Cost implications to health care payers of improving glucose management among adults with type 2 diabetes.

Objective. To assess the cost implications to payers of improving glucose management among adults with type 2 diabetes. Data Source/Study Setting. Medical-record data from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare Fee Schedule (2009), published literature. Study Design. Probability tree depicting glucose management over 1 year. Data Collection/Extraction Methods. We determined how frequently CQI study subjects received recommended care processes and attained Health Care Effectiveness Data and Information Set (HEDIS) treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. Principal Findings. Relative to current care, improved glucose management would cost U.S.$327 (U.S.$192-711 in sensitivity analyses) more per person with diabetes annually, largely due to antihyperglycemic medications. Cost-effectiveness to payers, defined as incremental annual cost per patient newly attaining any one of three HEDIS goals, would be U.S.$1,128; including glycemic crises reduces this to U.S.$555-1,021. Conclusions. The cost of improving glucose management appears modest relative to diabetes-related health care expenditures. The incremental cost per patient newly attaining HEDIS goals enables payers to consider costs as well as outcomes that are linked to future profitability.

Cost implications of improving blood pressure management among U.S. adults.

OBJECTIVE: To examine the cost-effectiveness of improving blood pressure management from the payer perspective. DATA SOURCE/STUDY SETTING: Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature. STUDY DESIGN: A probability tree depicted blood pressure management over 2 years. DATA COLLECTION/EXTRACTION METHODS: We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. PRINCIPAL FINDINGS: Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185. CONCLUSIONS: Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.

Non-pharmaceutical public health interventions for pandemic influenza: an evaluation of the evidence base.

BACKGROUND: In an influenza pandemic, the benefit of vaccines and antiviral medications will be constrained by limitations on supplies and effectiveness. Non-pharmaceutical public health interventions will therefore be vital in curtailing disease spread. However, the most comprehensive assessments of the literature to date recognize the generally poor quality of evidence on which to base non-pharmaceutical pandemic planning decisions. In light of the need to prepare for a possible pandemic despite concerns about the poor quality of the literature, combining available evidence with expert opinion about the relative merits of non-pharmaceutical interventions for pandemic influenza may lead to a more informed and widely accepted set of recommendations. We evaluated the evidence base for non-pharmaceutical public health interventions. Then, based on the collective evidence, we identified a set of recommendations for and against interventions that are specific to both the setting in which an intervention may be used and the pandemic phase, and which can be used by policymakers to prepare for a pandemic until scientific evidence can definitively respond to planners' needs. METHODS: Building on reviews of past pandemics and recent historical inquiries, we evaluated the relative merits of non-pharmaceutical interventions by combining available evidence from the literature with qualitative and quantitative expert opinion. Specifically, we reviewed the recent scientific literature regarding the prevention of human-to-human transmission of pandemic influenza, convened a meeting of experts from multiple disciplines, and elicited expert recommendation about the use of non-pharmaceutical public health interventions in a variety of settings (healthcare facilities; community-based institutions; private households) and pandemic phases (no pandemic; no US pandemic; early localized US pandemic; advanced US pandemic). RESULTS: The literature contained a dearth of evidence on the efficacy or effectiveness of most non-pharmaceutical interventions for influenza. In an effort to inform decision-making in the absence of strong scientific evidence, the experts ultimately endorsed hand hygiene and respiratory etiquette, surveillance and case reporting, and rapid viral diagnosis in all settings and during all pandemic phases. They also encouraged patient and provider use of masks and other personal protective equipment as well as voluntary self-isolation of patients during all pandemic phases. Other non-pharmaceutical interventions including mask-use and other personal protective equipment for the general public, school and workplace closures early in an epidemic, and mandatory travel restrictions were rejected as likely to be ineffective, infeasible, or unacceptable to the public. CONCLUSION: The demand for scientific evidence on non-pharmaceutical public health interventions for influenza is pervasive, and present policy recommendations must rely heavily on expert judgment. In the absence of a definitive science base, our assessment of the evidence identified areas for further investigation as well as non-pharmaceutical public health interventions that experts believe are likely to be beneficial, feasible and widely acceptable in an influenza pandemic.

Cost-effectiveness of peginterferon alpha-2a compared with lamivudine treatment in patients with HBe-antigen-positive chronic hepatitis B in the United Kingdom.

BACKGROUND: Peginterferon alpha-2a (40 kDa), a new treatment for chronic hepatitis B, produces seroconversion within 48 weeks in approximately 32% of HBeAg-positive patients. Over a defined treatment duration it offers improved efficacy over lamivudine, but at higher cost. We assessed the clinical outcomes and costs, from the perspective of the UK National Health Service, of 48 weeks of peginterferon alpha-2a (40 kDa) vs. 4 years of lamivudine. METHODS: Cost-effectiveness was analysed using a state-transition Markov model simulating HBeAg-positive chronic hepatitis B natural history. Efficacy data were obtained from a large randomized trial comparing peginterferon alpha-2a (40 kDa) with lamivudine over 48 weeks. Use of adefovir salvage treatment for lamivudine-resistant patients was also evaluated. Long-term lamivudine efficacy, treatment durability, disease progression, cost, and quality-of-life estimates were derived from the literature. One-way and probabilistic sensitivity analyses evaluated uncertainty. RESULTS: Treatment with peginterferon alpha-2a (40 kDa) for 48 weeks resulted in higher discounted total healthcare costs ( pound 3100), but an increase of 0.3 discounted quality-adjusted life years compared with long-term lamivudine, giving an incremental cost-effectiveness ratio of pound 10,400 per quality-adjusted life year gained ( pound 8300- pound 15,400 in one-way sensitivity analyses). The cost-effectiveness acceptability curve showed intervention was below the pound 30,000/QALY threshold in over 95% of the simulations. When adefovir was included for patients with lamivudine resistance, peginterferon alpha-2a (40 kDa) had an incremental cost of pound 6100/QALY gained. CONCLUSIONS: Treatment with peginterferon alpha-2a (40 kDa) for a defined duration of 48 weeks, although more expensive than lamivudine therapy, provides improvement in health outcomes, with a cost-effectiveness ratio well below the current UK cost-effectiveness threshold.

The cost effectiveness of gonorrhea screening in urban emergency departments.

BACKGROUND: The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical. GOAL: The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests. STUDY: We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs. RESULTS: Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs. CONCLUSION: Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.