Health care resource utilization and costs associated with atrial fibrillation and rural-urban disparities.

BACKGROUND: Atrial fibrillation (AF) imposes substantial health care and economic burden on health care systems and patients. Previous studies failed to examine health care resource utilization (HCRU) and costs among patients with incident AF and potential disparity with regard to geographic location. OBJECTIVES: To examine HCRU and costs among patients with incident AF compared with patients without AF and examine whether a geographic disparity exists. METHODS: This was a retrospective cohort study. We selected patients with AF and patients without AF from IBM/Watson MarketScan Research Databases 2014-2019. HCRU and costs were collected 12 months following an AF index date. We used 2-part models with bootstrapping to obtain the marginal estimates and CIs. Rural status was identified based on Metropolitan Statistical Area. We adjusted for age, sex, plan type, US region, and comorbidities. RESULTS: Among 156,732 patients with AF and 3,398,490 patients without AF, patients with AF had 9.04 (95% CI = 8.96-9.12) more outpatient visits, 0.82 (95% CI = 0.81-0.83) more emergency department (ED) visits, 0.33 (95% CI = 0.33-0.34) more inpatient admission, and $15,095 (95% CI = 14,871-15,324) higher total costs, compared with patients without AF. Among patients with AF, rural patients had 1.99 fewer (95% CI = -2.26 to -1.71) outpatient visits and 0.05 (95% CI = 0.02-0.08) more ED visits than urban patients. Overall, rural patients with AF had decreased total costs compared with urban patients (mean = $751; 95% CI = -1,227 to -228). CONCLUSIONS: Incident AF was associated with substantial burden of health care resources and an economic burden, and the burden was not equally distributed across patients in urban vs rural settings. DISCLOSURES: Dr Hansen reports grants from the National Science Foundation during the conduct of the study.

Cost of TB services in healthcare facilities in Kenya (No 3).

BACKGROUND: The reduction of Kenya´s TB burden requires improving resource allocation both to and within the National TB, Leprosy and Lung Disease Program (NTLD-P). We aimed to estimate the unit costs of TB services for budgeting by NTLD-P, and allocative efficiency analyses for future National Strategic Plan (NSP) costing.METHODS: We estimated costs of all TB interventions in a sample of 20 public and private health facilities from eight counties. We calculated national-level unit costs from a health provider´s perspective using bottom-up (BU) and top-down (TD) approaches for the financial year 2017-2018 using Microsoft Excel and STATA v16.RESULTS: The mean unit cost for passive case-finding (PCF) was respectively US$38 and US$60 using the BU and TD approaches. The unit BU and TD costs of a 6-month first-line treatment (FLT) course, including monitoring tests, was respectively US$135 and US$160, while those for adult drug-resistant TB (DR-TB) treatment was respectively US$3,230.28 and US$3,926.52 for the 9-month short regimen. Intervention costs highlighted variations between BU and TD approaches. Overall, TD costs were higher than BU, as these are able to capture more costs due to inefficiency (breaks/downtime/leave).CONCLUSION: The activity-based TB unit costs form a comprehensive cost database, and the costing process has built-in capacity within the NTLD-P and international TB research networks, which will inform future TB budgeting processes.

Economic evaluation of patient costs associated with tuberculosis diagnosis and care in Solomon Islands.

BACKGROUND: Tuberculosis (TB) care can be costly for patients and their families. The End TB Strategy includes a target that zero TB affected households should experience catastrophic costs associated with TB care. Costs are catastrophic when a patient spends 20% or more of their annual household income on their TB diagnosis and care. In Solomon Islands the costs of TB care are unknown. The aim of this study was to determine the costs of TB diagnosis and care, the types of costs and the proportion of patients with catastrophic costs. METHODS: This was a nationally representative cross-sectional survey of TB patients carried out between 2017 and 2019. Patients were recruited from health care facilities, from all ten provinces in Solomon Islands. During an interview they were asked about the costs of TB diagnosis and care. These data were analysed using descriptive statistics to describe the costs overall and the proportions of different types of costs. The proportion of patients with catastrophic costs was calculated and a multivariate logistic regression was undertaken to determine factors associated with catastrophic costs. RESULTS: One hundred and eighty-three TB patients participated in the survey. They spent a mean of 716 USD (inter quartile range: 348-1217 USD) on their TB diagnosis and care. Overall, 62.1% of costs were attributable to non-medical costs, while income loss and medical costs comprised 28.5 and 9.4%, respectively. Overall, 19.7% (n = 36) of patients used savings, borrowed money, or sold assets as a financial coping mechanism. Three patients (1.6%) had health insurance. A total of 92.3% (95% CI: 88.5-96.2) experienced catastrophic costs, using the output approach. Being in the first, second or third poorest wealth quintile was significantly associated with catastrophic costs (adjusted odds ratio: 67.3, 95% CI: 15.86-489.74%, p <  0.001). CONCLUSION: The costs of TB care are catastrophic for almost all patients in Solomon Islands. The provision of TB specific social and financial protection measures from the National TB and Leprosy Programme may be needed in the short term to ameliorate these costs. In the longer term, advancement of universal health coverage and other social and financial protection measures should be pursued.

Leprosy services in primary health care in India: comparative economic cost analysis of two public-health settings.

OBJECTIVES: The WHO recommends inclusion of post-exposure chemoprophylaxis with single-dose rifampicin in national leprosy control programmes. The objective was to estimate the cost of leprosy services at primary care level in two different public-health settings. METHODS: Ingredient-based costing was performed in eight primary health centres (PHCs) purposively selected in the Union Territory of Dadra and Nagar Haveli (DNH) and the Umbergaon block of Valsad district, Gujarat, India. All costs were bootstrapped, and to estimate the variation in total cost under uncertainty, a univariate sensitivity analysis was performed. RESULTS: The mean annual cost of providing leprosy services was USD 29 072 in the DNH PHC (95% CI: 22 125-36 020) and USD 11 082 in Umbergaon (95% CI: 8334-13 830). The single largest cost component was human resources: 79% in DNH and 83% in Umbergaon. The unit cost for screening the contact of a leprosy patient was USD 1 in DNH (95% CI: 0.8-1.2) and USD 0.3 in Umbergaon (95% CI: 0.2-0.4). In DNH, the unit cost of delivering single-dose of rifampicin (SDR) as chemoprophylaxis for contacts was USD 2.9 (95% CI: 2.5-3.7). CONCLUSIONS: The setting with an enhanced public-health financing system invests more in leprosy services than a setting with fewer financial resources. In terms of leprosy visits, the enhanced public-health system is hardly more expensive than the non-enhanced public-health system. The unit cost of contact screening is not high, favouring its sustainability in the programme.

Guidelines for management of rheumatic diseases in developing countries from basics to real-world situation: relevance, need, and processes for development.

Guidelines or recommendations help to provide uniform standards in medical practice. The development of guidelines requires adherence to pre-defined norms prescribed by different international organizations such as the European League against Rheumatism (EULAR). We searched Pubmed and LILACS to identify published papers in five major rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathies, osteoarthritis, and scleroderma) from different countries based on their economic prosperity and could find a lack of published literature from most economically weaker regions. Similarly, published guidelines in these rheumatic diseases were sparse from Asia and Africa, which are economically developed to a lesser extent than other regions of the world. Considering differing economic realities driving patient care in different regions of the world, unique challenges in certain geographic areas such as musculoskeletal manifestations of infectious diseases like leprosy and tuberculosis, as well as distinct risk of malignancies and other comorbid conditions, National Rheumatology societies should work towards developing more guidelines for rheumatic diseases from regions such as Asia and Africa, while following strictly the prescribed norms for the same. With a paucity of guidelines for such regions currently, an alternative (although less preferable) suggestion would be that major international societies, whose guidelines are widely read and followed the world over, should consider inputs from experts from diverse regions of the world while developing these guidelines.

Health Care Costs Associated with Addition, Titration, and Switching Antihypertensive Medications After First-Line Treatment: Results from a Commercially Insured Sample.

BACKGROUND: Treatment modifications are necessary for addressing issues related to efficacy and tolerance of first-line monotherapy, but they increase the economic burden on patients and their health plans. Understanding the differences in costs between alternative treatment modification strategies, if any, can serve as a guideline for clinical decision making and for designing cost-containment strategies. OBJECTIVE: To compare the health care utilization costs between (a) addition (i.e., use of free-pill combinations [FPCs] or fixed-dose combinations [FDCs]) and uptitration as alternatives for addressing efficacy issues and (b) switching and downtitration as alternatives for addressing tolerance issues with first-line antihypertensive monotherapy. METHODS: This is a retrospective cohort study that used the 2008-2012 BlueCross BlueShield of Texas claims database. Patients who had a treatment modification within 12 months of initiating antihypertensive monotherapy were identified. All-cause and disease-related health care utilization costs and drug costs were estimated from the BlueCross BlueShield health plan's perspective over a 12-month period, starting from the date of treatment modification. Propensity score-adjusted generalized linear models were used to compare costs between alternative treatment modification strategies. RESULTS: We identified 5,998 patients who met study criteria and had a modification of treatment: FPC (n = 1,395), FDC (n = 1,207), uptitration (n = 1,659), switching (n = 1,282), and downtitration (n = 455). All-cause and disease-related health services utilization costs were estimated for 12 months following treatment modification. Mean annual drug utilization costs were highest for the FDC strategy. All-cause inpatient and outpatient services utilization costs were significantly different between strategies used for addressing issues of tolerance and efficacy, respectively. Disease-related inpatient services utilization costs were lower for the FDC strategy compared with the uptitration strategy. However, disease-related inpatient services utilization costs were not significantly different for the downtitration strategy compared with the switch strategy. CONCLUSIONS: Health care costs following treatment modifications vary by type of strategy. The high costs of FDCs may be offset by the reduction of inpatient services utilization costs. Careful consideration should be given to the differences in costs between alternative strategies. DISCLOSURES: No outside funding supported this study. The dataset used in this study was created for dissertational research on the patterns and outcomes of treatment modification in hypertensive patients. Data and database support were provided by University of Texas School of Public Health/BlueCross BlueShield of Texas research program in payment systems and policy. Sonawane Deshmukh was an employee of Anthem BlueCross BlueShield from August 2015 to August 2016. Hansen has received consulting funds from Daichii Sankyo and has provided expert testimony for Allergan and Boehringer Ingelheim. All other authors have no known conflicts of interest. Study concept and design were contributed by Sonawane Deshmukh, Garza, Wright, and Hansen. Sonawane Deshmukh and Ganduglia Cazaban collected the data, and data interpretation was performed by Sonawane Deshmukh, Qian, Wright, and Zeng. The manuscript was written primarily by Sonawane Deshmukh, along with Qian and Garza, and revised by Sonawane Deshmukh, Qian, Ganduglia Cazaban, and Hansen.

Costos directos e indirectos del diagnóstico y tratamiento de pacientes con lepra / Direct and indirect costs of diagnosis and treatment in patients with leprosy

Se realizó un estudio descriptivo de los 32 pacientes con diagnóstico de lepra en la provincia de Santiago de Cuba durante 2013, para mostrar la incidencia de esta enfermedad, así como describir los costos directos e indirectos pertinentes para el diagnóstico y tratamiento de los afectados. En la casuística predominaron el grupo de 46 y más años de edad (78,5 por ciento) y la forma clínica multibacilar (96,8 por ciento); también se encontró que el costo de esta última fue superior, dado por $ 16385, 53 (pesos cubanos)(AU)

A descriptive study of 32 patients with diagnosis of leprosy in Santiago de Cuba was carried out during 2013, to show the incidence of this disease, as well as to describe the pertinent direct and indirect costs for the diagnosis and treatment of those affected. In the case material the group of 46 years and more (78.5 percent) and the multibacilar clinical type (96.8 percent) prevailed; it was also found that the cost of this last one was higher, estimated in $16385, 53 (Cuban pesos)(AU)

Health Care Costs Among Renal Cancer Patients Using Pazopanib and Sunitinib.

Publications that aim to assess the economics of different therapies are important because they complement clinical trial data and may aid in decision making. We therefore read with interest the study by Hansen et al. in the January 2015 issue of JMCP. This study compared  costs between pazopanib (PAZ) and sunitinib (SU) in the first-line treatment of patients with metastatic renal cell carcinoma (mRCC).1 The authors assessed health care costs through assignment of costs from the Truven Health MarketScan Databases to the self-reported health care resource utilization (HCRU) data from the population studied in the phase III noninferiority clinical trial COMPARZ (Pazopanib versus sunitinib in metastatic renal cell carcinoma).2 We are writing to comment on the conclusions drawn from the results presented, the methodology used, and to request additional information and clarification on data presented.

Comparing cutaneous research funded by the US National Institutes of Health (NIH) with the US skin disease burden.

BACKGROUND: Disease burden should be an important component for guiding research funding. OBJECTIVE: We sought to examine the relationship between dermatologic research funded from 2012 to 2013 by the National Institutes of Health (NIH) and US skin disease burden as measured by disability-adjusted life years in the Global Burden of Disease 2010 study. METHODS: A cross-sectional analysis was independently performed by 2 researchers who matched projects from the 2012 to 2013 NIH Research Portfolio Online Reporting Tools with 15 skin conditions and their respective disability-adjusted life years from Global Burden of Disease 2010. RESULTS: The NIH funded 1108 projects spanning the 15 skin conditions. Melanoma received almost half of the total skin condition budget (49.5%). Melanoma, nonmelanoma skin cancer, and leprosy were funded above what would be suggested by their disease burden, whereas dermatitis, acne vulgaris, pruritus, urticaria, decubitus ulcer, fungal skin diseases, alopecia areata, cellulitis, and scabies appeared underfunded. Bacterial skin diseases, viral skin diseases, and psoriasis were well matched with disease burden. LIMITATIONS: Disease burden is one of many factors that may be used to guide priority-setting decisions. CONCLUSION: Skin disease burden measured by disability-adjusted life year metrics partially correlates with NIH funding prioritization. Comparing US disease burden with NIH funding suggests possible underfunded and overfunded skin diseases.

Household costs of leprosy reactions (ENL) in rural India.

BACKGROUND: Erythema nodosum leprosum (ENL) is a common immune-mediated complication of lepromatous (LL) and borderline lepromatous (BL) leprosy. Most patients experience chronic or multiple acute ENL over many years during an economically active period of their lives. Understanding the economic burden of ENL is essential to provide effective patient support, yet this area has not been investigated. METHODS: Ninety-one patients with LL or BL leprosy attending a leprosy hospital in Purulia district of West Bengal, India, were interviewed using a structured questionnaire. Cases (n = 53) were identified as those who had one or more episodes of ENL within the last 3 years. Controls (n = 38) had LL or BL leprosy but no history of ENL. Data were collected on household income, direct and indirect costs, and coping strategies. FINDINGS: The total household cost was Rs 1543 per month or 27.9% (IQR 13.2-52.6) of monthly household income for cases, and Rs 237 per month or 4.9% (IQR 1.7-13.4) of monthly household income for controls. Indirect costs accounted for 65% of total household costs for cases. Direct costs accounted for the remaining 35% of household costs, and resulted almost entirely from treatment-seeking in the private sector. Total household costs exceeded 40% of household income for 37.7% of cases (n = 20) and 2.6% of controls (n = 1) [1 USD = 59 INR]. INTERPRETATION: Households affected by ENL face significant economic burden and are at risk of being pushed further into poverty. Health policy should acknowledge the importance of private sector provision and the significant contribution to total household costs of lost productivity (indirect cost). Further work is needed to explore this area and identify solutions.

Avaliação da importância do diagnóstico e tratamento precoce da hanseníase em relação ao custo do tratamento / Evaluation of the importance of the diagnosis and earlier treatment ofhansen´s disease regarding to the cost of treatment

O presente trabalho teve como objetivo evidenciar a importância do diagnóstico e tratamento precoce da hanseníase, e identificar o perfil epidemiológico dos clientes atendidos em um ambulatório de dermatologia de um hospital-escola no município de São José do Rio Preto - SP. Realizou-se a análise de prontuários e fichas de controle de tratamento de uma amostra representativa de 72 clientes que iniciaram o tratamento no período de Janeiro de 2000 a Janeiro de 2005. As variáveis estudadas foram: sexo, faixa etária, esquema terapêutico administrado e avaliação quanto ao grau de incapacidade apresentado no diagnóstico da doença, além dos valores das drogas utilizadas no tratamento e a estimativa do custo do tratamento nos grupos paucibacilares e multibacilares. Resultados: em 58 (80,5%) dos clientes que foram avaliados quanto ao grau de incapacidade, 52,8% enquadravam-se na escala de avaliação como Grau Zero, 19,4% apresentavam Grau I e 8,3% apresentavam Grau II/ Grau III, somando assim 27,8% de casos com incapacidade física. Conclui-se que o expressivo número de casos de incapacidades observado foram submetidos tardiamente ao diagnóstico e tratamento sendo necessário reforçar as medidas preventivas como, ações de busca ativa e controle de comunicantes intradomiciliares, bem como, a descentralização do atendimento no município. Evidencia-se que o tratamento poliquimioterápico é caro, caso o tratamento deixasse de ser subsidiado na rede pública.

The present work had as objectives to show the importance of the diagnosis and earlier treatment of the Hansen´s disease (leprosy), and to identify the client’s epidemiological profile assisted in a Dermatology out patient of a school-hospital in the municipality of São José do Rio Preto – SP. The medical charts and treatment control records of 72 clients who initiated the treatment from January 2000 to January 2005 were analyzed. The variables studied were: sex, age group, therapeutic management, and the evaluation of the disability degree presented in the disease diagnosis. The costs of both the drugs and the treatment were investigated. The treatment cost was estimated according to paucibacillary as well as multibacillary forms of the disease. Results: Of the total 58 clients (80.5%) evaluated according to their disabilty degree; 52.8% were classified in the scale as Zero Degree; 19.4% presented Degree I; and 8.3% Degree II/ Degree III, summing up 27.8% of cases with physical disability. In conclusion, the expressive number of cases of physical disabilities have been lately submitted to diagnosis and treatment, being necessary to reinforce preventive measuressuch as: the search of active actions and control of home communicants as well as the decentralization of the service in the municipality. Furthermore, polychemiotherapical treatment should be evidenced since it isvery expensive if it is not subsidized by the public health service.

A comparison of economic aspects of hospitalization versus ambulatory care in the management of neuritis occurring in lepra reaction.

Neuritis is one of the important causes of deformities and disabilities in leprosy. Neuritis has been managed both in the field and in hospital. This study was done to compare the economic aspects of cost of ambulatory vs in-patient management of neuritis in leprosy. The quality of life of the affected patients and the clinical improvement in the 2 groups were also studied. Twenty six patients fulfilling the study criteria were randomized into the ambulatory and in-patient group (13 in each group). The primary outcome examined was cost, in various categories; the secondary outcomes included pre- and post-treatment comparison of Quality of Life (QOL) scores and tests of sensory and motor function. The direct and indirect medical costs incurred by patients in the hospitalized group were higher than those patients in the ambulatory group. The difference in the direct medical costs between the two groups was Rs. 9110.5, and the extra direct non medical costs incurred by patients in the hospitalized group was Rs. 888.50 because of more frequent visits of family members. A greater percentage of ambulatory than in-patients returned to work in

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Machakos District, Kenya.

SETTING: Machakos District, Kenya, a rural area 50 km east of Nairobi. OBJECTIVE: To assess the cost and cost-effectiveness of new treatment strategies for tuberculosis patients, involving decentralisation of care from hospitals to peripheral health units and the community, compared to the conventional approaches to care used until October 1997. METHODS: Costs were analysed in 1998 US dollars from the perspective of health services, patients, family members and the community, using standard methods. Separate analyses were undertaken for 1) new smear-positive pulmonary patients and 2) new smear-negative and extrapulmonary patients. Cost-effectiveness was calculated as the cost per patient successfully completing treatment (smear-positive cases) and as the cost per patient completing treatment (new smear-negative and extra-pulmonary cases). FINDINGS: The cost per patient treated for new smear-positive patients was dollars 591 with the conventional hospital-based approach to care, and dollars 209 with decentralised care. Costs fell from all perspectives, and by 65% overall. Cost-effectiveness improved by 66%. The cost per patient treated for new smear-negative/extra-pulmonary patients was dollars 311 with the conventional approach to care, and dollars 197 with decentralised care. Costs fell from all perspectives, and cost-effectiveness improved by 61%. CONCLUSION: There is a strong economic case for expansion of decentralisation and strengthened community-based care in Kenya. The National Tuberculosis and Leprosy Control Programme will require new funds for start-up training and community mobilisation costs in order to do this.

Cost-effectiveness and total costs of three alternative strategies for the prevention and management of severe skin reactions attributable to thiacetazone in the treatment of Human Immunodeficiency Virus positive patients with tuberculosis in Kenya.

SETTING: Severe skin reactions due to thiacetazone (T) in Human Immunodeficiency Virus (HIV) positive tuberculosis patients have been reported in several publications, one of them from Kenya. However, the abandoning of T may not be feasible in Kenya as this may increase the cost of drugs by about three-fold per regimen. OBJECTIVE: To compare the cost-effectiveness and total cost of three strategies in which T is replaced with ethambutol (E). DESIGN: Three strategies are compared with a baseline strategy in which T is not replaced. The indicator for cost-effectiveness is the cost-per-averted-death attributable to T. RESULTS: Education of patients on the possibility of side-effects and replacement of T with E is the most cost-effective strategy at HIV prevalence rates of 1-90%. Abandonment of T and replacement with E is the most cost-effective at over 90% HIV prevalence. CONCLUSION: In Kenya, education of patients on the possibility of skin reactions should be preferred at low range HIV prevalence rates. Routine HIV testing would be the most attractive strategy in the middle range, and total replacement of T with E is to be preferred in the higher range of HIV prevalence.

PIP: In Kenya, the National Leprosy Tuberculosis Programme (NLTP) used previously reported data from Nairobi to compare the cost-effectiveness and total costs of a hypothetical strategy with three intervention strategies for the prevention and management of severe skin reactions caused by thiacetazone in treating HIV-positive patients with tuberculosis (TB). The hypothetical strategy was continued use of thiacetazone despite adverse skin reactions. The intervention strategies included patient education about possible side effects of anti-TB drugs (discontinue use if skin rash develops, report situation to clinic, replace thiacetazone with ethambutol when other skin diseases have been excluded), abandonment of thiacetazone and replacement with ethambutol, and HIV testing and pre- and post-test counseling. NLTP currently used the education strategy. It assumed a mortality rate of 5%. When the HIV prevalence rate is 1-90%, the education strategy is the most cost-effective strategy. In terms of total costs, the education strategy was also the most inexpensive strategy regardless of the HIV prevalence. At an HIV prevalence rate greater than 65%, the abandonment of thiacetazone strategy was the cheapest strategy. When the assumed mortality rate was 3%, the cost per averted death for the education strategy was reduced from about US$120 to about US$80 and the education strategy became the most cost-effective strategy over the entire range of HIV prevalence. In addition, the cost of HIV testing significantly increased the cost per averted death. Thus, the findings of this study are truly sensitive to different program conditions. Based on these findings, the authors recommended that the education strategy be applied with a range of HIV prevalence of 1-45%, that HIV testing be applied with a range of 46-72%, and that total abandonment be applied with an HIV prevalence greater than 72%.