Literature Bank, New York Academy of Medicine Library Grey Literature Collection, and reference lists were searched up until June 2012. STUDY SELECTION: Two reviewers independently identified original research papers (randomized, controlled trials; interrupted time series; uncontrolled and controlled before-after studies; and cohort comparisons). DATA EXTRACTION: Two reviewers independently extracted the data. DATA SYNTHESIS: The literature search identified 4 randomized, controlled trials; 5 interrupted time series; 3 controlled before-after studies; 1 nonrandomized, controlled study; 15 uncontrolled before-after studies; and 2 uncontrolled cohort studies. The variation in study quality, target conditions, and reported outcomes precluded meta-analysis. Uncontrolled studies (15 before-after studies, 2 cohort comparisons) suggested that P4P improves quality of care, but higher-quality studies with contemporaneous controls failed to confirm these findings. Two of the 4 randomized trials were negative, and the 2 statistically significant trials reported small incremental improvements in vaccination rates over usual care (absolute differences, 8.4 and 7.8 percentage points). Of the 5 interrupted time series, 2 did not detect any improvements in processes of care or clinical outcomes after P4P implementation, 1 reported initial statistically significant improvements in guideline adherence that dissipated over time, and 2 reported statistically significant improvements in blood pressure control in patients with diabetes balanced against statistically significant declines in hemoglobin A1c control. LIMITATION: Few methodologically robust studies compare P4P with other payment models for individual practitioners; most are small observational studies of variable quality. CONCLUSION: The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain. Implementation of P4P models should be accompanied by robust evaluation plans. PRIMARY FUNDING SOURCE: None.

Benefits of pharmaceutical innovation: the case of simvastatin in Canada.

BACKGROUND: The benefits of pharmaceutical innovations are widely diffused; they accrue to the healthcare providers, patients, employers, and manufacturers. We estimate the societal monetary benefits of simvastatin in Canada and its distribution among different beneficiaries overtime. METHODS: Monetary benefits to developing and generic manufacturers were estimated by calculating public and private revenues minus the development costs of simvastatin and the contribution toward further research and development. We used a dynamic Markov model to estimate monetary benefits to healthcare and employment sectors in terms of cost avoidance associated with prevented cardiovascular events, including stroke and myocardial infarction, and lost productivity due to disability and premature death in working population. RESULTS: Cumulative monetary benefits of simvastatin from 1990 to 2009 were $4.8 billion (2010 CA$), of which developing and generic manufacturers, and healthcare and employment sectors accounted for 32 percent, 27 percent, 32 percent, and 9 percent, respectively. The yearly trend showed that after the patent expired in 2002 the generic manufacturers became dominant in the market. Benefits for the healthcare sector started to decrease from 2003 corresponding to the decreasing population taking simvastatin during the same time period. Sensitivity analysis showed the higher the compliance or the efficacy, the larger the benefits to healthcare and employment sectors, while monetary benefits for manufacturers were unchanged. CONCLUSIONS: Societal monetary benefits of simvastatin are significant and the distributions of the benefits have changed overtime. Patent, compliance, and efficacy play a vital role in the estimation of the benefits. Analysis of all beneficiaries separately overtime is important when assessing the value of pharmaceutical innovation.

Effect of a pharmacist-managed hypertension program on health system costs: an evaluation of the Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN).

STUDY OBJECTIVE: To quantify the potential cost savings of a community pharmacy-based hypertension management program based on the results of the Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN) study in terms of avoided cardiovascular events-myocardial infarction, stroke, and heart failure hospitalization, and to compare these cost savings with the cost of the pharmacist intervention program. DESIGN: An economic model was developed to estimate the potential cost avoidance in direct health care resources from reduced cardiovascular events over a 1-year period. MEASUREMENTS AND MAIN RESULTS: The SCRIP-HTN study found that patients with diabetes mellitus and hypertension who were receiving the pharmacist intervention had a greater mean reduction in systolic blood pressure of 5.6 mm Hg than patients receiving usual care. For our model, published meta-analysis data were used to compute cardiovascular event absolute risk reductions associated with a 5.6-mm Hg reduction in systolic blood pressure over 6 months. Costs/event were obtained from administrative data, and probabilistic sensitivity analyses were performed to assess the robustness of the results. Two program scenarios were evaluated-one with monthly follow-up for a total of 1 year with sustained blood pressure reduction, and the other in which pharmacist care ended after the 6-month program but the effects on systolic blood pressure diminished over time. The cost saving results from the economic model were then compared with the costs of the program. Annual estimated cost savings (in 2011 Canadian dollars) from avoided cardiovascular events were $265/patient (95% confidence interval [CI] $63-467) if the program lasted 1 year or $221/patient (95%CI $72-371) if pharmacist care ceased after 6 months with an assumed loss of effect afterward. Estimated pharmacist costs were $90/patient for 6 months or $150/patient for 1 year, suggesting that pharmacist-managed programs are cost saving, with the annual net total cost savings/patient estimated to be $131 for a program lasting 6 months or $115 for a program lasting 1 year. CONCLUSION: Our model found that community pharmacist interventions capable of reducing systolic blood pressure by 5.6 mm Hg within 6 months are cost saving and result in improved patient outcomes. Wider adoption of pharmacist-managed hypertension care for patients with diabetes and hypertension is encouraged.

Blood pressure kiosks for medication therapy management programs: business opportunity for pharmacists.

OBJECTIVE: To develop an economic model based on the use of pharmacy-based blood pressure kiosks for case finding of remunerable medication therapy management (MTM) opportunities. DESIGN: Descriptive, exploratory, nonexperimental study. SETTING: Ontario, Canada, between January 2010 and September 2011. PATIENTS: More than 7.5 million blood pressure kiosk readings were taken from 341 pharmacies. INTERVENTION: A model was developed to estimate revenues achievable by using blood pressure kiosks for 1 month to identify a cohort of patients with blood pressure of 130/80 mm Hg or more and caring for those patients during 1 year. MAIN OUTCOME MEASURE: Revenue generated from MTM programs. RESULTS: Pharmacies could generate an average of $12,270 (range $4,523-24,420) annually in revenue from billing for MTM services. CONCLUSION: Blood pressure kiosks can be used to identify patients with elevated blood pressure who may benefit from reimbursable pharmacist cognitive services. Revenue can be reinvested to purchase automated dispensing technology or offset pharmacy technician costs to free pharmacists to provide pharmaceutical care. Improved patient outcomes, increased patient loyalty, and improved adherence are additional potential benefits.

Pharmacoeconomic evaluation of 10- and 13-valent pneumococcal conjugate vaccines.

INTRODUCTION: There are three different pneumococcal vaccines available for infants, each oriented to a specific set of serotypes. The vaccination of newborns will prevent pneumococcal disease in this vaccinated group via direct effects, and will also affect the non-vaccinated population through indirect or "herd" immunity. OBJECTIVE: To develop a model that compares the health and economic consequences between the three vaccines. METHOD: We developed a simulation model for an entire population, providing vaccine to children less than 2 years of age. The vaccines varied by serotypes covered and included a 7- (4, 6B, 9V, 14, 18C, 19F and 23F), 10- (1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F) and 13-valent (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F) vaccines. The base case was PCV-7, and clinical and economic outcomes were estimated for the vaccinated persons and for other persons through assumptions about a herd effect. By comparison, clinical and economic outcomes for the population were also estimated for the 10 and 13 serotype vaccines. RESULTS: In the base case (PCV-7), with the seven serotype vaccine, there were 9.38 cases of hospitalized pneumonia, 0.22 cases of meningitis, 3.69 cases of bacteremia, 60.19 cases of otitis media, and 373 cases of pneumonia, per 100,000 persons in the population, at all ages. With the 10-valent vaccine and a herd effect, invasive pneumonia fell to 8.71 cases, meningitis to 0.21 cases, and bacteremia to 3.39 cases. Otitis media fell to 57 cases and pneumonia to 344 cases. There were further reductions with the 13-valent vaccine, with invasive pneumonia falling to 8.37 cases, bacteremia to 3.33 cases, otitis media to 51.9 cases and all-cause pneumonia to 336.2 cases. Among the vaccines evaluated, PCV-13 was associated with the lowest health services costs and the greatest improved health outcomes. CONCLUSIONS: Increased serotype coverage of the 13-valent vaccine is expected to have a substantial public health and economic impact on infectious disease, when considering direct and indirect effects.

Cost-effectiveness of 21 alternative cervical cancer screening strategies.

OBJECTIVES: The aim of this study is to assess the cost-effectiveness of 21 alternative cervical cancer screening (CCS) strategies. METHODS: A cohort simulation model was developed to determine from a health systems perspective the cost-effectiveness of the 21 alternative CCS strategies that incorporated combinations of Papanicolaou's smear test (PAP), liquid-based cytology (LBC) or human papillomavirus deoxyribonucleic acid (HPV-DNA) testing. The model was calibrated to categorize total costs into four budgetary authorities: testing, physician, inpatient, and outpatient services. Within each category, alternative screening strategies were contrasted in terms of their cost impacts and the percent change calculated within each category. Epidemiologic data and costs were derived from administrative health databases. Estimates of test characteristics and quality-adjusted life years (QALYs) were derived from available literature. RESULTS: Three-year screening with PAP and HPV-DNA triage testing for women older than 30 years of age (3-year PAP+HPV+PAP-age) is less costly and more effective saving $16,078 per additional QALY gained. Although there was an associated net cost decrease of 4.2% driven by a reduction in testing and physician costs of 22.1% and 18.6%, respectively, there is a cost increase of 0.8% and 27.7% in inpatient and outpatient services, respectively. CONCLUSION: There is economic evidence to support adopting 3-year PAP+HPV+PAP-age. Budgetary resources can potentially be shifted from testing and physician services to fund the additional resource requirements for inpatient and outpatient services.

Cost-effectiveness of combination therapy for chronic obstructive pulmonary disease.

BACKGROUND: There is evidence that combination therapy (CT) in the form of long-acting beta(2)-agonists (LABAs) and inhaled corticosteroids can improve lung function for patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To determine the cost-effectiveness of using CT in none, all or a selected group of COPD patients. METHODS: A Markov model was designed to compare four treatment strategies: no use of CT regardless of COPD severity (patients receive LABA only); use of CT in patients with stage 3 disease only (forced expiratory volume in 1 s [FEV(1)] less than 35% of predicted); use of CT in patients with stages 2 and 3 disease only (FEV(1) less than 50% of predicted); and use of CT in all patients regardless of severity of COPD. Estimates of mortality, exacerbation and disease progression rates, quality- adjusted life years (QALYs) and costs were derived from the literature. Three-year and lifetime time horizons were used. The analysis was conducted from a health systems perspective. RESULTS: CT was associated with a cost of $39,000 per QALY if given to patients with stage 3 disease, $47,500 per QALY if given to patients with stages 2 and 3 disease, and $450,333 per QALY if given to all COPD patients. Results were robust to various assumptions tested in a Monte Carlo simulation. CONCLUSION: Providing CT for COPD patients in stage 2 or 3 disease is cost-effective. The message to family physicians and specialists is that as FEV(1) worsens and reaches 50% of predicted values, CT is recommended.