Telehealth Screening for Diabetic Retinopathy: Economic Modeling Reveals Cost Savings.

Introduction: The use of telehealth screening (TS) for diabetic retinopathy (DR) consists of fundus photography in a primary care setting with remote interpretation of images. TS for DR is known to increase screening utilization and reduce vision loss compared with standard in-person conventional diabetic retinal exam (CDRE). Anti-vascular endothelial growth factor intravitreal injections have become standard of care for the treatment of DR, but they are expensive. We investigated whether TS for DR is cost-effective when DR management includes intravitreal injections using national data. Materials and Methods: We compared cost and effectiveness of TS and CDRE using decision-tree analysis and probabilistic sensitivity analysis with Monte Carlo simulation. We considered the disability weight (DW) of vision impairment and 1-year direct medical costs of managing patients based on Medicare allowable rates and clinical trial data. Primary outcomes include incremental costs and incremental effectiveness. Results: The average annual direct cost of eye care was $196 per person for TS and $275 for CDRE. On average, TS saves $78 (28%) compared with CDRE and was cost saving in 88.9% of simulations. The average DW outcome was equivalent in both groups. Discussion: Although this study was limited by a 1-year time horizon, it provides support that TS for DR can reduce costs of DR management despite expensive treatment with anti-VEGF agents. TS for DR is equally effective as CDRE at preserving vision. Conclusions: Annual TS for DR is cost saving and equally effective compared with CDRE given a 1-year time horizon.

Non-invasive assessment of muscle oxygenation may aid in optimising transfusion threshold decisions in ambulatory paediatric patients.

OBJECTIVE: To assess the potential utility of a novel non-invasive muscle oxygen measurement to determine the presence of muscle hypoxia in patients with anaemia. BACKGROUND: Recent assessment of the risk/benefit ratio of blood transfusion has led to clinical strategies optimising transfusion decisions. These decisions are primarily based on haematocrit (Hct) but not oxygen delivery, the primary function of red blood cells (RBCs). We hypothesised that muscle oxygenation (MOx) would correlate with Hct in patients with anaemia and may be a physiologically relevant determinant of the transfusion threshold. METHODS/MATERIALS: MOx was non-invasively determined in children in the Cancer and Blood Disorders Center ambulatory clinic at Seattle Children's Hospital using a custom-designed optical probe and spectrometer. MOx was compared with contemporaneous Hct. In subjects receiving RBCs, MOx and Hct were also determined following transfusion. RESULTS: MOx ranged from 36·7 to 100%, and Hct ranged from 17·0 to 38·6% in 27 measurements from 16 patients. High MOx values were associated with high Hct. Mean MOx for patients with normal Hct for age (n = 5) was 95·9 ± 2·9%. RBC transfusion increased mean Hct from 19·1 ± 1·5% to 29·3 ± 2·0 and mean MOx from 67·9 ± 21·1% to 89·9 ± 9·8%. Among six transfusion episodes (in five patients) with initial Hct < 22, only three had a pre-transfusion MOx of <70%. Patients with the lowest pre-transfusion MOx had the largest increase in MOx after transfusion. CONCLUSIONS: These preliminary data suggest that MOx may aid in making transfusion decisions when used in combination with Hct.

What predicts depression in cardiac patients: sociodemographic factors, disease severity or theoretical vulnerabilities?

Depression is associated with increased cardiovascular risk in acute coronary syndrome (ACS) patients, but some argue that elevated depression is actually a marker of cardiovascular disease severity. Therefore, disease indices should better predict depression than established theoretical causes of depression (interpersonal life events, reinforcing events, cognitive distortions, type D personality). However, little theory-based research has been conducted in this area. In a cross-sectional design, ACS patients (n = 336) completed questionnaires assessing depression and psychosocial vulnerabilities. Nested logistic regression assessed the relative contribution of demographic or vulnerability factors, or disease indices or vulnerabilities to depression. In multivariate analysis, all vulnerabilities were independent significant predictors of depression (scoring above threshold on any scale, 48%). Demographic variables accounted for <1% of the variance of depression status, with vulnerabilities accounting for significantly more (pseudo R² = 0.16, χ²(change) = 150.9, df = 4, p < 0.001). Disease indices accounted for 7% of the variance in depression (pseudo R² = 0.07, χ² = 137.9, p < 0.001). However, adding the vulnerabilities increased the overall variance explained to 22% (pseudo R² = 0.22, χ² = 58.6, df = 4, p < 0.001). Theoretical vulnerabilities predicted depression status better than did either demographic or disease indices. The presence of these proximal causes of depression suggests that depression in ACS patients is not simply a result of cardiovascular disease severity.

Economic and demographic consequences of AIDS in Namibia: rapid assessment of the costs.

Recent announcements by the Government of Namibia to provide financial support to people living with AIDS (and their family members) have received considerable media attention. However, given the fact that government budgets are already stretched, and the need for resources to devote the prevention efforts remains, there is an urgent need to assign some values to the support the government is considering within the context of an explosive epidemic. It is against this background that this study attempts to provide a rapid assessment of the economic costs of HIV/AIDS in Namibia over the next 5 years of the First National Development Plan. The estimates include the direct and indirect costs. The direct costs are costs to the economy for inpatient and outpatient medical services, as well as the costs of support payments to people living with AIDS, their families and children orphaned by AIDS. Government and donor expenditure on national prevention and control efforts are also included. The study concludes that no sector of the Namibian economy will escape the impact of AIDS. The epidemic will definitely tax hospital, public health, private and community resources, and these substantial burdens underscore the need for coordinated long-term planning.

PIP: Namibia, with a population of 1.6 million people, is one of the countries most severely affected with HIV/AIDS. While more than 28,000 cases of HIV infection have been reported in Namibia since the first case was documented in 1986, some estimate that there are more than 100,000 HIV cases in the country. The AIDS epidemic in Namibia will most likely aggravate poverty and increase levels of social inequity. The government of Namibia recently announced that it plans to provide financial support to people living with AIDS and their family members. However, government budgets are already stretched and funds are still needed for HIV/AIDS prevention. Results are presented from a rapid assessment of the economic costs of HIV/AIDS in Namibia over the next 5 years of the First National Development Plan. The estimates, based upon projections calculated by the DEMPROJ and AIDS Impact Model computer models, include the direct and indirect costs, with the direct costs being the costs to the economy of support payments to people living with AIDS, their families and children orphaned due to AIDS. Government and donor expenditure on national prevention and control efforts are also included. When specific data were unavailable for Namibia, the programs' default values for sub-Saharan Africa were used when deemed reasonable. The HIV/AIDS epidemic in Namibia will affect all sectors of the economy, taxing hospital, public health, and private and community resources.

The economics of a nurse-developed critical pathway.

During this study the use of a nurse-developed, patient-oriented critical pathway and its effects on two indicators of cost were analyzed at St. John Hospital and Medical Center in Detroit, Michigan. Financial data for 64 mastectomy cases were tracked and analyzed. Findings showed improved length of stay with substantial decreases in cost per case.

Assessment of therapeutic relationship of community-agency workers.

This article reports on the ratings of the personal and professional characteristics of community-based workers for children and adolescents who had recently been released from a psychiatric inpatient service. The child/adolescent's family members/caregivers and the community workers both responded to the same items of a questionnaire. Families/caregivers rated the community workers with whom they were the most and the least satisfied. Community workers rated themselves in relation to these study children and/or their families. Findings indicate that both family members/caregivers and the community workers themselves saw community workers performing relatively well in the areas of providing information and offering support to families. Likewise, both assessed the service providers as having the greatest deficits in the area of teaching skills for child/adolescent home management. Suggestions for meeting the needs of the families and for ensuring that a system of care for child/adolescents is child-centered and family-focused are discussed.

Predicting elderly patients' mobility using fall history and physician assessment.

This study tested whether a patient's history of falls or an office clinician's general assessment can predict which ambulatory elderly patients will do poorly on mobility testing. Ambulatory patients making routine visits who were age 65 or older, mentally competent, and not acutely ill were eligible. Fifty-two (91%) of these patients participated by completing a fall history questionnaire and undergoing mobility testing. After the visit, the attending physician estimated how the patient would score on the mobility test. Twelve (23%) of the patients reported falls and seven (13.5%) reported fall injuries in the preceding year. Both fall history and physician estimate of mobility score significantly correlated with the measured mobility score. Only the physician estimate of mobility score, however, had adequate sensitivity (94.4%) and specificity (82.4%) to be clinically useful. This estimate will allow the clinician to selectively apply mobility testing to those patients likely to score poorly.

Long-term care: workable options for employers now.

Lost in the labyrinth of long-term care benefits possibilities (or impossibilities)? There are ways that employers can begin today to provide at least a modicum of long-term care coverage for retired (and active) employees--and at very little cost. A long-term care consultant shares some practical approaches, along with insights into how federal government activities may affect employers' efforts.