Population health impact and economic evaluation of the CARDIO4Cities approach to improve urban hypertension management.

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with 80% of that mortality occurring in low- and middle-income countries. Hypertension, its primary risk factor, can be effectively addressed through multisectoral, multi-intervention initiatives. However, evidence for the population-level impact on cardiovascular (CV) event rates and mortality, and the cost-effectiveness of such initiatives is scarce as long-term longitudinal data is often lacking. Here, we model the long-term population health impact and cost-effectiveness of a multisectoral urban population health initiative designed to reduce hypertension, conducted in Ulaanbaatar (Mongolia), Dakar (Senegal), and in the district of Itaquera in São Paulo (Brazil) in collaboration with the local governments. We based our analysis on cohort-level data among hypertensive patients on treatment and control rates from a real-world effectiveness study of the CARDIO4Cities approach (built on quality of care, early access, policy reform, data and digital, Intersectoral collaboration, and local ownership). We built a decision tree model to estimate the CV event rates during implementation (1-2 years) and a Markov model to project health outcomes over 10 years. We estimated the number of CV events averted and quality-adjusted life-years gained (QALYs through the initiative and assessed its cost-effectiveness based on the costs reported by the funder using the incremental cost effectiveness ratio (ICER) and published thresholds. A one-way sensitivity analysis was performed to assess the robustness of the results. The modelled patient cohorts included 10,075 patients treated for hypertension in Ulaanbaatar, 5,236 in Dakar, and 5,844 in São Paulo. We estimated that 3.3-12.8% of strokes and 3.0-12.0% of coronary heart disease (CHD) events were averted during 1-2 years of implementation in the three cities. We estimated that over the subsequent 10 years, 3.6-9.9% of strokes, 2.8-7.8% of CHD events, and 2.7-7.9% of premature deaths would be averted. The estimated ICER was USD 748 QALY gained in Ulaanbaatar, USD 3091 in Dakar, and USD 784 in São Paulo. With that, the intervention was estimated to be cost-effective in Ulaanbaatar and São Paulo. For Dakar, cost-effectiveness was met under WHO-CHOICE standards, but not under more conservative standards adjusted for purchasing power parity (PPP) and opportunity costs. The findings were robust to the sensitivity analysis. Our results provide evidence that the favorable impact of multisector systemic interventions designed to reduce the hypertension burden extend to long-term population-level CV health outcomes and are likely cost-effective. The CARDIO4Cities approach is predicted to be a cost-effective solution to alleviate the growing CVD burden in cities across the world.

Clinical Remission of Chronic Spontaneous Urticaria (CSU): A Targeted Literature Review.

INTRODUCTION: Chronic spontaneous (previously known as idiopathic) urticaria (CSU) is a chronic skin disease with the potential for natural remission. The objectives of this targeted literature review were to identify evidence on the clinical course of CSU, including remission rates, and to estimate cumulative remission rates for different time points. METHODS: Electronic databases (MEDLINE, MEDLINE-In Process, Embase, Web of Science, BIOSIS Previews and the Cochrane Library) and relevant conference proceedings were searched to identify studies involving patients with CSU aged ≥ 12 years that provide data on remission rates and disease duration. Observational studies with patient follow-ups of ≥ 1 year or review articles were included. Data extracted from five selected studies were used to run Kaplan-Meier (KM) analyses and best-fit distributions to calculate remission rates per 4-week period and weighted averages. RESULTS: Ten publications were included in this review. The proportion of patients achieving remission within year 1 ranged from 21 to 47%, while reported remission rate estimates at year 5 were 34% and 45%. Based on calculated 4-weekly remission rates, cumulative remission estimates ranged from 9 to 38% at year 1, from 29 to 71% at year 5 and from 52 to 93% at year 20. Cumulative weighted average estimates for the proportion of patients remitting at years 1, 5 and 20 were 17%, 45% and 73%, respectively. CONCLUSIONS: Published evidence suggests that CSU is a self-limiting condition with variable disease severity and duration, apparently dependent on multiple factors. However, data sources differed in terms of definitions of disease severity and remission, as well as in conclusions on influencing factors. Further studies and uniform definitions are required.

Pharmacist-provided medication therapy management (MTM) program impacts outcomes for employees with diabetes.

The objective of this prospective, pre-post longitudinal study was to assess the impact of pharmacist-provided medication therapy management (MTM) services on employees' health and well-being by evaluating their clinical and humanistic outcomes. City of Toledo employees and/or their spouses and dependents with diabetes with or without comorbid conditions were enrolled in the pharmacist-conducted MTM program. Participants scheduled consultations with the pharmacist at predetermined intervals. Overall health outcomes, such as clinical markers, health-related quality of life (HRQoL), disease knowledge, and social and process measures, were documented at these visits and assessed for improvement. Changes in patient outcomes over time were analyzed using Wilcoxon signed rank and Friedman test at an a priori level of 0.05. Spearman correlation was used to measure the relationship between clinical and humanistic outcomes. A total of 101 patients enrolled in the program. At the end of 1 year, patients' A1c levels decreased on average by 0.27 from their baseline values. Systolic and diastolic blood pressure also decreased on average by 6.0 and 4.2 mmHg, respectively. Patient knowledge of disease conditions and certain aspects or components of HRQoL also improved. Improvements in social and process measures also were also observed. Improved clinical outcomes and quality of life can affect employee productivity and help reduce costs for employers by reducing disease-related missed days of work. Employers seeking to save costs and impact productivity can utilize the services provided by pharmacists.

Improving the economic and humanistic outcomes for diabetic patients: making a case for employer-sponsored medication therapy management.

BACKGROUND: The purpose of this study was to determine the cost savings of a pharmacist-led, employer-sponsored medication therapy management (MTM) program for diabetic patients and to assess for any changes in patient satisfaction and self-reported medication adherence for enrollees. METHODS: Participants in this study were enrollees of an employer-sponsored MTM program. They were included if their primary medical insurance and prescription coverage was from the City of Toledo, they had a diagnosis of type 2 diabetes, and whether or not they had been on medication or had been given a new prescription for diabetes treatment. The data were analyzed on a prospective, pre-post longitudinal basis, and tracked for one year following enrollment. Outcomes included economic costs, patient satisfaction, and self-reported patient adherence. Descriptive statistics were used to characterize the population, calculate the number of visits, and determine the mean costs for each visit. Friedman's test was used to determine changes in outcomes due to the nonparametric nature of the data. RESULTS: The mean number of visits to a physician's office decreased from 10.22 to 7.07. The mean cost of these visits for patients increased from $47.70 to $66.41, but use of the emergency room and inpatient visits decreased by at least 50%. Employer spending on emergency room visits decreased by $24,214.17 and inpatient visit costs decreased by $166,610.84. Office visit spending increased by $11,776.41. A total cost savings of $179,047.80 was realized by the employer at the end of the program. Significant improvements in patient satisfaction and adherence were observed. CONCLUSION: Pharmacist interventions provided through the employer-sponsored MTM program led to substantial cost savings to the employer with improved patient satisfaction and adherence on the part of employees at the conclusion of the program.

Evaluation of outcomes of a medication therapy management program for patients with diabetes.

OBJECTIVE: To measure the impact of an employer-sponsored, pharmacist-provided medication therapy management (MTM) program on clinical outcomes and social and process measures for patients with diabetes with or without associated comorbid conditions. METHODS: Prospective longitudinal study that took place at seven independent pharmacies in Lucas County, OH. A total of 228 patients with diabetes were enrolled. At 6-month intervals, patients were counseled by their pharmacists. Outcome measures included clinical outcomes (glycosylated hemoglobin [A1C], systolic blood pressure (SBP), and diastolic blood pressure [DBP]), social measures (caffeine intake, alcohol consumption, smoking, and exercise), and process measures (visits to ophthalmologist, podiatrist, and dentist). Wilcoxon signed-rank test and percentages were used to report findings. RESULTS: Mean (± SD) A1C concentration decreased from 7.08 ± 1.54% to 6.89 ± 1.30% at 12 months. Patients with A1C levels greater than 7% at baseline averaged a decrease of 0.5% at 6 months and 0.75% at 12 months. Mean SBP values decreased significantly from baseline to 12 months. A total of 87 patients with a baseline SBP greater than 130 mm Hg experienced a significant change in blood pressure from baseline to 6 months (-7.1 ± 3.32 mm Hg), and 65 patients experienced a significant change in blood pressure from baseline to 12 months (-11.49 ± 0.15 mm Hg). A total of 104 patients with a baseline DBP more than 80 mm Hg experienced a significant decrease of 4.44 ± 1.25 mm Hg at 6 months. Caffeine and alcohol consumption and smoking decreased and exercise increased. In addition, the percentage of patients who visited specialists increased. CONCLUSION: Patients with diabetes experienced improvements in multiple clinical, social, and process measures.

Gender differences in utilization of preventive care services in the United States.

BACKGROUND: The utilization of preventive care services in the United States remains low, despite health-care costs being as high as $2.3 trillion. While gender disparities have been known to exist for utilization of overall health-care services, the same issue has not been probed for preventive care utilization. METHODS: A retrospective, cross-sectional study using the 2008 Medical Expenditure Panel Survey (MEPS). Preventive care services common to both genders were included (blood pressure checkup, cholesterol checkup, sigmoidoscopy/colonoscopy, flu shot, and dental checkup). Guideline adherence was determined using clinically accepted guidelines such as Joint National Committee 7 and the American Cancer Society. Descriptive statistics were used to describe the population, and chi-square analysis was used to determine the within group differences between the two genders. A multivariate logistic regression was built to determine the likelihood of guideline adherence based on gender while adjusting for known demographic confounders such as age, race, and ethnicity. RESULTS: There were 33,066 MEPS respondents for 2008. Of these, 4,291 to 30,629 met the inclusion criteria depending on the specific preventive care service being analyzed. Men were found to have significantly lower odds of using blood pressure check (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.32-0.38), cholesterol check (OR 0.64, CI 0.60-0.69), dental check (OR 0.71, CI 0.68-0.75), and flu shots (OR 0.71, CI 0.67-0.76). While men had lower utilization for sigmoidoscopy/colonoscopy, the difference was nonsignificant. CONCLUSIONS: Preventive care utilization was found to be higher in women than in men. The gender disparity issue needs to be explored in greater detail to understand these differences.

Utilization of preventive care services and their effect on cardiovascular outcomes in the United States.

OBJECTIVE: To describe and analyze utilization of preventive care services and their effect on cardiovascular outcomes in the United States. METHODS: Data from the 2007 Medical Expenditure Panel Survey (MEPS) were used to analyze utilization of preventive care services and their effect on cardiovascular outcomes. Recommendations by the Seventh Report of the Joint Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure and the National Cholesterol Education Program were used to determine appropriate levels of preventive care utilization. Utilization of blood pressure screening and cholesterol checkup services were used as the dependent variable, while age, gender, race, ethnicity, insurance status, and perceived health status were used as independent variables. Since guidelines differ for people with elevated blood pressure, respondents with elevated blood pressure were identified in the MEPS database by self-reported diagnosis. Descriptive statistics were used to describe the population, while a multivariate logistic regression model was built to predict odds of utilizing appropriate levels of preventive services. RESULTS: Total number of adult respondents for which data were available for blood pressure checkup and cholesterol checkup was 20,523 and 15,784, respectively. Overall, MEPS respondents were found to adhere to guideline recommendations for preventive care utilization. Multivariate logistic regression showed that odds of utilization of preventive care services were higher for elderly patients (age >65 years) for blood pressure (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.92-2.97) and cholesterol (OR = 3.05, 95% CI: 2.18-4.27) preventive services compared with younger population (age 18-54 years). Males had much lower odds of getting blood pressure (OR = 0.33, 95% CI: 0.30-0.37) and cholesterol (OR = 0.59, 95% CI: 0.50-0.70) checks done compared with females. Odds of utilization were nearly similar for all races. Uninsured had lower odds for blood pressure (OR = 0.26, 95% CI: 0.23-0.30) and cholesterol (OR = 0.30, 95% CI: 0.24-0.39) checks compared with privately insured people. Asians had lower odds of getting blood pressure checkups compared to Whites (OR = 0.49, 95% CI: 0.39-0.63). Similar trends were recorded for other covariates such as race and perceived health status. CONCLUSION: The study was successful in identifying existing age, race, income, and insurance-status related disparities in preventive care utilization within a US population.