Assessing the cost-effectiveness of integrated case management of Neglected Tropical Diseases in Liberia.

BACKGROUND: In 2017, Liberia became one of the first countries in the African region to develop and implement a national strategy for integrated case management of Neglected Tropical Diseases (CM-NTDs), specifically Buruli ulcer, leprosy, lymphatic filariasis morbidities, and yaws. Implementing this plan moves the NTD program from many countries' fragmented (vertical) disease management. This study explores to what extent an integrated approach offers a cost-effective investment for national health systems. METHODS: This study is a mixed-method economic evaluation that explores the cost-effectiveness of the integrated CM-NTDs approach compared to the fragmented (vertical) disease management. Primary data were collected from two integrated intervention counties and two non-intervention counties to determine the relative cost-effectiveness of the integrated program model vs. fragmented (vertical) care. Data was sourced from the NTDs program annual budgets and financial reports for integrated CM-NTDs and Mass Drug Administration (MDA) to determine cost drivers and effectiveness. RESULTS: The total cost incurred by the integrated CM-NTD approach from 2017 to 2019 was US$ 789,856.30, with the highest percentage of costs for program staffing and motivation (41.8%), followed by operating costs (24.8%). In the two counties implementing fragmented (vertical) disease management, approximately US$ 325,000 was spent on the diagnosis of 84 persons and the treatment of twenty-four persons suffering from NTDs. While 2.5 times as much was spent in integrated counties, 9-10 times more patients were diagnosed and treated. CONCLUSIONS: The cost of a patient being diagnosed under the fragmented (vertical) implementation is five times higher than integrated CM-NTDs, and providing treatment is ten times as costly. Findings indicate that the integrated CM-NTDs strategy has achieved its primary objective of improved access to NTD services. The success of implementing an integrated CM-NTDs approach in Liberia, presented in this paper, demonstrates that NTD integration is a cost-minimizing solution.

Costing electronic private sector malaria surveillance in the Greater Mekong Subregion.

BACKGROUND: Private sector malaria programmes contribute to government-led malaria elimination strategies in Cambodia, Lao PDR, and Myanmar by increasing access to quality malaria services and surveillance data. However, reporting from private sector providers remains suboptimal in many settings. To support surveillance strengthening for elimination, a key programme strategy is to introduce electronic surveillance tools and systems to integrate private sector data with national systems, and enhance the use of data for decision-making. During 2013-2017, an electronic surveillance system based on open source software, District Health Information System 2 (DHIS2), was implemented as part of a private sector malaria case management and surveillance programme. The electronic surveillance system covered 16,000 private providers in Myanmar (electronic reporting conducted by 200 field officers with tablets), 710 in Cambodia (585 providers reporting through mobile app), and 432 in Laos (250 providers reporting through mobile app). METHODS: The purpose of the study was to document the costs of introducing electronic surveillance systems and mobile reporting solutions in Cambodia, Lao PDR, and Myanmar, comparing the cost in different operational settings, the cost of introduction and maintenance over time, and assessing the affordability and financial sustainability of electronic surveillance. The data collection methods included extracting data from PSI's financial and operational records, collecting data on prices and quantities of resources used, and interviewing key informants in each setting. The costing study used an ingredients-based approach and estimated both financial and economic costs. RESULTS: Annual economic costs of electronic surveillance systems were $152,805 in Laos, $263,224 in Cambodia, and $1,310,912 in Myanmar. The annual economic cost per private provider surveilled was $82 in Myanmar, $371 in Cambodia, and $354 in Laos. Cost drivers varied depending on operational settings and number of private sector outlets covered in each country; whether purchased or personal mobile devices were used; and whether electronic (mobile) reporting was introduced at provider level or among field officers who support multiple providers for case reporting. CONCLUSION: The study found that electronic surveillance comprises about 0.5-1.5% of national malaria strategic plan cost and 7-21% of surveillance budgets and deemed to be affordable and financially sustainable.

Economic costs analysis of uncomplicated malaria case management in the Peruvian Amazon.

BACKGROUND: Case management is one of the principal strategies for malaria control. This study aimed to estimate the economic costs of uncomplicated malaria case management and explore the influence of health-seeking behaviours on those costs. METHODS: A knowledge, attitudes and practices (KAP) survey was applied to 680 households of fifteen communities in Mazan-Loreto in March 2017, then a socio-economic survey was conducted in September 2017 among 161 individuals with confirmed uncomplicated malaria in the past 3 months. Total costs per episode were estimated from both provider (Ministry of Health, MoH) and patient perspectives. Direct costs were estimated using a standard costing estimation procedure, while the indirect costs considered the loss of incomes among patients, substitute labourers and companions due to illness in terms of the monthly minimum wage. Sensitivity analysis evaluated the uncertainty of the average cost per episode. RESULTS: The KAP survey showed that most individuals (79.3%) that had malaria went to a health facility for a diagnosis and treatment, 2.7% received those services from community health workers, and 8% went to a drugstore or were self-treated at home. The average total cost per episode in the Mazan district was US$ 161. The cost from the provider's perspective was US$ 30.85 per episode while from the patient's perspective the estimated cost was US$ 131 per episode. The average costs per Plasmodium falciparum episode (US$ 180) were higher than those per Plasmodium vivax episode (US$ 156) due to longer time lost from work by patients with P. falciparum infections (22.2 days) than by patients with P. vivax infections (17.0 days). The delayed malaria diagnosis (after 48 h of the onset of symptoms) was associated with the time lost from work due to illness (adjusted mean ratio 1.8; 95% CI 1.3, 2.6). The average cost per malaria episode was most sensitive to the uncertainty around the lost productivity cost due to malaria. CONCLUSIONS: Despite the provision of free malaria case management by MoH, there is delay in seeking care and the costs of uncomplicated malaria are mainly borne by the families. These costs are not well perceived by the society and the substantial financial impact of the disease can be frequently undervalued in public policy planning.

Case manager-assisted rehabilitation for lumbar spinal fusion patients: an economic evaluation alongside a randomized controlled trial with two-year follow-up.

OBJECTIVE: To examine the cost-effectiveness of case manager-assisted rehabilitation as an add-on to usual physical rehabilitation after lumbar spinal fusion, given the lack of any clinical benefits found on analysing the clinical data. DESIGN: Economic evaluation alongside a randomized controlled trial with two-year follow-up. SETTING: Patients from the outpatient clinics of a university hospital and a general hospital. SUBJECTS: A total of 82 lumbar spinal fusion patients. INTERVENTIONS: Patients were randomized one-to-one to case manager-assisted rehabilitation programme as an add-on to usual physical rehabilitation or to usual physical rehabilitation. MAIN MEASURES: Oswestry Disability Index and EuroQol 5-dimension. Danish preference weights were used to estimate quality-adjusted life years. Costs were estimated from micro costing and national registries. Multiple imputation was used to handle missing data. Costs and effects were presented with means (95% confidence interval (CI)). The incremental net benefit was estimated for a range of hypothetical values of willingness to pay per gain in effects. RESULTS: No impact of case manager-assisted rehabilitation on the Oswestry Disability Index or estimate quality-adjusted life years was observed. Intervention cost was Euros 3984 (3468; 4499), which was outweighed by average reductions in inpatient resource use and sickness leave. A cost reduction of Euros 1716 (-16,651; 20,084) was found in the case manager group. Overall, the probability for the case manager-assisted rehabilitation programme being cost-effective did not exceed a probability of 56%, regardless of willingness to pay. Sensitivity analysis did not change the conclusion. CONCLUSION: This case manager-assisted rehabilitation programme was unlikely to be cost-effective.

Addressing challenges in tuberculosis adherence via performance-based payments for integrated case management: protocol for a cluster randomized controlled trial in Georgia.

BACKGROUND: Tuberculosis is one of the greatest global health concerns and disease management is challenging particularly in low- and middle-income countries. Despite improvements in addressing this epidemic in Georgia, tuberculosis remains a significant public health concern due to sub-optimal patient management. Low remuneration for specialists, limited private-sector interest in provision of infectious disease care and incomplete integration in primary care are at the core of this problem. METHODS: This protocol sets out the methods of a two-arm cluster randomized control trial which aims to generate evidence on the effectiveness of a performance-based financing and integrated care intervention on tuberculosis loss to follow-up and treatment adherence. The trial will be implemented in health facilities (clusters) under-performing in tuberculosis management. Eligible and consenting facilities will be randomly assigned to either intervention or control (standard care). Health providers within intervention sites will form a case management team and be trained in the delivery of integrated tuberculosis care; performance-related payments based on monthly records of patients adhering to treatment and quality of care assessments will be disbursed to health providers in these facilities. The primary outcomes include loss to follow-up among adult pulmonary drug-sensitive and drug-resistant tuberculosis patients. Secondary outcomes are adherence to treatment among drug-sensitive and drug-resistant tuberculosis patients and treatment success among drug-sensitive tuberculosis patients. Data on socio-demographic characteristics, tuberculosis diagnosis and treatment regimen will also be collected. The required sample size to detect a 6% reduction in loss to follow-up among drug-sensitive tuberculosis patients and a 20% reduction in loss to follow-up among drug-resistant tuberculosis patients is 948 and 136 patients, respectively. DISCUSSION: The trial contributes to a limited body of rigorous evidence and literature on the effectiveness of supply-side performance-based financing interventions on tuberculosis patient outcomes. Realist and health economic evaluations will be conducted in parallel with the trial, and associated composite findings will serve as a resource for the Georgian and wider regional Ministries of Health in relation to future tuberculosis and wider health policies. The trial and complementing evaluations are part of Results4TB, a multidisciplinary collaboration engaging researchers and Georgian policy and practice stakeholders in the design and evaluation of a context-sensitive tuberculosis management intervention. TRIAL REGISTRATION: ISRCTN, ISRCTN14667607 . Registered on 14 January 2019.

Cost-effectiveness of Housing First Intervention With Intensive Case Management Compared With Treatment as Usual for Homeless Adults With Mental Illness: Secondary Analysis of a Randomized Clinical Trial.

Importance: In the At Home/Chez Soi trial for homeless individuals with mental illness, the scattered-site Housing First (HF) with Intensive Case Management (ICM) intervention proved more effective than treatment as usual (TAU). Objective: To evaluate the cost-effectiveness of the HF plus ICM intervention compared with TAU. Design, Setting, and Participants: This is an economic evaluation study of data from the At Home/Chez Soi randomized clinical trial. From October 2009 through July 2011, 1198 individuals were randomized to the intervention (n = 689) or TAU (n = 509) and followed up for as long as 24 months. Participants were recruited in the Canadian cities of Vancouver, Winnipeg, Toronto, and Montreal. Participants with a current mental disorder who were homeless and had a moderate level of need were included. Data were analyzed from 2013 through 2019, per protocol. Interventions: Scattered-site HF (using rent supplements) with off-site ICM services was compared with usual housing and support services in each city. Main Outcomes and Measures: The analysis was performed from the perspective of society, with days of stable housing as the outcome. Service use was ascertained using questionnaires. Unit costs were estimated in 2016 Canadian dollars. Results: Of 1198 randomized individuals, 795 (66.4%) were men and 696 (58.1%) were aged 30 to 49 years. Almost all (1160 participants, including 677 in the HF group and 483 in the TAU group) contributed data to the economic analysis. Days of stable housing were higher by 140.34 days (95% CI, 128.14-153.31 days) in the HF group. The intervention cost $14 496 per person per year; reductions in costs of other services brought the net cost down by 46% to $7868 (95% CI, $4409-$11 405). The incremental cost-effectiveness ratio was $56.08 (95% CI, $29.55-$84.78) per additional day of stable housing. In sensitivity analyses, adjusting for baseline differences using a regression-based method, without altering the discount rate, caused the largest change in the incremental cost-effectiveness ratio with an increase to $60.18 (95% CI, $35.27-$86.95). At $67 per day of stable housing, there was an 80% chance that HF was cost-effective compared with TAU. The cost-effectiveness of HF appeared to be similar for all participants, although possibly less for those with a higher number of previous psychiatric hospitalizations. Conclusions and Relevance: In this study, the cost per additional day of stable housing was similar to that of many interventions for homeless individuals. Based on these results, expanding access to HF with ICM appears to be warranted from an economic standpoint. Trial Registration: isrctn.org Identifier: ISRCTN42520374.

Does an all-condition case management program for high-risk patients reduce health care utilization in medicaid and medicare beneficiaries with diabetes?

OBJECTIVE: To assess whether an all-condition case management program can improve health care utilization and clinical outcomes in patients with diabetes. RESEARCH DESIGN AND METHODS: 1342 patients with diabetes were enrolled in the Johns Hopkins Community Health Partnership (J-CHiP) Case Management program for high-risk patients with any chronic disease. We categorized participants into two intervention exposure categories based on the number of contacts with case manager (CM) and community health worker (CHW) per month: low contact (≤1 contact/month), and high contact (>1 contacts/month). The primary outcomes were rates of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions. RESULTS: In analyses adjusted for age, sex, race, risk score, and baseline health utilization rate, Medicaid participants in the high contact group had 42% (rate ratio (RR): 1.42; 95% CI: 1.08-1.86) and 64% (RR: 1.64; 95% CI: 1.08-2.48) higher risks for hospital admission and readmission, respectively, than the low contact group. Similar increases were seen in the Medicare participants with 20% (RR: 1.20; 95% 1.02-1.42) and 42% (RR:1.42; 95% 1.09-1.84) higher risks for admission and readmission, respectively. The associations were not statistically significant for ED visits. Subsidiary analysis of a subset with HbA1c available (n = 545) revealed a statistically significant decrease in HbA1c among Medicare participants (mean (SD): -0.17% (1.50%)), with a larger decrease in the high contact group (mean (SD): -0.23% (1.59%)). CONCLUSION: In an all-condition case management program for high-risk patients, the higher intensity of contacts with CHW and CM was not associated with a reduced health care utilization in adults with diabetes.

Perspectives on Implementation Considerations and Costs of Malaria Case Management Supportive Supervision.

Between 2012 and 2017, the U.S. President's Malaria Initiative-funded MalariaCare project supported national malaria control programs in sub-Saharan Africa to implement a case management quality assurance (QA) system for malaria and other febrile illnesses. A major component of the system was outreach training and supportive supervision (OTSS), whereby trained government health personnel visited health facilities to observe health-care practices using a standard checklist, to provide individualized feedback to staff, and to develop health facility-wide action plans based on observation and review of facility registers. Based on MalariaCare's experience, facilitating visits to more than 5,600 health facilities in nine countries, we found that programs seeking to implement similar supportive supervision schemes should consider ensuring the following: 1) develop a practical checklist that balances information gathering and mentorship; 2) establish basic competency criteria for supervisors and periodically assess supervisor performance in the field; 3) conduct both technical skills training and supervision skills training; 4) establish criteria for selecting facilities to conduct OTSS and determine the appropriate frequency of visits; and 5) use electronic data collection systems where possible. Cost will also be a significant consideration: the average cost per OTSS visit ranged from $44 to $333. Significant variation in costs was due to factors such as travel time, allowances for government personnel, length of the visit, and involvement of central level officials. Because the cost of conducting supportive supervision prohibits regularly visiting all health facilities, internal QA measures could also be considered as alternative or complementary activities to supportive supervision.

Improving Outcomes and Costs With System-Level, Physician-Led Interdisciplinary Case Review.

Improving outcomes and reducing costs for individuals with frequent acute episodes of care is a high priority for community behavioral health systems and managed care organizations. This column illustrates the application of interdisciplinary, interagency teamwork-with clinical leadership by the system psychiatric medical director-to a county-level quality improvement team process, a change that resulted in significant improvements in outcomes and costs over a 7-year period.

Performance indicator as the main and the only goal: a "dark side" of the intervention aims to accelerate HIV treatment entry among people who inject drugs in Kyiv, Ukraine.

BACKGROUND: To improve healthcare entry and antiretroviral therapy (ART) initiation for HIV-positive people who inject drugs (PWID) in Ukraine, an intervention built upon a successful community-based harm reduction project and the existing best practices was developed. In this article, we present the results of the study conducted in collaboration with one of the recipient organizations of the intervention in Kyiv. The research question was formulated as follows: how does the interaction between different actors work to lead it to a positive outcome (initiation PWIDs into ART) within the limited period of the intervention implementation? METHODS: The central focus of the study was on the work activities of case managers. Their daily routines as well as their interactions with their clients and medical workers were observed and analyzed. Using the institutional ethnography approach, we explore the institutional orders, power imbalances, and social factors that play different roles in coordinating the process of PWIDs entry into healthcare and HIV treatment. RESULTS: The most intriguing result of the study is that the performance indicator that must be completed in order to receive a full salary-as a way to manage the activities of case managers-produces conditions for them to develop their cooperation with medical workers but leaves the clients and their needs out of this "boat" because interaction with them, in fact, does not help to meet case managers' goals. CONCLUSIONS: Accountability of case managers' work assumes the primacy of the result over the process, which makes the process itself less important and the need to achieve the goal becomes the main and the only goal. This can be identified as an unintended consequence of the intervention implementation on the ground, or wider-an unintended consequence of the payment by results practice as a part of the general number-based policy.

Case Management for People with Dementia and its Translations: A Discussion Paper.

Case management is generally seen as a way to provide efficient, cost-saving person-centred care for people with dementia by connecting together fragmented services, but the available evidence in favour of its merits is often considered inconclusive, unclear and sketchy. This discussion paper investigates the evidence of the benefit of case management for people with dementia and explores the complexity of the concept and the experiences of its implementation. It offers a comprehensive framework for conceptualising various types of case management and asks the question: who can be a case manager? Building on examples from three European countries it addresses the problem of the expansion and adoption of the case management method. It compares the conventional model of diffusion of innovation with the ideas of interessement and co-constitution and envisions a successful model of case management as a fluid technology that is both friendly and flexible, allowing it to adapt to different settings and systems.

Trends and challenges in diabetes for middle-income countries: Evidence from Mexico.

The epidemiological and economic burden of diabetes poses one of the main challenges for health systems worldwide. This is particularly relevant in middle-income countries because of the constant growing trends that have been observed in recent years. In order to identify trends and challenges on epidemiological and economic burden from diabetes in a middle-income country we developed a longitudinal analysis on costs and trends in the number of cases of diabetes in Mexico. The study population included total annual cases of diabetes at national level. Regarding the annual cumulative incidence for 2016 versus 2018, depending on the institution there is an increase of 9-13% (p < 0.001). Comparing the economic burden from incidence in 2016 versus 2018 (p < 0.05), there is a 26% increase. The total amount for diabetes in 2017 (US dollars) was $9,684,780,574. It includes $ 4,292,085,964 in direct costs and $ 5,392,694,610 in indirect costs. The total direct costs are: $ 510,986,406 for uninsured population; $ 1,416,132,058 for insured population; $ 2,235,969,330 for users' pockets. This is an example of what is happening in the management of diabetes care in middle-income countries and we suggest review and rethinking strategies of prevention, planning, organisation and resource allocation.

Potential savings in the treatment pathway of liver transplantation: an inter-sectorial analysis of cost-rising factors.

INTRODUCTION: Identification of cost-driving factors in patients undergoing liver transplantation is essential to target reallocation of resources and potential savings. AIM: The aim of this study is to identify main cost-driving factors in liver transplantation from the perspective of the Statutory Health Insurance. METHODS: Variables were analyzed with multivariable logistic regression to determine their influence on high cost cases (fourth quartile) in the outpatient, inpatient and rehabilitative healthcare sectors as well as for medications. RESULTS: Significant cost-driving factors for the inpatient sector of care were a high labMELD-score (OR 1.042), subsequent re-transplantations (OR 7.159) and patient mortality (OR 3.555). Expenditures for rehabilitative care were significantly higher in patients with a lower adjusted Charlson comorbidity index (OR 0.601). The indication of viral cirrhosis and hepatocellular carcinoma resulted in significantly higher costs for medications (OR 21.618 and 7.429). For all sectors of care and medications each waiting day had a significant impact on high treatment costs (OR 1.001). Overall, cost-driving factors resulted in higher median treatment costs of 211,435 €. CONCLUSIONS: Treatment costs in liver transplantation were significantly influenced by identified factors. Long pre-transplant waiting times that increase overall treatment costs need to be alleviated by a substantial increase in donor organs to enable transplantation with lower labMELD-scores. Disease management programs, the implementation of a case management for vulnerable patients, medication plans and patient tracking in a transplant registry may enable cost savings, e.g., by the avoidance of otherwise necessary re-transplants or incorrect medication.

Pediatric integrated behavioral health service delivery models: Using a federal framework to assess levels of integration.

OBJECTIVE: To assess the level of integration of pediatric integrated behavioral health service delivery models (IBHSDM) since it has not been well established. DATA SOURCES: A systematic review of journal databases (e.g., PubMed) and Google searches was used to identify publications. STUDY SELECTION: Studies were included if they examined children who were treated in an IBHSDM. DATA EXTRACTION: The authors extracted data from studies and assessed them for level of integration using a federal conceptual framework. DATA SYNTHESIS: Guided by PRISMA standards, the authors identified 40 journal articles that described 32 integrated delivery models. Five models (15.6%) were rated at integration level 1 or 2 (coordinated care), eight models (25%) were rated level 3 and five models (15.6%) were rated level 4 (co-located care), and fourteen models (43.8%) were rated level 5 or 6 (integrated care). CONCLUSIONS: In general, it is assumed that more completely integrated care will result in higher quality care and reduced costs. Thirteen of the models described (40.6%) had levels of integration of 3 or lower that may be too low to produce desired effects on quality and cost. Future research should address potential barriers that impede the development of models with higher degrees of integration.

Cost-effectiveness of home blood pressure telemonitoring and case management in the secondary prevention of cerebrovascular disease in Canada.

Home blood pressure (BP) telemonitoring and pharmacist case management reduce BP, but cost-effectiveness assessments are mixed. We examined the incremental cost-effectiveness of this intervention vs usual care in Canadians with cerebrovascular disease. A Markov decision model cost-utility analysis examining community-residing, high-risk patients with a recent nondisabling cerebrovascular event was created. A lifetime time horizon and health care payer perspective were used. Achieved BP, future cardiovascular risks, and attendant consequences on quality-adjusted life years and Canadian dollar costs were modeled. BP telemonitoring was assumed to occur for 3 months, then quarterly. Life tables were used to determine overall mortality, adjusted by cardiovascular disease mortality. Relative efficacies of intervention-associated BP lowering, resource use, and costs were obtained from Canadian published literature. Reduction in systolic BP of 9.7 mmHg was used in the base case; subsequently, robust sensitivity analyses were conducted. The results showed that, over the lifetime horizon, telemonitoring with case management led to net health care savings of $1929 Canadian and increased per-patient QALYs by 0.83. These findings were robust to sensitivity analysis, with the intervention remaining dominant or highly cost-effective. Increasing telemonitoring costs by 50% still resulted in the intervention being dominant; if the costs of telemonitoring plus case management were 2-3 times base case cost, incremental cost-effectiveness was $1200-$4700 per quality-adjusted life year gained. In conclusion, home BP telemonitoring and pharmacist case management poststroke lowered costs and improved QALYs. Strategies and funding for broad implementation of this dominant strategy should be implemented.

Costs and effects of interventions targeting frequent presenters to the emergency department: a systematic and narrative review.

BACKGROUND: Previous systematic reviews have examined the effectiveness of interventions for frequent presenters to the Emergency Department (ED) but not the costs and cost-effectiveness of such interventions. METHOD: A systematic literature review was conducted which screened the following databases: Pubmed, Medline, Embase, Cochrane and Econlit. An inclusion and exclusion criteria were developed following PRISMA guidelines. A narrative review methodology was adopted due to the heterogeneity of the reporting of the costs across the studies. RESULTS: One thousand three hundred eighty-nine papers were found and 16 were included in the review. All of the interventions were variations of a case management approach. Apart from one study which had mixed results, all of the papers reported a decrease in ED use and costs. There were no cost effectiveness studies. CONCLUSION: The majority of interventions for frequent presenters to the ED were found to decrease ED use and cost. Future research should be undertaken to examine the cost effectiveness of these interventions.

Medicaid Cost Trajectories for Children With Serious Emotional Disturbance: The HCBS Waiver Program Versus Targeted Case Management.

OBJECTIVE: The study compared Medicaid cost-effectiveness for children with serious emotional disturbance receiving services from two programs operated by the New York State Office of Mental Health: the Home and Community-Based Services (HCBS) Waiver program and targeted case management (TCM). METHODS: Children ages four to 18 who received services from the HCBS Waiver program (N=1,602) or TCM (N=2,740) during 2009-2012 were selected. A quasi-experimental study design with propensity score-matched comparison groups was used to examine Medicaid costs (per member per month [PMPM] total cost) before admission to and after discharge from the HCBS Waiver and TCM programs. Exponential smoothing models were used to examine Medicaid cost trends before and after each program. Difference-in-difference techniques were used to estimate the average annual difference in PMPM Medicaid cost. RESULTS: Trends for PMPM total Medicaid cost for HCBS Waiver-enrolled children after discharge decreased by 25%, whereas postdischarge costs for TCM-enrolled children increased by 15%. The adjusted pre-to-post difference in PMPM total Medicaid cost for HCBS Waiver children decreased by $498 and increased for TCM children by $448-a statistically significant decline of $946 (range $927-$963) in average PMPM Medicaid cost for HCBS Waiver children compared with TCM children. CONCLUSIONS: The PMPM Medicaid cost for children during HCBS Waiver enrollment was higher than for similar children enrolled in TCM. However, Medicaid cost savings for the HCBS Waiver group after the program may support investment in the more intensive HCBS Waiver program for children with comparable psychiatric needs.

Cost-utility analysis of low-intensity case management to increase contact with health services among ex-prisoners in Australia.

OBJECTIVES: The economic burden of incarceration is substantial in Australia. People released from prison are at high risk of poor health and this is an important predictor of recidivism. The 'Passports Study' was a randomised controlled trial of an intervention designed to increase health service utilisation after release from prison. The aim of this study is to conduct a cost-utility analysis of this transitional programme. SETTING: Australia DESIGN: A hybrid simulation model was developed to estimate the changes to total economic costs and effectiveness expressed as quality-adjusted life-years (QALYs) from the adoption of the 'Passports' intervention compared with the control group. Model parameters were informed by linked data from Queensland Corrective Services, Medicare, Pharmaceutical Benefits Scheme, Queensland Hospital Admission Patient Data Collection, Emergency Department Information System and National Death Index. Health-related quality of life was measured using the Short-Form 8 Health Survey (SF-8). The primary outcomes were the costs and estimated QALYs associated with the intervention group and the control group. Probabilistic sensitivity analysis was conducted to test parameter uncertainties. RESULTS: Compared with the control group where no attempt was made to encourage health service utilisation, an average participant in the intervention group incurred an extra cost of AUD 1790 and experienced slightly reduced QALYs, which indicated that the intervention was dominated in the baseline analysis. Probabilistic sensitivity analysis revealed that the transitional programme had a low probability of being cost-effective with the outcome measures selected. CONCLUSION: The findings of this study do not provide economic evidence to support the widespread adoption of the Passports intervention. Due to the reductionist nature of the cost-utility approach, it may be that important health-related benefits have been omitted. Another research approach using a wider range of health-related measures might generate different conclusions.