Optimal Transport System for Acute Ischemic Stroke Patients: A Cost-Effectiveness Analysis.

This study conducted cost utility analysis comparing 4 systems of transporting acute ischemic stroke patients in Hokkaido, Japan. Hypothetical patients were generated on a geographic information system, and their outcomes were estimated according to their transport time to hospitals administering tissue plasminogen activator and/or endovascular thrombectomy. The transport systems where a neurointerventionist traveled for earlier endovascular thrombectomy were most cost-effective in some rural areas, while direct transportation to comprehensive stroke centers was more cost-effective in other areas.

Optimal allocation of physicians improves accessibility and workload disparities in stroke care.

BACKGROUND: Inequalities in access to stroke care and the workload of physicians have been a challenge in recent times. This may be resolved by allocating physicians suitable for the expected demand. Therefore, this study analyzes whether reallocation using an optimization model reduces disparities in spatial access to healthcare and excessive workload. METHODS: This study targeted neuroendovascular specialists and primary stroke centers in Japan and employed an optimization model for reallocating neuroendovascular specialists to reduce the disparity in spatial accessibility to stroke treatment and workload for neuroendovascular specialists in Japan. A two-step floating catchment area method and an inverted two-step floating catchment area method were used to estimate the spatial accessibility and workload of neuroendovascular specialists as a potential crowdedness index. Quadratic programming has been proposed for the reallocation of neuroendovascular specialists. RESULTS: The reallocation of neuroendovascular specialists reduced the disparity in spatial accessibility and the potential crowdedness index. The standard deviation (SD) of the demand-weighted spatial accessibility index improved from 125.625 to 97.625. Simultaneously, the weighted median spatial accessibility index increased from 2.811 to 3.929. Additionally, the SD of the potential crowdedness index for estimating workload disparity decreased from 10,040.36 to 5934.275 after optimization. The sensitivity analysis also showed a similar trend of reducing disparities. CONCLUSIONS: The reallocation of neuroendovascular specialists reduced regional disparities in spatial accessibility to healthcare, potential crowdedness index, and disparities between facilities. Our findings contribute to planning health policies to realize equity throughout the healthcare system.

Regional disparity in the provision of rehabilitation services using the open data from the Japanese national claims database: an ecological study.

OBJECTIVES: There are few reports on regional differences in the supply/utilisation balance and provision of rehabilitation services. This study analysed those regional differences in Japan to help policymakers provide more uniform and efficient rehabilitation services and optimally allocate related resources. DESIGN: An ecological study. SETTING: 47 prefectures and 9 regions in Japan in 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary measures were 'supply/utilisation (S/U) ratio', calculated by dividing rehabilitation supply converted to service units, by rehabilitation utilisation and 'utilisation/expected utilisation (U/EU) ratio', calculated by dividing utilisation by EU. The EU was defined as utilisation expected from the demography in each area. Data required to calculate these indicators were collected from open sources such as the National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data Japan. RESULTS: The S/U ratios were higher in Shikoku, Kyusyu, Tohoku and Hokuriku regions, and lower in Kanto and Tokai regions. The number of rehabilitation providers per population was higher mostly in the western part of Japan and lower mostly in the eastern part. The U/EU ratios were also higher mostly in the western part, and lower mostly in the eastern part such as Tohoku and Hokuriku regions. The same trend was seen for cerebrovascular disease and musculoskeletal disorder rehabilitation, which accounted for approximately 84% of rehabilitation services. For disuse syndrome rehabilitation, such a trend did not exist, and the U/EU ratio differed by prefectures. CONCLUSIONS: The large surplus in rehabilitation supply in the western part was attributed to the greater number of providers, while the smaller surplus in Kanto and Tokai regions was due to the smaller amount of supply. The number of rehabilitation services used was lesser in the eastern part such as Tohoku and Hokuriku regions, indicating regional differences in the provision of rehabilitation services.

Cost-effectiveness of seven-days-per-week rehabilitation schedule for acute stroke patients.

BACKGROUND: Rehabilitation is an essential medical service for patients who have suffered acute stroke. Although the effectiveness of 7-days-per-week rehabilitation schedule has been studied in comparison with 5- or 6-days-per-week rehabilitation schedule, its cost-effectiveness has not been analyzed. In this research, to help formulate more cost-effective medical treatments for acute stroke patients, we analyzed the cost-effectiveness of 7-days-per-week rehabilitation for acute stroke from public health payer's perspective, and public healthcare and long-term care payer's perspective in Japan. METHODS: Cost-effectiveness of 7-days-per-week rehabilitation for acute stroke patients was analyzed based on the result from a previous study using a Japanese database examining the efficacy of 7-days-per-week rehabilitation. Cost utility analysis was conducted by comparing 7-days-per-week rehabilitation with 5- or 6-days-per-week rehabilitation, with its main outcome incremental cost-effectiveness ratio (ICER) calculated by dividing estimated incremental medical and long-term care costs by incremental quality-adjusted life years (QALY). The costs were estimated using the Japanese fee table and from published sources. The time horizon was 5 years, and Markov modeling was used for the analysis. RESULTS: The ICER was $6339/QALY from public health payer's perspective, lower than 5,000,000 Yen/QALY (approximately US$37,913), which was the willingness-to-pay used for the cost-effectiveness evaluation in Japan. The 7-day-per-week rehabilitation was dominant from public healthcare and long-term care payer's perspective. The result of sensitivity analysis confirmed the results. CONCLUSION: The results indicated that 7-days-per-week rehabilitation for acute stroke rehabilitation was likely to be cost-effective.

Cost-effectiveness analysis using lifetime attributable risk of proton beam therapy for pediatric medulloblastoma in Japan.

Compared to conventional X-ray therapy, proton beam therapy (PBT) has more clinical and physical advantages such as irradiation dose reduction to normal tissues for pediatric medulloblastoma. However, PBT is expensive. We aimed to compare the cost-effectiveness of PBT for pediatric medulloblastoma with that of conventional X-ray therapy, while focusing on radiation-induced secondary cancers, which are rare, serious and negatively affect a patient's quality of life (QOL). Based on a systematic review, a decision tree model was used for the cost-effectiveness analysis. This analysis was performed from the perspective of health care payers; the cost was estimated from medical fees. The target population was pediatric patients with medulloblastoma below 14 years old. The time horizon was set at 7.7 years after medulloblastoma treatment. The primary outcome was the incremental cost-effectiveness ratio (ICER), which was defined as the ratio of the difference in cost and lifetime attributable risk (LAR) between conventional X-ray therapy and PBT. The discount rate was set at 2% annually. Sensitivity analyses were performed to model uncertainty. Cost and LAR in conventional X-ray therapy and PBT were Japanese yen (JPY) 1 067 608 and JPY 2436061 and 42% and 7%, respectively. The ICER was JPY 3856398/LAR. In conclusion, PBT is more cost-effective than conventional X-ray therapy in reducing the risk of radiation-induced secondary cancers in pediatric medulloblastoma. Thus, our constructed ICER using LAR is one of the valid indicators for cost-effectiveness analysis in radiation-induced secondary cancer.

Analyzing Cost-Effectiveness of Allocating Neurointerventionist for Drive and Retrieve System for Patients with Acute Ischemic Stroke.

OBJECTIVES: There are regional disparities in implementation rates of endovascular thrombectomy due to time and resource constraints such as endovascular thrombectomy specialists. In Hokkaido, Japan, Drive and Retrieve System (DRS), where endovascular thrombectomy specialists perform early endovascular thrombectomies by traveling from the facilities where they normally work to facilities closer to the patient. This study analyzed the cost-effectiveness of allocating a endovascular thrombectomy specialist for DRS to treat stroke patients. MATERIALS AND METHODS: he number of ischemic stroke patients expected to receive endovascular thrombectomy in Hokkaido in 2015 was estimated. It was assumed that an additional neutointerventionist was allocated for DRS. The analysis was performed from the government's perspective, which includes medical and nursing-care costs, and the personnel cost for endovascular thrombectomy specialist. The analysis was conducted comparing the current scenario, where patients received endovascular thrombectomy in facilities where endovascular thrombectomy specialists normally work, with the scenario with DRS within 60 min drive distance. Patient transport time was analyzed using geographic information system, and patient severity was estimated from the transport time. The primary outcome was incremental cost-effectiveness ratio (ICER) in each medical area which was calculated from the incremental costs and the incremental quality-adjusted life years (QALYs), estimated from patient severity using published literature. The entire process was repeated 100 times. RESULTS: DRS was most cost-effective in Kamikawachubu area, where the ICER was $14,173±16,802/QALY, significantly lower than the threshold that the Japanese guideline suggested. CONCLUSIONS: Since DRS was cost-effective in Kamikawachubu area, the area should be prioritized when a endovascular thrombectomy specialist for DRS is allocated as a policy.

Cost-Effectiveness of a Continuous Glucose Monitoring Mobile App for Patients With Type 2 Diabetes Mellitus: Analysis Simulation.

BACKGROUND: Apps for real-time continuous glucose monitoring (CGM) on smartphones and other devices linked to CGM systems have recently been developed, and such CGM apps are also coming into use in Japan. In comparison with conventional retrospective CGM, the use of CGM apps improves patients' own blood glucose control, which is expected to help slow the progression of type 2 diabetes mellitus (DM) and prevent complications, but the effect of their introduction on medical costs remains unknown. OBJECTIVE: Our objective in this study was to perform an economic appraisal of CGM apps from the viewpoint of assessing public medical costs associated with type 2 DM, using the probability of developing type 2 DM-associated complications, and data on medical costs and utility value to carry out a medical cost simulation using a Markov model in order to ascertain the cost-effectiveness of the apps. METHODS: We developed a Markov model with the transition states of insulin therapy, nephrosis, dialysis, and cardiovascular disease, all of which have a major effect on medical costs, to identify changes in medical costs and utility values resulting from the introduction of a CGM app and calculated the incremental cost-effectiveness ratio (ICER). RESULTS: The ICER for CGM app use was US $33,039/quality-adjusted life year (QALY). CONCLUSIONS: Sensitivity analyses showed that, with the exception of conditions where the transition probability of insulin therapy, utility value, or increased medical costs increases, the ICER for the introduction of CGM apps was below the threshold of US $43,478/QALY used by the Central Social Insurance Medical Council. Our results provide basic data on the cost-effectiveness of introducing CGM apps, which are currently starting to come into use.

Cost comparison between open radical cystectomy, laparoscopic radical cystectomy, and robot-assisted radical cystectomy for patients with bladder cancer: a systematic review of segmental costs.

BACKGROUND: Robot-assisted radical cystectomy is becoming a common treatment for bladder carcinoma. However, in comparison with open radical cystectomy, its cost-effectiveness has not been confirmed. Although few published reviews have compared total costs between the two surgical procedures, no study has compared segmental costs and explained their impact on total costs. METHODS: A systematic review was conducted based on studies on the segmental costs of open, laparoscopic, and robot-assisted radical cystectomy using PubMed, Web of Science, and Cochrane Library databases to provide insight into cost-effective management methods for radical cystectomy. The segmental costs included operating, robot-related, complication, and length of stay costs. A sensitivity analysis was conducted to determine the impact of the annual number of cases on the per-case robot-related costs. RESULTS: We identified two studies that compared open and laparoscopic surgeries and nine that compared open and robotic surgeries. Open radical cystectomy costs were higher than those of robotic surgeries in two retrospective single-institution studies, while robot-assisted radical cystectomy costs were higher in 1 retrospective single-institution study, 1 randomized controlled trial, and 4 large database studies. Operating costs were higher for robotic surgery, and accounted for 63.1-70.5% of the total robotic surgery cost. Sensitivity analysis revealed that robot-related costs were not a large proportion of total surgery costs in institutions with a large number of cases but accounted for a large proportion of total costs in centers with a small number of cases. CONCLUSIONS: The results show that robot-assisted radical cystectomy is more expensive than open radical cystectomy. The most effective methods to decrease costs associated with robotic surgery include a decrease in operating time and an increase in the number of cases. Further research is required on the cost-effectiveness of surgeries, including quality measures such as quality of life and quality-adjusted life years.

A Cost-Effectiveness Simulation of Specialist Dispatching System in Japan for Treatments of Patients with Acute Ischemic Stroke Using a Geographic Information System.

Regional disparities in the implementation rates of recombinant tissue-type plasminogen activator and endovascular thrombectomy treatments have been reported in Japan. We simulated the cost-effectiveness of specialist dispatching system in Hokkaido, Japan using Geographic Information System. In the system a qualified specialist is dispatched to another hospital for endovascular thrombectomy. Since the system improved patient accessibility, and the cost- effectiveness was excellent, the system could help enhance the equality and cost-effectiveness of ischemic stroke treatments in Hokkaido.

Cost Effectiveness of Drive and Retrieve System in Hokkaido for Acute Ischemic Stroke Patient Treatment Using Geographic Information System.

BACKGROUND AND PURPOSE: Although endovascular thrombectomy combined with recombinant tissue-type plasminogen activator is effective for treatment of acute ischemic stroke, regional disparities in implementation rates of those treatments have been reported. Drive and retrieve system, where a qualified neurointerventionist travels to another primary stroke center for endovascular thrombectomy, has been practiced in parts of Hokkaido, Japan. This study aims to simulate the cost effectiveness of the drive and retrieve system, which can be a method to enhance equality and cost effectiveness of treatments for acute ischemic stroke. MATERIALS AND METHODS: The number of patients who had acute ischemic stroke in 2015 is estimated. Those patients are generated according to the population distribution, and thereafter patient transport time is analyzed in the 3 scenarios (1) 60-minute drive scenario, (2) 90-minute drive scenario, in which the drive and retrieve system operates within 60-minute or 90-minute driving distance (3) without the system, using geographic information system. Incremental cost-effectiveness rate, quality-adjusted life years, and medical and nursing care costs are estimated from the analyzed transport time. FINDINGS: The incremental cost-effectiveness rate by implementing the system was dominant. Cost reductions of $213,190 in 60-minute drive scenario, and $247,274 in the 90-minute scenario were expected, respectively. Such benefits are the most significant in Soya, Emmon, Rumoi, and Kamikawahokubu medical areas. CONCLUSIONS: The drive and retrieve system could enhance regional equality and cost effectiveness of ischemic stroke treatments in Hokkaido, which can be achieved using existing resources. Further studies are required to clarify its cost effectiveness from hospital perspective.