An imperfect test for a virus can Be worse than No test at all.

This note studies the effect of the availability of a test for a virus on the public health of a population. It is shown by example that the existence of a freely available and moderately informative test for a virus may lower society's welfare in comparison to the case where no test exists or access to the test is restricted. In this setting, any test provided to any subset of agents who would find it optimal not to isolate absent the test improves welfare.

Early detection of lung cancer in Czech high-risk asymptomatic individuals (ELEGANCE): A study protocol.

BACKGROUND: Lung cancer screening in high-risk population increases the proportion of patients diagnosed at a resectable stage. AIMS: To optimize the selection criteria and quality indicators for lung cancer screening by low-dose CT (LDCT) in the Czech population of high-risk individuals. To compare the influence of screening on the stage of lung cancer at the time of the diagnosis with the stage distribution in an unscreened population. To estimate the impact on life-years lost according to the stage-specific cancer survival and stage distribution in the screened population. To calculate the cost-effectiveness of the screening program. METHODS: Based on the evidence from large national trials - the National Lung Screening Trial in the USA (NLST), the NELSON study, the recent recommendations of the Fleischner society, the American College of Radiology, and I-ELCAP action group, we developed a protocol for a single-arm prospective study in the Czech Republic for the screening of high-risk asymptomatic individuals. The study commenced in August 2020. RESULTS: The inclusion criteria are: age 55 to 74 years; smoking: ≥30 pack-years; smoker or ex-smoker <15 years; performance status (0-1). The screening timepoints are at baseline and 1 year. The LDCT acquisition has a target CTDIvol ≤0.5mGy and effective dose ≤0.2mSv for a standard-size patient. The interpretation of findings is primarily based on nodule volumetry, volume doubling time (and related risk of malignancy). The management includes follow-up LDCT, contrast enhanced CT, PET/CT, tissue sampling. The primary outcome is the number of cancers detected at a resectable stage, secondary outcomes include the average cost per diagnosis of lung cancer, the number, cost, complications of secondary examinations, and the number of potentially important secondary findings. CONCLUSIONS: A study protocol for early detection of lung cancer in Czech high-risk asymptomatic individuals (ELEGANCE) study using LDCT has been described.

Economic value of information from an alert system on physiological imbalance in fresh cows.

Physiological imbalance is an abnormal physiological condition that cannot be directly observed but is assumed to precede subclinical and clinical diseases in the beginning of lactation. Alert systems to detect the physiological imbalance in a cow using Fourier transform mid-infrared spectroscopy in milk have been developed. The objective of this study was to estimate the value of information provided from such system with different indicator accuracies, herd prevalence and prices. A decision tree was created to model the probabilities of detection and associated costs of test outcome, intervention and occurrence of disease. We assumed that the negative effect of physiological imbalance was the development of subclinical ketosis and that this negative effect was prevented by drenching the cows with propylene glycol for 5 days. We simulated the economic impact of subclinical ketosis mediated through physiological imbalance to be $194 per case. The results showed that if the alert system was highly accurate (Se = 0.99/Sp = 0.99), and the prevalence of physiological imbalance was 30 %, the value of information provided from the system is $19 per cow-year. In case the prevalence is 5 % or 50 %, the value of information is $3 and $13, respectively. These estimates for the value do not cover the capital costs and operational costs of the alert system. This study furthermore clearly demonstrated that in order to estimate the value of information correctly, it is important to consider that drenching all cows and not drenching any of the cows are the two relevant alternative options in the absence of the alert system. In conclusion, the decision tree and sensitivity analysis developed in this study show that final economic results are highly variable to the prevalence of physiological imbalance and highest at an intermediate prevalence. Other relevant factors are the costs associated with drenching and the cost associated with treating false positives and not treating false negatives. In addition, this study highlights the benefits of simulation to pinpoint where additional information is needed to further quantify the economic value and required accuracy of an indication-based intervention system.

Use of a Risk Stratification Tool to Guide Evaluation of Patients With Asymptomatic Microscopic Hematuria.

OBJECTIVE: To determine if use of the hematuria risk index can reduce testing and cost, while maintaining equivalent lesion detection in patients with asymptomatic microscopic hematuria. MATERIALS AND METHODS: Retrospective cohort study of 1049 patients at single institution. Hematuria risk index score was calculated based on clinical factors including age, sex, smoking history, and degree of hematuria for each patient along with evaluation studies performed and total number of tumors discovered. Cost benefit analysis was performed based on published Medicare averages. RESULTS: Tumor detection rate in overall, low-risk, and moderate-risk groups were 1.2%, 0%, and 2.96% at a total cost of $408,376. When low-risk group is not screened cost decreases to $166,252 with no lesions missed. The cost to discover one lesion/cancer in the overall group was $34,031.3, the cost to find one high-grade clinically significant lesion/cancer was $136,125.3 for the overall group. When the low-risk group was removed, the cost to find a high-grade clinically significant lesion/cancer decreased to $55,417.3 without missing any significant lesions. Ultrasound may be utilized instead of computed tomography with minimal loss of lesion detection in select moderate risk patients. CONCLUSION: None of the low-risk hematuria risk patients were diagnosed with any lesions, as such these patients may not need an evaluation. Furthermore, by utilizing a risk-stratified approach to the assessment of asymptomatic microscopic hematuria health care costs can be significantly decreased with limited negative consequences in terms of lesion detection.

Derivation of a cost-saving screening strategy for asymptomatic primary hyperparathyroidism.

BACKGROUND: Our study seeks to find a cost-saving screening strategy in a primary care population for diagnosing primary hyperparathyroidism based on peak serum total calcium level, age, and patient sex. METHODS: Laboratory data resulting from primary care office visits at our institution between January 2016 through December 2017 to evaluate patients who had at least 1 episode of hypercalcemia (≥10.5 mg/dL). For each serum calcium threshold, we calculated the percentage of patients who were found to have an increased parathyroid hormone level (≥65 pg/mL). We determined whether net cost savings could be achieved by screening hypercalcemic patients given their probability of primary hyperparathyroidism and expected cost savings from fracture risk reduction, given their sex and age. RESULTS: From 155,350 unique patients in the study period, a total of 2,271 had a minimum of 1 hypercalcemic lab value. After exclusion criteria, there were 1,326 patients of whom 27.5% had a parathyroid hormone level checked. Cost savings was established at a screening threshold of 10.5 for all patients until age 66 years for men and 69 years for women. For men aged 67-68 y and women aged 70-71 years, the optimal screening threshold was 10.8 mg/dl. CONCLUSION: Cost savings can be achieved by screening hypercalcemic patients with a life expectancy exceeding 16 years, with varying thresholds based on age and sex.

Cost-effectiveness analysis of screen-and-treat strategy in asymptomatic Chinese for preventing Helicobacter pylori-associated diseases.

BACKGROUND: The high prevalence of Helicobacter pylori (H pylori) infection in China results in a substantial public health burden. Medical experts have not agreed on the best solution of population intervention for this problem. We presented a health economic evaluation of a population-based H pylori screen-and-treat strategy for preventing gastric cancer, peptic ulcer disease (PUD), and nonulcer dyspepsia (NUD). MATERIALS AND METHODS: Decision trees and Markov models were developed to evaluate the cost-effectiveness of H pylori screening followed by eradication treatment in asymptomatic Chinese. The modeled screen-and-treat strategy reduced the risk of gastric cancer, PUD, and NUD. The main outcomes were the costs, effectiveness, and the incremental cost-effectiveness ratio. Uncertainty was explored by one-way and probabilistic sensitivity analyses. RESULTS: For preventing gastric cancer, PUD, and NUD together in a cohort of 10 million asymptomatic Chinese at the age of 20 years, the H pylori screen-and-treat strategy saved 288.1 million dollars, 28 989 life years, and 111 663 quality-adjusted life years, and prevented 11 611 gastric cancers, 5422 deaths from gastric cancer, and 1854 deaths from PUD during life expectancy. Uncertainty of screening age from 20 to 60 did not affect the superiority of the screen-and-treat strategy over the no-screen strategy. The one-way and probabilistic sensitivity analyses confirmed the robustness of our study's results. CONCLUSIONS: Compared with the no-screen strategy, population-based screen-and-treat strategy for H pylori infection proved cheaper and more effective for preventing gastric cancer, PUD, and NUD in Chinese asymptomatic general population.

Examining variation in Medicare payments and drivers of cost for carotid endarterectomy.

BACKGROUND: There is a growing interest in providing high quality and low-cost care to Americans. A pursuit exists to measure not only how well hospitals are performing but also at what cost. We examined the variation in costs associated with carotid endarterectomy (CEA), to determine which components contribute to the variation and what drives increased payments. MATERIALS AND METHODS: Patients undergoing CEA between 2009 and 2012 were identified in the Medicare provider and analysis review database. Hospital quintiles of cost were generated and variation examined. Multivariable logistic regression was performed to identify independent predictors of high-payment hospitals for both asymptomatic and symptomatic patients undergoing CEA. RESULTS: A total of 264,018 CEAs were performed between 2009 and 2012; 250,317 were performed in asymptomatic patients in 2302 hospitals and 13,701 in symptomatic patients in 1851 hospitals. Higher payment hospitals had a higher percentage of nonwhite patients and comorbidity burden. The largest contributors to variation in overall payments were diagnosis-related groups, postdischarge, and readmission payments. After accounting for clustering at the hospital level, independent predictors of high-payment hospitals for all patients were postoperative stroke, length of stay, and readmission ,whereas in the symptomatic group, additional drivers included yearly volume and serious complications. CONCLUSIONS: CEA Medicare payments vary nationwide with diagnosis-related group, readmission, and postdischarge payments being the largest contributors to overall payment variation. In addition, stroke, length of stay, and readmission were the only independent predictors of high payment for all patients undergoing CEA.

Clinical Effect and Cost-Effectiveness of Screening for Asymptomatic Carotid Stenosis: A Markov Model.

OBJECTIVE/BACKGROUND: The cost-effectiveness of screening depends on the cost of screening, prevalence of asymptomatic carotid artery stenosis (ACAS), and the potential effect of medical intervention in reducing the risk of stroke. The aim of the study was to determine the threshold values for these parameters in order for screening for ACAS to be cost-effective. METHODS: The clinical effect and cost-effectiveness of ultrasound screening for ACAS with subsequent initiation of preventive therapy versus not screening was assessed in a Markov model with a lifetime perspective. Key parameters, including stroke risk, all cause mortality, and costs, were based on contemporary published data, population statistics, and data from an ongoing screening program in Uppsala county (population 300,000), Sweden. Prevalence of ACAS (2%) and the rate of best medical treatment (BMT; 40%) were based on data from a male Swedish population recently screened for ACAS. The required stroke risk reduction from BMT, incremental cost-efficiency ratio (ICER), absolute risk reduction for stroke (ARR), and number needed to screen (NNS) were calculated. RESULTS: Screening was cost-effective at an ICER of €5744 per incremental quality adjusted life year (QALY) gained. ARR was 135 per 100,000 screened, NNS was 741, and QALYs gained were 6700 per 100,000 invited. At a willingness to pay (WTP) threshold of €50,000 per QALY the minimum required stroke risk reduction from BMT was 22%. The assumed degree of stroke risk reduction was the most important determinant of cost-efficiency. CONCLUSION: A moderate (22%) reduction in the risk of stroke was required for an ACAS screening strategy to be cost-effective at a WTP of €50,000/QALY. Targeting populations with a higher prevalence of ACAS could further improve cost-efficiency.

10-Year Resource Utilization and Costs for Cardiovascular Care.

BACKGROUND: Cardiovascular disease (CVD) imparts a heavy economic burden on the U.S. health care system. Evidence regarding the long-term costs after comprehensive CVD screening is limited. OBJECTIVES: This study calculated 10-year health care costs for 6,814 asymptomatic participants enrolled in MESA (Multi-Ethnic Study of Atherosclerosis), a registry sponsored by the National Heart, Lung, and Blood Institute, National Institutes of Health. METHODS: Cumulative 10-year costs for CVD medications, office visits, diagnostic procedures, coronary revascularization, and hospitalizations were calculated from detailed follow-up data. Costs were derived by using Medicare nationwide and zip code-specific costs, inflation corrected, discounted at 3% per year, and presented in 2014 U.S. dollars. RESULTS: Risk factor prevalence increased dramatically and, by 10 years, diabetes, hypertension, and dyslipidemia was reported in 19%, 57%, and 53%, respectively. Self-reported symptoms (i.e., chest pain or shortness of breath) were common (approximately 40% of enrollees). At 10 years, approximately one-third of enrollees reported having an echocardiogram or exercise test, whereas 7% underwent invasive coronary angiography. These utilization patterns resulted in 10-year health care costs of $23,142. The largest proportion of costs was associated with CVD medication use (78%). Approximately $2 of every $10 were spent for outpatient visits and diagnostic testing among the elderly, obese, those with a high-sensitivity C-reactive protein level >3 mg/l, or coronary artery calcium score (CACS) ≥400. Costs varied widely from <$7,700 for low-risk (Framingham risk score <6%, 0 CACS, and normal glucose measurements at baseline) to >$35,800 for high-risk (persons with diabetes, Framingham risk score ≥20%, or CACS ≥400) subgroups. Among high-risk enrollees, CVD costs accounted for $74 million of the $155 million consumed by MESA participants. CONCLUSIONS: Longitudinal patterns of health care resource use after screening revealed new evidence on the economic burden of treatment and testing patterns not previously reported. Maintenance of a healthy population has the potential to markedly reduce the economic burden of CVD among asymptomatic individuals.

Self-Reported Medication Adherence Barriers Among Ambulatory Older Adults with Mild Cognitive Impairment.

STUDY OBJECTIVE: To compare the frequencies of barriers to medication adherence reported by ambulatory older adults with a diagnosis of mild cognitive impairment (MCI) and ambulatory older adults with normal cognition. DESIGN: Cross-sectional study. SETTING: Outpatient clinics within a safety-net health care system. PARTICIPANTS: Ambulatory older adults (≥ 65 yrs) with a diagnosis of MCI (96 participants) or normal cognition (104 participants). MEASUREMENTS AND MAIN RESULTS: Self-reported beliefs and barriers to medication nonadherence were assessed by items from the Morisky Medication Adherence Survey, the Adherence Estimator, and barriers derived from a systematic review of studies in older adults with cognitive impairment. Participants with a diagnosis of MCI had a mean age of 72 years, 77% were female, and 37% were African-American. Participants with normal cognition had a mean age of 76 years, 79% were female, and 47% were African-American. Among all participants, 83% reported the presence of at least one barrier to medication adherence, and 62.5% reported two or more barriers to medication adherence. The most commonly reported barriers were difficulty remembering the amount or time of each medication to take (49%), difficulty opening or reading prescription bottles (42%), feeling worse when taking medications (29%), and trouble affording medications (26%). Considering the multiple comparisons made in this analysis, few significant differences in barrier frequencies were identified between the groups with MCI and normal cognition. CONCLUSION: Multiple medication adherence barriers were identified among all participants, including cognitive, physical, and financial barriers, although few significant differences were identified between those with and without MCI. Interventions capable of addressing multiple barriers are required to improve medication adherence in older adults with and without MCI.

Education, individual time preferences, and asymptomatic disease detection.

Asymptomatic conditions such as hypertension are generally hard to diagnose, absent routine medical examinations. This is especially problematic in developing countries, where most citizens do not engage in routine examinations due to limited economic resources. We study the roles of education and individual time preferences in asymptomatic disease detection and management. Using discrete choice models on a sample of 4209 hypertensive Indonesian adults surveyed between November 2007 and April 2008, we find that both education and individual time preferences play important roles. However, the effects are different for people in good health than they are for people in bad health. Education does not seem to matter for disease detection when respondents are in good general health, and its effects on disease management vary largely in magnitudes between these groups. In terms of disease detection, more educated respondents have a higher probability of being diagnosed, but only conditional on being in poor general health. Time preferences, on the other hand, matter for respondents in good general health, but the effect is not significant for those in bad health. More impatient respondents that are in good health have a higher probability of being under-diagnosed because they are more likely to forgo routine physicals. The findings point to two distinct channels through which education can affect health, and suggest that different types of policies need to be implemented, in order to reach the entire population. Traditional programs that stimulate education and improve the socio-economic status of individuals in developing countries are helpful, but they do not address the whole problem. Besides its more usual positive effects, education can also negatively affect the health of asymptomatic patients, because it reflects a higher opportunity cost of engaging in preventative health screenings.

Cost-effectiveness of various risk stratification methods for asymptomatic ventricular pre-excitation.

Accessory pathways with "high-risk" properties confer a small but potential risk of sudden cardiac death. Pediatric guidelines advocate for either risk stratification or ablation in patients with ventricular pre-excitation but do not advocate specific methodology. We sought to compare the cost of differing risk-stratification methodologies in pediatric patients with ventricular pre-excitation in this single institutional, retrospective cohort study of asymptomatic pediatric patients who underwent risk stratification for ventricular pre-excitation. Institutional methodology consisted of stratification using graded exercise testing (GXT) followed by esophageal testing in patients without loss of pre-excitation and ultimately ablation in high-risk patients or patients who became clinically symptomatic during follow-up. A decision analysis model was used to compare this methodology with hypothetical methodologies using different components of the stratification technique and an "ablate all" method. One hundred and two pediatric patients with asymptomatic ventricular pre-excitation underwent staged risk stratification; 73% of patients were deemed low risk and avoided ablation and the remaining 27% ultimately were successfully ablated. The use of esophageal testing was associated with a 23% (p ≤0.0001) reduction in cost compared with GXT stratification alone and a 48% (p ≤0.0001) reduction compared with the "ablate all" model. GXT as a lone stratification method was also associated with a 15% cost reduction (p ≤0.0001) compared with the "ablate all" method. In conclusion, risk stratification of pediatric patients with asymptomatic ventricular pre-excitation is associated with reduced cost. These outcomes of cost-effectiveness need to be combined with the risks and benefits associated with ablation and risk stratification.

Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis.

BACKGROUND: The aim of this study was to model the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis versus medical therapy based on 10-year data from the Asymptomatic Carotid Surgery Trial (ACST). METHODS: This was a cost-utility analysis based on clinical effectiveness data from the ACST with UK-specific costs and stroke outcomes. A Markov model was used to calculate the incremental cost-effectiveness ratio (ICER, or cost per additional quality-of-life year) for a strategy of early endarterectomy versus medical therapy for the average patient and published subgroups. An exploratory analysis considered contemporary event rates. RESULTS: The ICER was £7584 per additional quality-adjusted life-year (QALY) for the average patient in the ACST. At thresholds of £20,000 and £30,000 there was a 74 and 84 per cent chance respectively of early endarterectomy being cost-effective. The ICER for men below 75 years of age was £3254, and that for men aged 75 years or above was £71,699. For women aged under 75 years endarterectomy was less costly and more effective than medical therapy; for women aged 75 years or more endarterectomy was less effective and more costly than medical therapy. At contemporary perioperative event rates of 2·7 per cent and background any-territory stroke rates of 1·6 per cent, early endarterectomy remained cost-effective. CONCLUSION: In the ACST, early endarterectomy was predicted to be cost-effective in those below 75 years of age, using a threshold of £20,000 per QALY. If background any-territory stroke rates fell below 1 per cent per annum, early endarterectomy would cease to be cost-effective.

What costs are associated with the management of third molars?

PURPOSE: The purpose of this study was to estimate the treatment costs directly related to operative and nonoperative management of asymptomatic, disease-free, third molar (M3) teeth. MATERIALS AND METHODS: The data reviewed were limited to claims submitted by oral and maxillofacial surgeons. The data collected included charges for consultations, radiographs, surgical removal of bony impacted teeth, and general anesthesia, using the 2009 data extracts from Delta Dental of Virginia. The median charges were used as a proxy for the actual costs attributable to the removal or retention of M3 teeth. Three clinical scenarios were executed using the available claims data to calculate the treatment costs associated with nonoperative and operative M3 management. An assumption made in the computation of expenses was that for subjects who elected to retain their M3s, the recommended management strategy was active surveillance. Active surveillance is a prescribed treatment to monitor the retained M3s characterized by performing a clinical examination and panoramic imaging every 2 years. The author assumed a 3% increase in charges per annum. RESULTS: The 3 scenarios were as follows: scenario 1 (nonoperative management), retention of asymptomatic, disease-free M3s and monitoring for 20 years from age 18 to 38 years; scenario 2 (operative management), removal of 2 asymptomatic, disease-free, bony impacted M3s for 18-year-old patients using general anesthesia (30 minutes) in an office-based ambulatory setting; and scenario 3 (failure of non-operative management), removal of 1 previously asymptomatic, disease-free, bony impacted M3 after 10 years of follow-up in a now 28-year-old patient using general anesthesia (30 minutes) in an office-based ambulatory setting. The estimated charges for managing M3s were $2,342, $1,184, and $1,997 for scenarios 1, 2, and 3, respectively. CONCLUSIONS: A simplified financial analysis derived from the dental claims data suggests that during the course of the patient's lifetime, the charges associated with non-operative management of asymptomatic, disease-free M3s will exceed the charges of operative management. The difference in costs might be important to patients when choosing between operative and non-operative management of their M3s.