Financial incentives for physical activity in adults: systematic review and meta-analysis.

OBJECTIVE: The use of financial incentives to promote physical activity (PA) has grown in popularity due in part to technological advances that make it easier to track and reward PA. The purpose of this study was to update the evidence on the effects of incentives on PA in adults. DATA SOURCES: Medline, PubMed, Embase, PsychINFO, CCTR, CINAHL and COCH. ELIGIBILITY CRITERIA: Randomised controlled trials (RCT) published between 2012 and May 2018 examining the impact of incentives on PA. DESIGN: A simple count of studies with positive and null effects ('vote counting') was conducted. Random-effects meta-analyses were also undertaken for studies reporting steps per day for intervention and post-intervention periods. RESULTS: 23 studies involving 6074 participants were included (64.42% female, mean age = 41.20 years). 20 out of 22 studies reported positive intervention effects and four out of 18 reported post-intervention (after incentives withdrawn) benefits. Among the 12 of 23 studies included in the meta-analysis, incentives were associated with increased mean daily step counts during the intervention period (pooled mean difference (MD), 607.1; 95% CI: 422.1 to 792.1). Among the nine of 12 studies with post-intervention daily step count data incentives were associated with increased mean daily step counts (pooled MD, 513.8; 95% CI:312.7 to 714.9). CONCLUSION: Demonstrating rising interest in financial incentives, 23 RCTs were identified. Modest incentives ($1.40 US/day) increased PA for interventions of short and long durations and after incentives were removed, though post-intervention 'vote counting' and pooled results did not align. Nonetheless, and contrary to what has been previously reported, these findings suggest a short-term incentive 'dose' may promote sustained PA.

The energy expenditure benefits of reallocating sedentary time with physical activity: a systematic review and meta-analysis.

Background: We compared direct and daily cumulative energy expenditure (EE) differences associated with reallocating sedentary time to physical activity in adults for meaningful EE changes. Methods: Peer-reviewed studies in PubMed, Medline, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to March 2017. Randomized and non-randomized interventions with sedentary time and EE outcomes in adults were included. Study quality was assessed by the National Heart Lung and Blood Institute tool, and summarized using random-effects meta-analysis and meta-regression. Results: In total, 26 studies were reviewed, and 24 studies examined by meta-analysis. Reallocating 6-9 h of sedentary time to light-intensity physical activity (LIPA) (standardized mean difference [SMD], 2.501 [CI: 1.204-5.363]) had lower cumulative EE than 6-9 h of combined LIPA and moderate-vigorous intensity physical activity (LIPA and moderate-vigorous physical activity [MVPA]) (SMD, 5.218 [CI: 3.822-6.613]). Reallocating 1 h of MVPA resulted in greater cumulative EE than 3-5 h of LIPA and MVPA, but <6-9 h of LIPA and MVPA. Conclusions: Comparable EE can be achieved by different strategies, and promoting MVPA might be effective for those individuals where a combination of MVPA and LIPA is challenging.

Relationship Between Cardiac Rehabilitation Participation and Health Service Expenditures Within a Universal Health Care System.

OBJECTIVES: To examine the relationship between cardiac rehabilitation participation and health service expenditures in Ontario, Canada. PATIENTS AND METHODS: A total of 6284 patients referred to cardiac rehabilitation between April 1, 2003, and December 31, 2010, were linked to 6284 matched cardiac rehabilitation eligible nonreferred controls and followed over a 3-year period across multiple linked administrative databases to identify health service utilization expenditures and mortality. All patients had previous cardiac hospitalizations within the preceding year. Four cardiac rehabilitation eligible groups of patients were balanced using propensity score weights: (1) no referral; (2) no participation; (3) low participation levels (ie, attending <67% of prescheduled classes); and (4) high participation levels (ie, attending ≥67% prescheduled classes). Each group of patients was balanced in age, sex, geography, socioeconomic status, previous hospitalizations, ambulatory care conditions, cardiovascular risk factors, comorbidities, and previous health care expenditures. Generalized linear models were used to examine differences in health service expenditures (from all sources including hospitalizations, physician visits, diagnostic tests, and drugs for those older than 65 years) per "eligible day alive" over the 3-year period. RESULTS: Compared with the nonreferred population, health service expenditures followed a dose-response relationship and were lowest in patients who had the highest cardiac rehabilitation programmatic participation levels (P<.001). Cost differences across groups separated early, remained divergent, and applied to all components of health care expenditures (P<.001). Sensitivity analyses confirmed that the findings were not secondary to reverse causality. CONCLUSION: Participation in cardiac rehabilitation is associated with lower long-term health service utilization expenditures within a publicly funded health care system.

The Feasibility of Financial Incentives to Increase Exercise Among Canadian Cardiac Rehabilitation Patients.

PURPOSE: To examine the feasibility of conducting a randomized controlled trial investigating the effectiveness of financial incentives for exercise self-monitoring in cardiac rehabilitation (CR). METHODS: A 12-week, 2 parallel-arm, single-blind feasibility study design was employed. A volunteer sample of CR program graduates was randomly assigned to an exercise self-monitoring intervention only (control; n = 14; mean age ± SD, 62.7 ± 14.6 years), or an exercise self-monitoring plus incentives approach (incentive; n = 13; mean age ± SD, 63.6 ± 11.8 years). Control group participants received a "home-based" exercise self-monitoring program following CR program completion (exercise diaries could be submitted online or by mail). Incentive group participants received the "home-based" program, plus voucher-based incentives for exercise diary submissions ($2 per day). A range of feasibility outcomes is presented, including recruitment and retention rates, and intervention acceptability. Data for the proposed primary outcome of a definitive trial, aerobic fitness, are also reported. RESULTS: Seventy-four CR graduates were potentially eligible to participate, 27 were enrolled (36.5% recruitment rate; twice the expected rate), and 5 were lost to followup (80% retention). Intervention acceptability was high with three-quarters of participants indicating that they would likely sign up for an incentive program at baseline. While group differences in exercise self-monitoring (the incentive "target") were not observed, modest but nonsignificant changes in aerobic fitness were noted with fitness increasing by 0.23 mL·kg-·min- among incentive participants and decreasing by 0.68 mL·kg-·min- among controls. CONCLUSION: This preliminary study demonstrates the feasibility of studying incentives in a CR context, and the potential for incentives to be readily accepted in the broader context of the Canadian health care system.

Factors Affecting Attendance at an Adapted Cardiac Rehabilitation Exercise Program for Individuals with Mobility Deficits Poststroke.

OBJECTIVE: The aim of this study was to determine the factors affecting attendance at an adapted cardiac rehabilitation program for individuals poststroke. METHODS: A convenience sample of ambulatory patients with hemiparetic gait rated 20 potential barriers to attendance on a 5-point Likert scale upon completion of a 6-month program of 24 prescheduled weekly sessions. Sociodemographic characteristics, depressive symptoms, cardiovascular fitness, and comorbidities were collected by questionnaire or medical chart. RESULTS: Sixty-one patients attended 77.3 ± 12% of the classes. The longer the elapsed time from stroke, the lower the attendance rate (r = -.34, P = .02). The 4 greatest barriers influencing attendance were severe weather, transportation problems, health problems, and traveling distance. Health problems included hospital readmissions (n = 6), influenza/colds (n = 6), diabetes and cardiac complications (n = 4), and musculoskeletal issues (n = 2). Of the top 4 barriers, people with lower compared to higher income had greater transportation issues (P = .004). Greater motor deficits of the stroke-affected leg were associated with greater barriers related to health issues (r = .7, P = .001). The only sociodemographic factor associated with a higher total mean barrier score was non-English as the primary language spoken at home (P = .002); this factor was specifically related to the barriers of cost (P = .007), family responsibilities (P = .018), and lack of social support (P = .001). No other associations were observed. CONCLUSION: Barriers to attendance were predominantly related to logistic/transportation and health issues. People who were more disadvantaged socioeconomically (language, finances), and physically (stroke-related deficits) were more affected by these barriers. Strategies to reduce these barriers, including timely referral to exercise programs, need to be investigated.

Observing temporal trends in cardiac rehabilitation from 1996 to 2010 in Ontario: characteristics of referred patients, programme participation and mortality rates.

OBJECTIVES: We sought to describe temporal trends in the sociodemographic and clinical characteristics of participants referred to cardiac rehabilitation (CR), and its effect on programme participation and all-cause mortality over 14 years. SETTING: A large CR centre in Toronto, Canada. PARTICIPANTS: Consecutive patients between 1996 and 2010. PRIMARY AND SECONDARY OUTCOME MEASURES: Referrals received were deterministically linked to administrative data, to complement referral form abstraction. Out-of-hospital deaths were identified using vital statistics. Patients were tracked until 2012, and mortality was ascertained. Percentage attendance at prescribed sessions was also assessed. RESULTS: There were 29,171 referrals received, of which 28,767 (98.6%) were successfully linked, of whom 22,795 (79.2%) attended an intake assessment. The age of the referred population steadily increased, with more females, less affluent and more single patients referred over time (p<0.001). More patients were referred following percutaneous coronary intervention and less following coronary artery bypass graft surgery (p<0.001). The number of comorbidities decreased (p<0.001). Hypertension increased over time (p<0.001), yet the control of cholesterol steadily improved over time. The proportion of smokers decreased over time (p<0.001). Participation in CR significantly declined, and there were no significant changes in mortality. 3-year mortality rates were less than 5%. CONCLUSIONS: Characteristics of referred patients tended to reflect broader trends in risk factors and cardiovascular disease burden. Physicians appear to be referring more sociodemographically diverse patients to CR; however, programmes may need to better adapt to engage these patients to fully participate. More complex patients should be referred, using explicit criteria-based referral processes.

'Will walk for groceries': Acceptability of financial health incentives among Canadian cardiac rehabilitation patients.

Financial health incentives, such as paying people to exercise, remain controversial despite widespread implementation. This focus group study explored the acceptability of incentives among a sample of Canadian cardiac rehabilitation (CR) patients (n = 15). Focus groups were conducted between March and April 2013 until further sampling ceased to produce new analytical concepts. A thematic analysis approach was adopted in analysing the data. Three broad themes emerged from the focus groups. First, ethical concerns were prominent. Half of participants disagreed with the incentive approach believing that it was unfair, unnecessary or a waste of limited resources. Second, ethical concerns were mitigated in considering a range of incentive features including type, size and source. Specifically, privately sponsored (not government funded) health-promoting voucher-based incentives (e.g., grocery or gym vouchers) were perceived to be highly acceptable. Third, if designed like this, then financial incentives were considered potentially effective in motivating behaviour change and in reducing economic barriers to exercise participation. Overall, the majority of participants welcomed incentives if ethical concerns were addressed through thoughtful incentive programme design. The results of this focus group study will inform the design of a financial health incentive feasibility RCT to promote post-CR programme exercise compliance in this population.

Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction.

OBJECTIVES: To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI). BACKGROUND: The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear. METHODS: We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity. RESULTS: As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87-0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70-1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation. CONCLUSIONS: Functional recovery may play an important role in explaining SES-mortality gradients following AMI.

Financial incentives for exercise adherence in adults: systematic review and meta-analysis.

CONTEXT: Less than 5% of U.S. adults accumulate the required dose of exercise to maintain health. Behavioral economics has stimulated renewed interest in economic-based, population-level health interventions to address this issue. Despite widespread implementation of financial incentive-based public health and workplace wellness policies, the effects of financial incentives on exercise initiation and maintenance in adults remain unclear. EVIDENCE ACQUISITION: A systematic search of 15 electronic databases for RCTs reporting the impact of financial incentives on exercise-related behaviors and outcomes was conducted in June 2012. A meta-analysis of exercise session attendance among included studies was conducted in April 2013. A qualitative analysis was conducted in February 2013 and structured along eight features of financial incentive design. EVIDENCE SYNTHESIS: Eleven studies were included (N=1453; ages 18-85 years and 50% female). Pooled results favored the incentive condition (z=3.81, p<0.0001). Incentives also exhibited significant, positive effects on exercise in eight of the 11 included studies. One study determined that incentives can sustain exercise for longer periods (>1 year), and two studies found exercise adherence persisted after the incentive was withdrawn. Promising incentive design feature attributes were noted. Assured, or "sure thing," incentives and objective behavioral assessment in particular appear to moderate incentive effectiveness. Previously sedentary adults responded favorably to incentives 100% of the time (n=4). CONCLUSIONS: The effect estimate from the meta-analysis suggests that financial incentives increase exercise session attendance for interventions up to 6 months in duration. Similarly, a simple count of positive (n=8) and null (n=3) effect studies suggests that financial incentives can increase exercise adherence in adults in the short term (<6 months).

Obesity, lifestyle risk-factors, and health service outcomes among healthy middle-aged adults in Canada.

BACKGROUND: The extent to which uncomplicated obesity among an otherwise healthy middle-aged population is associated with higher longitudinal health-care expenditures remains unclear. METHODS: To examine the incremental long-term health service expenditures and outcomes associated with uncomplicated obesity, 9398 participants of the 1994-1996 National Population Health Survey were linked to administrative data and followed longitudinally forward for 11.5 years to track health service utilization costs and death. Patients with pre-existing heart disease, those who were 65 years of age and older, and those with self-reported body mass indexes of <18.5 kg/m² at inception were excluded. Propensity-matching was used to compare obesity (+/- other baseline risk-factors and lifestyle behaviours) with normal-weight healthy controls. Cost-analyses were conducted from the perspective of Ontario's publicly-funded health care system. RESULTS: Obesity as an isolated risk-factor was not associated with significantly higher health-care costs as compared with normal weight matched controls (Canadian $8,294.67 vs. Canadian $7,323.59, P = 0.27). However, obesity in combination with other lifestyle factors was associated with significantly higher cumulative expenditures as compared with normal-weight healthy matched controls (CAD$14,186.81 for those with obesity + 3 additional risk-factors vs. CAD$7,029.87 for those with normal BMI and no other risk-factors, P < 0.001). The likelihood that obese individuals developed future diabetes and hypertension also rose markedly when other lifestyle factors, such as smoking, physical inactivity and/or psychosocial distress were present at baseline. CONCLUSIONS: The incremental health-care costs associated with obesity was modest in isolation, but increased significantly when combined with other lifestyle risk-factors. Such findings have relevance to the selection, prioritization, and cost-effective targeting of therapeutic lifestyle interventions.

Guidelines for health technologies: specific guidance for oncology products in Canada.

OBJECTIVE: Specific methodological challenges are often encountered during cancer-related economic evaluations. The objective of this study was to provide specific guidance to analysts on the methods for the conduct of high-quality economic evaluations in oncology by building on the Canadian Agency for Drugs and Technologies in Health Guidelines for the Economic Evaluation of Health Technologies (third edition). METHODS: Fifteen oncologists, health economists, health services researchers, and decision makers from across Canada identified sections in Canadian Agency for Drugs and Technologies in Health guidelines that would benefit from oncology-specific guidance. Fifteen sections of the guidelines were reviewed to determine whether 1) Canadian Agency for Drugs and Technologies in Health guidelines were sufficient for the conduct of oncology economic evaluations without further guidance specific for oncology products or 2) additional guidance was necessary. A scoping review was conducted by using a comprehensive and replicable search to identify relevant literature to inform recommendations. Recommendations were reviewed by representatives of academia, government, and the pharmaceutical industry in an iterative and formal review of the recommendations. RESULTS: Major adaptations for guidance related to time horizon, effectiveness, modeling, costs, and resources were required. Recommendations around the use of final outcomes over intermediate outcomes to calculate quality-adjusted life-years and life-years gained, the type of evidence, the source of evidence, and the use of time horizon and modeling were made. CONCLUSIONS: This article summarizes key recommendations for the conduct of economic evaluations in oncology and describes methods required to ensure that economic assessments in oncology are conducted in a standardized manner.

Musculoskeletal comorbidities in cardiac patients: prevalence, predictors, and health services utilization.

OBJECTIVES: To describe the prevalence of musculoskeletal conditions (MSKC) in patients with coronary artery disease (CAD); to examine the sociodemographic, clinical, and psychosocial predictors of these comorbidities; and to describe health care utilization by musculoskeletal comorbidity status. DESIGN: This was a cross-sectional, observational study in which patients were administered a questionnaire in the hospital and 1 year later. SETTING: Eleven hospitals in Ontario, Canada. PARTICIPANTS: CAD patients (N=1803). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sociodemographic, MSKC, clinical, and psychosocial factors were ascertained via questionnaire and in-hospital chart extraction. A health care utilization questionnaire was mailed 1 year later. RESULTS: Over half (56%) of the patients with CAD had MSKCs, with arthritis/joint pain accounting for 64.4% of these MSKCs. Patients who were older (odds ratio [OR]=1.03), women (OR=1.87), white (OR=1.80), with higher body mass index (OR=1.05), depressive symptoms (OR=1.92), and lower family income (OR=1.46) were more likely to present with MSKCs. One year posthospitalization, a greater proportion of those with MSKCs reported ≥1 cardiac-related emergency department visit (33.2% vs 28.3%, P=.03), hospital admission (30.7% vs 22%, P=.006), more primary care physician visits (6.6±5.6 vs 5.7±4.6, P<.001), and fewer cardiac rehabilitation referrals (61.5% vs 70%, P<.001). After adjusting for depressive symptoms, body mass index, age, income, ethnicity, and sex, MSKCs predicted only hospital readmissions. CONCLUSIONS: Over half of the patients hospitalized for CAD have MSKCs. Those with MSKCs have a physical and psychosocial profile that places them at greater cardiovascular risk than those with CAD only, explaining, in part, their greater health care utilization. Despite a greater need for comprehensive risk factor management in patients with MSKCs, fewer were referred to cardiac rehabilitation.

Pulse wave velocity for assessment of arterial stiffness among people with spinal cord injury: a pilot study.

BACKGROUND/OBJECTIVE: The most significant complication and leading cause of death for people with spinal cord injury (SCI) is coronary artery disease (CAD). It has been confirmed that aortic pulse wave velocity (PWV) is an emerging CAD predictor among able-bodied individuals. No prior study has described PWV values among people with SCI. The objective of this study was to compare aortic (the common carotid to femoral artery) PWV, arm (the brachial to radial artery) PWV, and leg (the femoral to posterior tibial artery) PWV in people with SCI (SCI group) to able-bodied controls (non-SCI group). METHODS: Participants included 12 men with SCI and 9 non-SCI controls matched for age, sex, height, and weight. Participants with a history of CAD or current metabolic syndrome were excluded. Aortic, arm, and leg PWV was measured using the echo Doppler method. RESULTS: Aortic PWV (mean +/- SD) in the SCI group (1,274 +/- 369 cm/s) was significantly higher (P < 0.05) than in the non-SCI group (948 +/- 110 cm/s). There were no significant between-group differences in mean arm PWV (SCI: 1,152 +/- 193 cm/s, non-SCI: 1,237 +/- 193 cm/s) or mean leg PWV (SCI: 1,096 +/- 173 cm/s, non-SCI: 994 +/- 178 cm/s) values. CONCLUSIONS: Aortic PWV was higher among the SCI group compared with the non-SCI group. The higher mean aortic PWV values among the SCI group compared with the non-SCI group indicated a higher risk of CAD among people with SCI in the absence of metabolic syndrome.

Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system.

BACKGROUND: The magnitude and mechanisms of survival benefit associated with cardiac rehabilitation services among real-world populations within a universal health care system remain unclear. METHODS: This retrospective matched cohort study compared the long-term survival of 2042 cardiac rehabilitation participants with 2042 matched controls after an index acute cardiac hospitalization between 1999 and 2003, in Ontario, Canada. Each patient survived at least 1 year without recurrent admissions after discharge from the index hospitalization, and was followed for a mean of 5.25 years. Additional matching criteria included the type of sentinel cardiac events, age, sex, socioeconomic status, geography, previous cardiac and noncardiac hospitalizations. A Cox proportional hazards model further adjusted for baseline cardiovascular risk factors and process factors, cardiovascular risk-factor progression, downstream coronary procedure and evidence-based pharmacotherapy utilization. RESULTS: Cardiac rehabilitation participation was associated with a 50% lower mortality rate (2.6 vs. 5.1%, P<0.001) as compared with population-matched controls. Statistically significant mortality benefits were observed among high-risk patients, and there was no significant interaction among age, cardiac rehabilitation participation, and survival (P=0.22). Associated survival advantages were not meaningfully altered after adjustment for cardiovascular risk-factor progression or the downstream utilization rates of cardiac procedures and evidence-based cardiovascular therapies; survival benefits predominantly applied to those patients that were most compliant with the program. CONCLUSION: Cardiac rehabilitation is associated with significant long-term survival advantages after index cardiovascular hospitalizations. Despite universal access to medical care, such survival advantages seem to be mediated by compliant behaviors more so than by ancillary health service or evidence-based pharmacotherapy utilization.

The cost-effectiveness of palivizumab for respiratory syncytial virus prophylaxis in premature infants with a gestational age of 32-35 weeks: a Canadian-based analysis .

BACKGROUND: Prophylactic therapy with palivizumab, a humanized monoclonal antibody, has been shown to reduce the number of respiratory syncytial virus (RSV)-related hospitalizations in preterm infants, including those in the 32-35 weeks' gestational age (GA) subgroup. The cost-effectiveness of this therapy in Canada is unknown. OBJECTIVES: To evaluate the cost-effectiveness of palivizumab as respiratory syncytial virus prophylaxis in premature infants born at 32-35 weeks' GA. DESIGN: A decision analytic model was designed to compare both direct and indirect medical costs and benefits of prophylaxis in this subgroup of premature infants. Sensitivity analyses were performed to ascertain the robustness of the model for five point estimates: mortality rate, discounting rates, health-utility values, degree of vial-sharing and administration costs. A probabilistic sensitivity analysis (PSA) was also conducted. SETTING: Canadian publicly funded health-care system (Ministry of Health payer perspective) for base-case analysis. Societal perspective, accounting for future lost productivity, was adopted for a secondary analysis. PARTICIPANTS: Canadian infants born at 32-35 weeks' GA without chronic lung disease. INTERVENTIONS: Palivizumab prophylaxis versus no prophylaxis. MAIN OUTCOME MEASURES: Expected costs and incremental cost-effectiveness ratio expressed as cost per life-year gained (LYG) and quality-adjusted life-year (QALY) using 2007 Canadian dollars. RESULTS: The expected costs were higher for palivizumab prophylaxis as compared with no prophylaxis. The incremental cost-effectiveness ratio (ICER) for the base-case scenario was $20 924 per QALY after discounting, which is considered cost-effective in Canada. When the uncertainty of the input parameter assumptions was tested through sensitivity analyses assessing several data sources for five key parameters, no substantial differences were found from the base-case results. The PSA indicated a 0.99 probability that the ICER for palivizumab was less than $50 000/QALY. Sub-analyses that varied the number of risk factors found that for infants with two or more risk factors, or at least moderate risk, palivizumab had incremental costs per QALY that indicated moderate-to-strong evidence for adoption (range: $808-81 331, per QALY). CONCLUSIONS: Palivizumab was cost-effective and the authors' model supports prophylaxis for infants born at 32-35 weeks' GA, particularly those with more than two risk factors or at least a moderate level of risk according to a risk scoring tool.

Economic evaluation of oseltamivir phosphate for postexposure prophylaxis of influenza in long-term care facilities.

OBJECTIVES: To compare the cost-effectiveness of oseltamivir postexposure prophylaxis during influenza A outbreaks with that of amantadine postexposure prophylaxis or no postexposure prophylaxis in long-term care facilities (LTCFs). DESIGN: Cost-effectiveness analysis based on decision analytic model from a government-payer perspective. SETTING: A Canadian LTCF, with high staff vaccination, at the beginning of influenza season. PARTICIPANTS: Elderly, influenza-vaccinated patients living in a Canadian LTCF. MEASUREMENTS: Incremental costs (or savings) per influenza-like illness case avoided compared with usual care. RESULTS: From a government-payer perspective, this analysis showed that oseltamivir was a dominant strategy because it was associated with the fewest influenza-like illness cases, with cost savings of $1,249 per 100 patients in 2001 Canadian dollars compared with amantadine and $3,357 per 100 patients compared with no prophylaxis. Costs for amantadine dose calculation and hospitalization for adverse events contributed to amantadine being a more-expensive prophylaxis strategy than oseltamivir. Both prophylaxis strategies were more cost-effective than no prophylaxis. CONCLUSION: Despite high influenza vaccination rates, influenza outbreaks continue to emerge in LTCFs, necessitating cost-effective measures to further limit the spread of influenza and related complications. Although amantadine has a lower acquisition cost than oseltamivir, it is associated with more adverse events, lower efficacy, and individualized dosing requirements, leading to higher overall costs and more influenza-like illness cases than oseltamivir. Therefore the use of oseltamivir postexposure prophylaxis is more cost-effective than the current standard of care with amantadine prophylaxis or no prophylaxis.

The economics of adjunctive therapies in coronary angioplasty: drugs, devices, or both?

BACKGROUND: Abciximab reduces the number of ischemic events in patients undergoing angioplasty compared to standard therapy. Coronary stenting reduces the need for repeat procedures. Abciximab or stents individually are considered cost effective interventions. There is a need to quantify the economic value of the combination of abciximab and stenting over stenting alone. METHODS: A decision analytic model was developed incorporating the outcomes from the EPISTENT study. Costs from Canadian sources for hospitalization, procedures and medications were used. Life expectancy was estimated using a Markov model. Total expected costs and outcomes of the abciximab and stent vs. stent alone were compared in an incremental analysis. The perspective of the analysis was a Canadian teaching hospital. RESULTS: The acquisition cost for abciximab was partially offset by reduced costs for managing clinical events resulting in a net incremental cost of 1,076 dollars per patient over one year (8,617 dollars combination vs. 7,541 dollars stent alone). This added cost was accompanied by a reduction in large MI or death by an absolute rate of 5.7% at one year (5.3% combination vs. 11.0% stent alone), yielding an incremental cost-effectiveness ratio of 18,877 dollars per death or large MI averted. The long-term survival gain was 0.15 to 0.37 years yielding an attractive incremental cost effectiveness ratio of 2,832 dollars to 7,173 dollars per life year gained. CONCLUSIONS: The combination of abciximab and stenting versus stenting alone provides improved clinical outcomes at a very reasonable cost from the Canadian hospital perspective.

Warfarin in the secondary prevention of thromboembolism in atrial fibrillation: impact of bioavailability on costs and outcomes.

BACKGROUND: The bioavailability of warfarin is an important factor affecting the achievement of therapeutic anticoagulation. It is uncertain whether less expensive generic preparations of warfarin would compromise prevention of thromboembolism or increase bleeding risk in patients with atrial fibrillation. OBJECTIVE: To compare the cost effectiveness of strategies using warfarin products with variable bioavailability in patients with a prior stroke or transient ischaemic attack related to atrial fibrillation. DESIGN: A Markov decision-analytic model simulating health and economic outcomes over 1 year using the perspective of a government provincial payer was created. Four strategies were compared (where F = 1 is the assumed bioavailability of the branded/reference product): (i) warfarin F = 1; (ii) warfarin F = 1.25; (iii) warfarin F = 0.80; and (iv) alternating warfarin F = 1.25 and 0.80 every other month. Direct medical costs for drugs, physician fees, laboratory testing and hospitalisation for morbid events were obtained from a government payer, a local accounting system and the medical literature. The cost of warfarin F = 1 was equivalent to the cost of the brand name warfarin and the cost of warfarin F not equal 1 was equivalent to generic warfarin. RESULTS: In our institution, warfarin F = 1 was similar in cost to the other three strategies (Can dollars 1361 vs Can dollars 1334-1613) and may be more effective than switching between generic preparations which have bioavailabilities at the extremes of acceptable limits (thromboembolism and bleeds 7. 1% vs 9.3%). CONCLUSIONS: In patients with atrial fibrillation and a prior ischaemic stroke or transient ischaemic attack, the use of one warfarin agent within the range of acceptable bioavailability can be considered economically attractive from the healthcare perspective.