Associations between clinical pathway concordance, cost, and survival outcomes for stage II colon cancer: a population-based study.

This study measures patient's concordance between clinical reference pathways with survival or cost among a population-based cohort of colon cancer patients applying a continuous measure of concordance. The primary hypothesis is that a higher concordance score with the clinical pathway is significantly associated with longer survival or lower cost. The study informs whether patient's adherence to a defined clinical pathway is beneficial to patients' outcomes or health system. An externally determined clinical pathway for colon cancer was used to identify treatment nodes in colon cancer care. Using observational data up to 2019, the study generated a continuous measure of pathway concordance. The study measured whether incremental improvements in pathway concordance were associated with survival and treatment costs. Concordance between patients' reference pathways and their observed trajectories of care was highly statistically associated with survivorship [hazard ratio: 0.95 (95% confidence interval, CI, 0.95-0.96)], showing that adherence to the clinical pathway was associated with a lower mortality rate. An increase in concordance was statistically significantly associated with a decrease in health system cost. When patients' care followed the clinical pathway, survival outcomes were better and total health system costs were lower in this cohort. This finding creates a compelling case for further research into understanding the barriers to pathway concordance and developing interventions to improve outcomes and help providers implement best practice care where appropriate.

Inverse optimization on hierarchical networks: an application to breast cancer clinical pathways.

Clinical pathways are standardized processes that outline the steps required for managing a specific disease. However, patient pathways often deviate from clinical pathways. Measuring the concordance of patient pathways to clinical pathways is important for health system monitoring and informing quality improvement initiatives. In this paper, we develop an inverse optimization-based approach to measuring pathway concordance in breast cancer, a complex disease. We capture this complexity in a hierarchical network that models the patient's journey through the health system. A novel inverse shortest path model is formulated and solved on this hierarchical network to estimate arc costs, which are used to form a concordance metric to measure the distance between patient pathways and shortest paths (i.e., clinical pathways). Using real breast cancer patient data from Ontario, Canada, we demonstrate that our concordance metric has a statistically significant association with survival for all breast cancer patient subgroups. We also use it to quantify the extent of patient pathway discordances across all subgroups, finding that patients undertaking additional clinical activities constitute the primary driver of discordance in the population.

Development of population-level colon cancer pathway concordance measures and association with survival.

Clinical cancer pathways help standardize healthcare delivery to optimize patient outcomes and health system costs. However, population-level measurement of concordance between standardized pathways and actual care received is lacking. Two measures of pathway concordance were developed for a simplified colon cancer pathway map for Stage II-III colon cancer patients in Ontario, Canada: a cumulative count of concordant events (CCCE) and the Levenshtein algorithm. Associations of concordance with patient survival were estimated using Cox proportional hazards models adjusted for patient characteristics and time-dependent cancer-related activities. Models were compared and the impact of including concordance scores was quantified using the likelihood ratio chi-squared test. The ability of the measures to discriminate between survivors and decedents was compared using the C-index. Normalized concordance scores were significantly associated with patient survival in models for cancer stage-a 10% increase in concordance for Stage II patients resulted in a CCCE score adjusted hazard ratio (aHR) of death of 0.93, 95% CI 0.88-0.98 and a Levenshtein score aHR of 0.64, 95% CI 0.60-0.67. A similar relationship was found for Stage III patients-a 10% increase in concordance resulted in a CCCE aHR of 0.85, 95% CI 0.81-0.88 and a Levenshtein aHR of 0.78, 95% CI, 0.74-0.81. Pathway concordance can be used as a tool for health systems to monitor deviations from established clinical pathways. The Levenshtein score better characterized differences between actual care and clinical pathways in a population, was more strongly associated with survival and demonstrated better patient discrimination.

Artificial intelligence in outcomes research: a systematic scoping review.

Introduction: Despite the number of systematic reviews of how artificial intelligence is being used in different areas of medicine, there is no study on the scope of artificial intelligence methods used in outcomes research, the cornerstone of health technology assessment (HTA). This systematic scoping review aims to systematically capture the scope of artificial intelligence methods used in outcomes research to enhance decision-makers' knowledge and broaden perspectives for health technology assessment and adoption.Areas covered: The review identified 370 studies, consisted of artificial intelligence methods applied to adult patients who underwent any health/medical intervention and reported therapeutic, preventive, or prognostic outcomes. Artificial intelligence was mainly used for the prediction/prognosis of more frequently reported outcomes, efficacy/effectiveness, among morbidity outcomes. The predictive analysis was common in neoplastic disorders. Neural networks algorithm was predominantly found in surgical method studies, but a mixture of artificial intelligence algorithms was applied to the studies with the rest of the interventions.Expert opinion: There are certain gaps in artificial intelligence applications used in outcomes research across therapeutic areas and further considerations are needed by decision-makers before incorporating artificial intelligence usage into HTA decision-making processes.

Forecasting Ontario Oncology Drug Expenditures: A Hybrid Approach to Improving Accuracy.

BACKGROUND: The Provincial Drug Reimbursement Program (PDRP) at Cancer Care Ontario (CCO) is responsible for monitoring actual and projected outpatient intravenous cancer drug spending in the province. We developed a hybrid forecasting approach combining automated time-series forecasting with expert-customizable input. OBJECTIVE: Our objectives were to provide a flexible tool in which to incorporate multiple forecasts and to improve the accuracy of the resulting forecast. METHODS: The approach employed linear and non-linear time-series techniques and a combined hybrid model incorporating both approaches. We developed an interactive tool that incorporated the statistical models and identified the best performing forecast according to standard goodness-of-fit measures. Model selection procedures considered both the amount of historical expenditure data available per drug policy and the individual policy contributions to the overall budget. The user was allowed to customize forecasts based on knowledge of external factors related to policy or price changes and new drugs that come to market RESULTS: A comparison of 2016/17 fiscal year expenditures showed that all policies with a significant contribution to the overall budget were forecast with < 4% error. Forecasting error was reduced by at least $Can5 million for the nine most expensive policies compared with expert opinion. This approach to drug budget forecasting was implemented in Ontario for the first time in the 2017/18 fiscal year, where 1% error was observed for the overall budget, corresponding to an overestimate of expenditures by $Can3.0 million. CONCLUSION: We introduced a pragmatic approach for regular forecasting by budget holders in Ontario. Our approach to isolating 'big budget' from 'small budget' drugs using an 80-20 rule and providing multiple forecasts depending on the length of the drug expenditure histories is transferable to other jurisdictions.

The characteristics of stroke units in Ontario: a pan-provincial survey.

BACKGROUND: Previous studies have demonstrated that organized, multidisciplinary care is the cornerstone of current strategies to reduce the death and disability caused by stroke. Identification of stroke units and an understanding of their composition and operation would provide insight for the further actions required to improve stroke care. The objective of this study was to identify and survey stroke units in Canada's largest province, Ontario (population of 13 million) in order to describe availability, structure, staffing, processes of care, and type of population stroke units serve. METHODS: The Ontario Stroke Network (2011) list of stroke units and snowball sampling was used to identify all stroke units. During 2013 - 2014 an interviewer conducted telephone surveys with the stroke unit managers using closed and semi-open ended questions. Descriptive statistics were used to summarize survey responses. RESULTS: The survey identified 32 stroke units, and a respondent from every stroke unit (100% response rate) was interviewed. Twenty one were acute stroke units, 10 were integrated stroke units and one was classified as a rehabilitation stroke unit. Stroke units were available in all 14 Local Health Integration Networks except Central West. The estimated average number of stroke patients served per stroke unit was 604 with six-fold variation (242 to 1480) across the province. The typical population served in stroke units were patients with either ischemic or hemorrhagic stroke. Data consistently reported on the processes of stroke care, including the availability of multidisciplinary staff, specific diagnostic imaging, use of validated assessment tools, and the delivery of patient education. Details about the core components of stoke care were provided by 16 stroke units (50%). CONCLUSIONS: This study demonstrates the heterogeneous structure of stroke units in Ontario and signaled potential disparity in access to stroke units. Many core components are in place, but half of the stroke units in Ontario do not meet all criteria. Areas for potential improvement include stroke care training for the multidisciplinary team, provision of individualized rehabilitation plans, and early discharge assessment.

Early prevention of pressure ulcers among elderly patients admitted through emergency departments: a cost-effectiveness analysis.

STUDY OBJECTIVE: Every year, approximately 6.2 million hospital admissions through emergency departments (ED) involve elderly patients who are at risk of developing pressure ulcers. We evaluated the cost-effectiveness of pressure-redistribution foam mattresses on ED stretchers and beds for early prevention of pressure ulcers in elderly admitted ED patients. METHODS: Using a Markov model, we evaluated the incremental effectiveness (quality-adjusted life-days) and incremental cost (hospital and home care costs) between early prevention and current practice (with standard hospital mattresses) from a health care payer perspective during a 1-year time horizon. RESULTS: The projected incidence of ED-acquired pressure ulcers was 1.90% with current practice and 1.48% with early prevention, corresponding to a number needed to treat of 238 patients. The average upgrading cost from standard to pressure-redistribution mattresses was $0.30 per patient. Compared with current practice, early prevention was more effective, with 0.0015 quality-adjusted life-days gained, and less costly, with a mean cost saving of $32 per patient. If decisionmakers are willing to pay $50,000 per quality-adjusted life-year gained, early prevention was cost-effective even for short ED stay (ie, 1 hour), low hospital-acquired pressure ulcer risk (1% prevalence), and high unit price of pressure-redistribution mattresses ($3,775). Taking input uncertainty into account, early prevention was 81% likely to be cost-effective. Expected value-of-information estimates supported additional randomized controlled trials of pressure-redistribution mattresses to eliminate the remaining decision uncertainty. CONCLUSION: The economic evidence supports early prevention with pressure-redistribution foam mattresses in the ED. Early prevention is likely to improve health for elderly patients and save hospital costs.

Potentially preventable hospital use for dental conditions: implications for expanding dental coverage for low income populations.

Recently, attention has been placed on the issue of poor access to dental care, and the implications this may have for health care systems, in particular emergency department use for basic dental problems. In 2006, approximately 26,000 of 12 million Ontarians used acute-care hospital services for select dental problems, representing a cost of $16.4 million. There were 964 hospital admissions. The majority of use is by low-income adults. Although better access to dental care may lessen this burden on the health care system, the potential costs averted are considerably less than current proposals to improve access to dental care for low-income groups in Canada. Justifying renewed government investments in dental care in economic terms will require a broader assessment of costs; these data provide a starting-point for policymakers.

Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: a cost-effectiveness analysis.

BACKGROUND: Patients who undergo prolonged surgical procedures are at risk of developing pressure ulcers. Recent systematic reviews suggest that pressure redistribution overlays on operating tables significantly decrease the associated risk. Little is known about the cost effectiveness of using these overlays in a prevention program for surgical patients. METHODS: Using a Markov cohort model, we evaluated the cost effectiveness of an intraoperative prevention strategy with operating table overlays made of dry, viscoelastic polymer from the perspective of a health care payer over a 1-year period. We simulated patients undergoing scheduled surgical procedures lasting ≥90 min in the supine or lithotomy position. RESULTS: Compared with the current practice of using standard mattresses on operating tables, the intraoperative prevention strategy decreased the estimated intraoperative incidence of pressure ulcers by 0.51%, corresponding to a number-needed-to-treat of 196 patients. The average cost of using the operating table overlay was $1.66 per patient. Compared with current practice, this intraoperative prevention strategy would increase slightly the quality-adjusted life days of patients and by decreasing the incidence of pressure ulcers, this strategy would decrease both hospital and home care costs for treating fewer pressure ulcers originated intraoperatively. The cost savings was $46 per patient, which ranged from $13 to $116 by different surgical populations. Intraoperative prevention was 99% likely to be more cost effective than the current practice. CONCLUSION: In patients who undergo scheduled surgical procedures lasting ≥90 min, this intraoperative prevention strategy could improve patients' health and save hospital costs. The clinical and economic evidence support the implementation of this prevention strategy in settings where it has yet to become current practice.