Cost-Effectiveness Analysis of Initial Treatment Strategies for Nonembolic Acute Limb Ischemia Using Real-Word Data.

BACKGROUND: Nonembolic acute limb ischemia (ALI) is a condition characterized by a sudden decrease in limb perfusion and requires immediate interventions. There are multiple treatment options available including surgery, catheter-directed thrombolysis (CDT), endovascular procedures, and hybrid treatment (a combination of open and endovascular techniques). Randomized trials provide information only on clinical efficacy, but not on economic outcomes. The objective of the study was to perform the cost-effective analysis comparing different treatment alternatives of ALI. METHODS: The data were collected from 4r ProMedica community hospitals in the Northwest Ohio from January 2009 to December 2012. Patients were included if they were treated within 14 days of onset of symptoms for nonembolic ALI and were divided into groups of receiving CDT, surgery, endovascular, or hybrid treatments. Demographics, comorbidities, medications taken before admission, and smoking status were collected at baseline for all patients and were compared among the treatment groups. A cost-effectiveness decision tree was developed to calculate expected costs and life years gained associated with available treatment options. A probabilistic sensitivity analysis was also performed to check the robustness of the model. RESULTS: A population of 205 patients with the diagnosis of ALI was included and divided into different treatment groups. There was no major significant difference in baseline characteristics among the studied groups (P > 0.05). The total costs were $17,163.47 for surgery, $20,620.39 for endovascular, $21,277.61 for hybrid, and $30,675.42 for CDT. The life years gained were 17.25 for surgery, 18 for endovascular, 18 for hybrid, and 17 for CDT. CDT was dominated because of the high cost and the low effectiveness, while hybrid treatment was dominated when compared with endovascular treatment because these 2 treatments have similar outcomes. The incremental cost-effectiveness ratio of the endovascular group over the surgery group was found to be $4,609.23 per life year gained. The sensitivity analysis showed that the endovascular treatment was found to be cost-effective under willingness to pay $50,000. CONCLUSIONS: This study provides economic evaluation of ALI treatments for a defined clinical population in the real-world setting. Compared with other available alternatives, the endovascular treatment showed to be a cost-effective use of healthcare resources.

Clinical and economic burden of first-line chemoimmunotherapy by risk status in chronic lymphocytic leukemia.

OBJECTIVES: To evaluate the trend in cytogenetic/molecular testing rate in chronic lymphocytic leukemia (CLL) and assess the clinical and economic burden of first-line (1 L) treatment with chemoimmunotherapy (CIT) by risk status. METHODS: This retrospective cohort study identified patients with CLL from a U.S. managed care population. Medical records were obtained for eligible patients who initiated 1 L CIT between 1/1/2007 and 7/31/2019 and underwent prognostic testing to classify them as high risk (del(17p), TP53 mutation, del(11q), unmutated IGHV or complex karyotype) or as non-high risk by FISH only (non-del(17p) and non-del(11q)). Study outcomes included testing rate, time to next treatment (TTNT) or death, time to treatment failure (defined as time to change of therapy, non-chemotherapy intervention, hospice care or death), and total plan paid costs (medical + pharmacy) per patient per month (PPPM) in the 1 L period. Cox proportional hazard models and generalized linear models were used to calculate adjusted hazard ratio or rate ratio. RESULTS: Among the 1,808 patients with CLL, 612 were FISH or IGHV tested and the rate of testing increased from 30% to 44% from 2007-2019. High-risk patients (n = 119) had 65% higher risk of next treatment or death (median time: 2.4 vs 3.7 years), 65% higher risk of treatment failure (median time: 3.0 vs 4.9 years), and 33% higher costs ($12,194 vs $9,055, p = 0.027) during 1 L treatment than non-high risk patients (n = 134). CONCLUSIONS: High-risk CLL patients treated with 1 L chemoimmunotherapy have poorer clinical and economic outcomes compared to non-high risk patients. Assessment of genetic risk remains suboptimal.

Cost-Effectiveness of a Proteomic Test for Preterm Birth Prediction.

BACKGROUND: Preterm birth (PTB) carries increased risk of short- and long-term health problems as well as higher healthcare costs. Current strategies using clinically accepted maternal risk factors (prior PTB, short cervix) can only identify a minority of singleton PTBs. OBJECTIVE: We modeled the cost-effectiveness of a risk-screening-and-treat strategy versus usual care for commercially insured pregnant US women without clinically accepted PTB risk factors. The risk-screening-and-treat strategy included use of a novel PTB prognostic blood test (PreTRM®) in the 19th-20th week of pregnancy, followed by treatment with a combined regimen of multi-component high-intensity-case-management and pharmacologic interventions for the remainder of the pregnancy for women assessed as higher-risk by the test, and usual care in women without higher risk. METHODS: We built a cost-effectiveness model using a combined decision-tree/Markov approach and a US payer perspective. We modeled 1-week cycles of pregnancy from week 19 to birth (preterm or term) and assessed costs throughout the pregnancy, and further to 12-months post-delivery in mothers and 30-months in infants. PTB rates and costs were based on >40,000 mothers and infants from the HealthCore Integrated Research Database® with birth events in 2016. Estimates of test performance, treatment effectiveness, and other model inputs were derived from published literature. RESULTS: In the base case, the risk-screening-and-treat strategy dominated usual care with an estimated 870 fewer PTBs (20% reduction) and $54 million less in total cost ($863 net savings per pregnant woman). Reductions were projected for neonatal intensive care admissions (10%), overall length-of-stay (7%), and births <32 weeks (33%). Treatment effectiveness had the strongest influence on cost-effectiveness estimates. The risk-screening-and-treat strategy remained dominant in the majority of probabilistic sensitivity analysis simulations and model scenarios. CONCLUSION: Use of a novel prognostic test during pregnancy to identify women at risk of PTB combined with evidence-based treatment is estimated to reduce total costs while preventing PTBs and their consequences.

Association Between Work Absence and Health Services Utilization and Costs Among Employed Individuals With Arthritis.

OBJECTIVE: To evaluate whether work absence is associated with increased health services utilization and health care costs among employed individuals with arthritis. METHODS: This was a retrospective cross-sectional study using pooled data from the 2011 to 2015 Medical Expenditure Panel Survey (MEPS). Employed individuals with arthritis were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes and Clinical Classification code. Generalized linear models were used to analyze utilization and costs outcomes. RESULTS: Individuals with arthritis who reported work absences had greater odds of having a hospitalization event (odds ratio [OR]: 9.198, P < 0.001), higher number of ambulatory care visits (ß = 0.549, P < 0.001), and had higher total health care costs (ß = 0.40, P < 0.001) and arthritis-related costs (ß = 0.035, P < 0.0002) compared with individuals without work absences. CONCLUSION: Among employed individuals with arthritis, self-reported work absence is associated with significantly higher health care utilization and health care costs.

The Impact of Work Absences on Health Services Utilization and Costs Among Employed Individuals With Depression.

OBJECTIVE: The aim of this study was to evaluate whether work absences are associated with increased health services utilization, total health care costs, and depression-related costs among employed individuals, aged 18 to 64 years with depression. METHODS: This was a retrospective observational study using pooled data from the 2011 to 2014 Medical Expenditure Panel Survey (MEPS). Employed individuals with depression were identified using ICD-9 codes and Clinical Classification code. Logistic regression, Poisson regression, and generalized linear models were used for analysis. RESULTS: Individuals with depression who reported work absences had greater odds of having a hospitalization event [odds ratio (OR): 7.111; 95% confidence interval (95% CI): 3.121 to 16.203], higher number of other health care visits (ß = 0.188, P = 0.041), and had higher total health care costs (ß = 0.550, P ≤ 0.001) than individuals with no work absences. CONCLUSION: Among employed individuals with depression, self-reported work absence is associated with significantly higher health care utilization and total health care costs.

Trends in Smoking Status and Utilization of Smoking Cessation Agents Among Females with Cardiovascular Diseases.

BACKGROUND: In the United States, cigarette smoking accounts for almost 20% of all deaths attributed to heart disease. More women than men die each year of cardiovascular diseases (CVDs). Women who smoke have shown to be at a higher risk of cardiac deaths. The current study aims to determine the trend in smoking prevalence among women with CVD and their utilization of smoking cessation agents from 2004 to 2011. MATERIALS AND METHODS: This was a retrospective exploratory study using Medical Expenditure Panel Survey data from 2004 to 2011. All female respondents with any one cardiovascular condition were identified. Descriptive statistics were carried out to obtain the number of female patients with CVD, their smoking status, and their use of smoking cessation agents. Furthermore, disparities in smoking status and smoking cessation agent utilization with respect to race and ethnicity were studied. RESULTS: Among total CVD patients, 53% were females, which corresponded to 25.3 million females in the United States. Around 12.3% among them were current smokers. Only 6.9% among these females used smoking cessation agents. Smoking trends in females were inconsistent throughout the 8 years. Overall, the trend showed a decrease in the percentage of female smokers, while use of smoking cessation agents remained low from 2004 to 2011. Whites and non-Hispanics had more current smokers and women using smoking cessation agents. CONCLUSION: The eight-year trend shows that the use of smoking cessation agents among females is very low, particularly among non-whites and Hispanics. This is of great concern and future efforts could focus on increasing the utilization of smoking cessation agents and collectively decreasing the risk of smoking in CVD by healthcare professionals.

Impact of cardiovascular complications among patients with Type 2 diabetes mellitus: a systematic review.

Macrovascular and microvascular complications that accompany Type 2 diabetes mellitus (T2DM) add to the burden among patients. The purpose of this systematic review is to conduct a comprehensive search of the medical literature investigating the prevalence of cardiovascular (CV) complications and assess their impact on healthcare costs, quality of life and mortality among patients with T2DM in the context of microvascular complications. A total of 76 studies and reports were used in this systematic review. Hypertension was the most prevalent complication among patients with T2DM. The additional cost burden due to CV complications was higher than any other complication except end-stage renal disease. Quality of life was much lower among patients with CV complications and T2DM, and mortality was higher than either illness alone.

Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients.

OBJECTIVE: Smoking is one of the major risk factors causing morbidity and mortality in chronic obstructive pulmonary disease (COPD) and lung cancer patients. Use of smoking cessation pharmacotherapy is an effective way to help quit smoking. The purpose of the study was to determine the prevalence of smoking and the proportion of patients using smoking cessation agents, and to identify the socio-demographic factors that affect the use of these agents among COPD and lung cancer patients. RESEARCH DESIGN AND METHODS: A retrospective study was done to identify smokers having COPD (ICD-9: 490-492) or lung cancer (ICD-9: 162), and those who use smoking cessation agents from 2006-2010, using Medical Expenditure Panel Survey (MEPS) data. A multiple logistic regression model was built to identify significant socio-demographic predictors associated with the use of smoking cessation agents. RESULTS: Around 16.8% of COPD patients and 15.1% of lung cancer patients reported smoking after diagnosis. Out of the total smokers, 8.8% patients with COPD and 12.6% patients with lung cancer reported use of smoking cessation agents during the 5 year period. Logistic regression showed that odds for smoking cessation use in COPD patients were lower for Hispanics (OR = 0.107, 95% CI 0.023-0.502) and higher for patients having insurance coverage (OR = 3.453, 95% CI 1.240-9.617). CONCLUSION: Results showed that a large number of patients continued to smoke even after the diagnosis of COPD and lung cancer; whereas only a few among them used smoking cessation agents. Ethnicity disparities and insurance status were associated with the use of smoking cessation agents. Differential use among population sub-groups suggests a requirement for need based smoking cessation programs and appropriate prescription drug coverage. Further research needs to be done to evaluate reasons for disparities in smoking cessation agents' use. The study had limitations common to research designs based on observational and self-reported datasets.

Characteristics of prescription and nonprescription sleep medication users in the United States.

Sleep deprivation and disturbances can result in lowered productivity and increased errors/accidents. Little is known about population characteristics associated with the use of sleep medications. The objective of this study was to investigate the association of sociodemographic factors with the use of sleep medications in the US population. This was a retrospective, cross-sectional study using data from the 2010 Medical Expenditure Panel Survey, which contains nationally representative data from the US population. The study population included all respondents older than 18 years of age. A multiple logistic regression model was built to analyze the odds of reporting use of prescription or nonprescription sleep medication. In 2010, an estimated 19 million survey respondents (10%) used some type of medication to fall asleep. The odds of reporting use of sleep medication were significantly lower among males (odds ratio [OR]=0.695, 95% confidence interval [CI]=0.599-0.808), and the uninsured (OR=0.613, 95% CI=0.439-0.855). The odds of sleep medication use were significantly higher among age groups 24-44 years and 44-64 years as compared with 18-24 years (OR=1.868, 95% CI=1.254-2.781 and OR=1.936, 95% CI=1.309-2.865, respectively), whites (OR=2.003, 95% CI=1.597-2.512) compared with African Americans, or non-Hispanics (OR=1.609, 95% CI=1.316-1.967), the unemployed (OR=1.773, 95% CI=1.496-2.101), and respondents with depression (OR=2.077, 95% CI=1.463-2.951) or anxiety (OR=6.855, 95% CI=4.998-9.403). Differences in sleep medication use were seen among specific subpopulations. Further research into why such differences exist is necessary. The factors identified in this study should be investigated further to identify vulnerable populations to determine the underlying causes of sleep disorders.