Prevalence of undiagnosed atrial fibrillation in elderly individuals and potential cost-effectiveness of non-invasive ambulatory electrocardiographic screening: The ASSERT-III study.

BACKGROUND: In approximately 10% of patients with implanted pacemakers or defibrillators, previously unrecognized atrial fibrillation (AF) is detected within 3 months. It is unknown whether elderly patients without implanted devices have a similar prevalence of undiagnosed AF using non-invasive ECG monitoring, and if this approach to screening in this population is cost-effective. METHODS: Individuals ≥80 years old attending outpatient clinics without a history of AF and with hypertension and one additional risk factor underwent 30 days of continuous ECG monitoring with an option for an additional 30 days of monitoring if no AF was detected. The primary outcome was AF ≥ 6 min. Cost-effectiveness to prevent stroke was estimated using a Markov model based on observed AF detection rates and data from the published literature. RESULTS: Among 129 patients enrolled, 100 initiated monitoring for an average duration of 36 ±â€¯21 days. The proportion of patients that completed at least 30 days of monitoring was 59%. Average age was 84 ±â€¯3 years and mean CHA2DS2-VASc score was 4.5 ±â€¯1.2. AF ≥ 6 min was documented in 14%, ≥6 h in 8%, and ≥24 h in 3%. One week of monitoring costed $50,000 per quality-adjusted life-year-gained, 30 days and 60 days of monitoring costed $70,000 and $84,000, respectively. CONCLUSIONS: Continuous non-invasive ECG monitoring is feasible in elderly patients. Undiagnosed AF is present in many elderly individuals, with 1 in 7 having episodes lasting ≥6 min. One week of monitoring may be cost-effective for stroke prevention in this population.

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke.

BACKGROUND AND PURPOSE: Prolonged ambulatory ECG monitoring after cryptogenic stroke improves detection of covert atrial fibrillation, but its long-term cost-effectiveness is uncertain. METHODS: We estimated the cost-effectiveness of noninvasive ECG monitoring in patients aged ≥55 years after a recent cryptogenic stroke and negative 24-hour ECG. A Markov model used observed rates of atrial fibrillation detection and anticoagulation from a randomized controlled trial (EMBRACE) and the published literature to predict lifetime costs and effectiveness (ischemic strokes, hemorrhages, life-years, and quality-adjusted life-years [QALYs]) for 30-day ECG (primary analysis) and 7-day or 14-day ECG (secondary analysis), when compared with a repeat 24-hour ECG. RESULTS: Prolonged ECG monitoring (7, 14, or 30 days) was predicted to prevent more ischemic strokes, decrease mortality, and improve QALYs. If anticoagulation reduced stroke risk by 50%, 30-day ECG (at a cost of USD $447) would be highly cost-effective ($2000 per QALY gained) for patients with a 4.5% annual ischemic stroke recurrence risk. Cost-effectiveness was sensitive to stroke recurrence risk and anticoagulant effectiveness, which remain uncertain, especially at higher costs of monitoring. Shorter duration (7 or 14 days) monitoring was cost saving and more effective than an additional 24-hour ECG; its cost-effectiveness was less sensitive to changes in ischemic stroke risk and treatment effect. CONCLUSIONS: After a cryptogenic stroke, 30-day ECG monitoring is likely cost-effective for preventing recurrent strokes; 14-day monitoring is an attractive value alternative, especially for lower risk patients. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention. Cost-effectiveness in practice will depend on careful patient selection.

COVID-related disruptions to colorectal cancer screening, diagnosis, and treatment could increase cancer Burden in Australia and Canada: A modelling study.

COVID-19 disrupted cancer control worldwide, impacting preventative screening, diagnoses, and treatment services. This modelling study estimates the impact of disruptions on colorectal cancer cases and deaths in Canada and Australia, informed by data on screening, diagnosis, and treatment procedures. Modelling was used to estimate short- and long-term effects on colorectal cancer incidence and mortality, including ongoing impact of patient backlogs. A hypothetical mitigation strategy was simulated, with diagnostic and treatment capacities increased by 5% from 2022 to address backlogs. Colorectal cancer screening dropped by 40% in Canada and 6.3% in Australia in 2020. Significant decreases to diagnostic and treatment procedures were also observed in Australia and Canada, which were estimated to lead to additional patient wait times. These changes would lead to an estimated increase of 255 colorectal cancer cases and 1,820 colorectal cancer deaths in Canada and 234 cases and 1,186 deaths in Australia over 2020-2030; a 1.9% and 2.4% increase in mortality, respectively, vs a scenario with no screening disruption or diagnostic/treatment delays. Diagnostic and treatment capacity mitigation would avert 789 and 350 deaths in Canada and Australia, respectively. COVID-related disruptions had a significant impact on colorectal cancer screening, diagnostic, and treatment procedures in Canada and Australia. Modelling demonstrates that downstream effects on disease burden could be substantial. However, backlogs can be managed and deaths averted with even small increases to diagnostic and treatment capacity. Careful management of resources can improve patient outcomes after any temporary disruption, and these results can inform targeted approaches early detection of cancers.

The Burden of Health-Related Out-of-Pocket Cancer Costs in Canada: A Case-Control Study Using Linked Data.

BACKGROUND: The burden of out-of-pocket costs among cancer patients/survivors in Canada is not well understood. The objective of this study was to examine the health-related out-of-pocket cost burden experienced by households with a cancer patient/survivor compared to those without, examine the components of health-related costs and determine who experiences a greater burden. DATA AND METHODS: This study used a data linkage between the Survey of Household Spending and the Canadian Cancer Registry to identify households with a cancer patient/survivor (cases) and those without (controls). The out-of-pocket burden (out-of-pocket costs measured relative to household income) and mean costs were described and regression analyses examined the characteristics associated with the household out-of-pocket burden and annual out-of-pocket costs. RESULTS: The health-related out-of-pocket cost burden and annual costs measured in households with a cancer patient/survivor were 3.08% (95% CI: 2.55-3.62%) and CAD 1600 (95% CI: 1456-1759), respectively, compared to a burden of 2.84% (95% CI: 2.31-3.38) and annual costs of CAD 1511 (95% CI: 1377-1659) measured in control households, respectively. Households with a colorectal cancer patient/survivor had a significantly higher out-of-pocket burden compared to controls (mean difference: 1.0%, 95% CI: 0.18, 0.46). Among both cases and controls, the lowest income quintile households experienced the highest health-related out-of-pocket cost burden. INTERPRETATION: Within a universal health care system, it is still relevant to monitor health-related out-of-pocket spending that is not covered by existing insurance mechanisms; however, this is not routinely assessed in Canada. We demonstrate the feasibility of measuring such costs in households with a cancer patient/survivor using routinely collected data. While the burden and annual health-related out-of-pocket costs of households with a cancer patient/survivor were not significantly higher than control households in this study, the routine measurement of out-of-pocket costs in Canada could be systemized, providing a novel, system-level, equity-informed performance indicator, which is relevant for monitoring inequities in the burden of out-of-pocket costs.

Participatory simulation modeling to inform colorectal cancer screening in a complex remote northern health system: Canada's Northwest Territories.

BACKGROUND & AIMS: Colorectal cancer (CRC) mortality in the Northwest Territories (NWT), a northern region of Canada, could be reduced by implementing a CRC screening program. However, this may require additional colonoscopy resources. We used participatory simulation modeling to predict colonoscopy demand and to develop strategies for implementing a feasible and effective CRC screening program in this complex remote northern health system. METHODS: Using a participatory simulation modeling approach, we first developed a conceptual model of CRC screening with local collaborators. This approach informed our parameter adjustments of an existing microsimulation model, OncoSim-CRC, using data from a retrospective cohort review of CRC screening between 2014-2019 and secondary data. Model scenarios reflecting program implementation were run for 500 million cases. Validity was assessed, and outputs analyzed with collaborators. Alternative scenarios were developed to reduce colonoscopy demand and results were presented to end-users. RESULTS: We estimated that colonoscopy demand with a CRC screening program phased-in over 5 years would surpass capacity within 2 years. If demand is met, screen-detected cancers would increase by 110 %, and clinically-detected cases would reduce by 26 % over the next 30 years. We also found that prolonging the phase-in period, or revising adenoma follow-up guidelines would reduce colonoscopy demand while still improving cancer detection. Both strategies were considered feasible by collaborators. The adjusted model was valid, and the projections informed local end-users plans for CRC screening delivery. CONCLUSIONS: Using participatory simulation modeling, we projected that a screening program would improve CRC detection but surpass current colonoscopy capacity. Phasing-in the screening program and reducing endoscopic adenoma follow-up would enhance feasibility of a CRC screening program in the NWT and help maintain its effectiveness.

Modelling airport catchment areas to anticipate the spread of infectious diseases across land and air travel.

Air travel is an increasingly important conduit for the worldwide spread of infectious diseases. However, methods to identify which airports an individual may use to initiate travel, or where an individual may travel to upon arrival at an airport is not well studied. This knowledge gap can be addressed by estimating airport catchment areas: the geographic extent from which the airport derives most of its patronage. While airport catchment areas can provide a simple decision-support tool to help delineate the spatial extent of infectious disease spread at a local scale, observed data for airport catchment areas are rarely made publicly available. Therefore, we evaluated a probabilistic choice behavior model, the Huff model, as a potential methodology to estimate airport catchment areas in the United States in data-limited scenarios. We explored the impact of varying input parameters to the Huff model on estimated airport catchment areas: distance decay exponent, distance cut-off, and measures of airport attractiveness. We compared Huff model catchment area patterns for Miami International Airport (MIA) and Harrisburg International Airport (MDT). We specifically compared our model output to observed data sampled for MDT to align model parameters with an established, observed catchment area. Airport catchment areas derived using the Huff model were highly sensitive to changes in model parameters. We observed that a distance decay exponent of 2 and a distance cut-off of 500 km represented the most realistic spatial extent and heterogeneity of the MIA catchment area. When these parameters were applied to MDT, the Huff model produced similar spatial patterns to the observed MDT catchment area. Finally, our evaluation of airport attractiveness showed that travel volume to the specific international destinations of interest for infectious disease importation risks (i.e., Brazil) had little impact on the predicted choice of airport when compared to all international travel. Our work is a proof of concept for use of the Huff model to estimate airport catchment areas as a generalizable decision-support tool in data-limited scenarios. While our work represents an initial examination of the Huff model as a method to approximate airport catchment areas, an essential next step is to conduct a quantitative calibration and validation of the model based on multiple airports, possibly leveraging local human mobility data such as call detail records or online social network data collected from mobile devices. Ultimately, we demonstrate how the Huff model could be potentially helpful to improve the precision of early warning systems that anticipate infectious disease spread, or to incorporate when local public health decision makers need to identify where to mobilize screening infrastructure or containment strategies at a local level.

Clinical impact and cost-effectiveness of integrating smoking cessation into lung cancer screening: a microsimulation model.

BACKGROUND: Low-dose computed tomography (CT) screening can reduce lung cancer mortality in people at high risk; adding a smoking cessation intervention to screening could further improve screening program outcomes. This study aimed to assess the impact of adding a smoking cessation intervention to lung cancer screening on clinical outcomes, costs and cost-effectiveness. METHODS: Using the OncoSim-Lung mathematical microsimulation model, we compared the projected lifetime impact of a smoking cessation intervention (nicotine replacement therapy, varenicline and 12 wk of counselling) in the context of annual low-dose CT screening for lung cancer in people at high risk to lung cancer screening without a cessation intervention in Canada. The simulated population consisted of Canadians born in 1940-1974; lung cancer screening was offered to eligible people in 2020. In the base-case scenario, we assumed that the intervention would be offered to smokers up to 10 times; each intervention would achieve a 2.5% permanent quit rate. Sensitivity analyses varied key model inputs. We calculated incremental cost-effectiveness ratios with a lifetime horizon from the health system's perspective, discounted at 1.5% per year. Costs are in 2019 Canadian dollars. RESULTS: Offering a smoking cessation intervention in the context of lung cancer screening could lead to an additional 13% of smokers quitting smoking. It could potentially prevent 12 more lung cancers and save 200 more life-years for every 1000 smokers screened, at a cost of $22 000 per quality-adjusted life-year (QALY) gained. The results were most sensitive to quit rate. The intervention would cost over $50 000 per QALY gained with a permanent quit rate of less than 1.25% per attempt. INTERPRETATION: Adding a smoking cessation intervention to lung cancer screening is likely cost-effective. To optimize the benefits of lung cancer screening, health care providers should encourage participants who still smoke to quit smoking.

A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis.

OBJECTIVE: To carry out a cost-effectiveness analysis of omitting chest radiography in the diagnosis of infant bronchiolitis. HYPOTHESIS: Omitting chest radiographs in the diagnosis of typical bronchiolitis was expected to reduce costs without adversely affecting the detection rate of alternate diseases. STUDY DESIGN: An economic evaluation was conducted using clinical and health resources. Emergency department (ED) physicians provided diagnoses pre- and post-radiography as well as a management plan. The primary outcome was the diagnostic accuracy (false-negative rate) of alternate diagnoses with and without X-ray. The incremental costs of omitting radiography in comparison to routine radiography per patient were assessed from a health system perspective. PATIENT SELECTION: We studied 265 infants, 2-23 months old, presenting at the ED with typical bronchiolitis. Patients with pre-existing conditions or radiographs were omitted from the study. METHODOLOGY: Expected costs to the health care system of including and excluding chest radiographs were compared, including costs associated with misdiagnosis. RESULTS: All alternate diagnoses (two cases) were missed by ED physicians pre- and post-radiography, resulting in a 100% false negative rate. The specificity in detecting alternate diseases was 96.6% pre-radiography and 88.6% post-radiography. Of the 17 cases of coexistent pneumonia, 88% were missed pre-radiography and 59% post-radiography, with respective false positive rates of 10.5% and 16.1%. Omission of routine chest radiograph saved CDN $59 per patient, primarily due to savings in radiography and hospitalization costs. The economic benefit persisted after the inpatient length of stay, ED overhead and radiograph costs were varied. CONCLUSION: For infants with typical bronchiolitis, omitting radiography is cost saving without compromising diagnostic accuracy of alternate diagnoses and of associated pneumonia.