Nutrition-Focused Care for Community-Living Adults: Healthcare Utilization and Economic Benefits.

OBJECTIVES: We assessed the impact of a recently reported nutritional quality improvement program (QIP) on healthcare resource utilization and costs for older, community-living adults in Bogotá, Colombia. METHODS: The study included 618 community-dwelling, older adults (> 60 years) who were at risk or malnourished and receiving outpatient clinical care. The intervention was a QIP that emphasized nutritional screening, dietary education, lifestyle counseling, 60-day consumption of oral nutritional supplements, and 90-day follow-up. For economic modeling, we performed 90-day budget impact and cost-effectiveness analyses from a Colombian third-party payer perspective. The base-case analysis quantified mean healthcare resource use in the QIP study population. Analysis was based on mean input values (deterministic) and distributions of input parameters (probabilistic). As the deterministic analysis provided a simple point estimate, the cost-effectiveness analysis focused on the probabilistic results informed by 1000 iterations of a Monte-Carlo simulation. RESULTS: Results showed that the total use of healthcare resources over 90 days was significantly reduced by > 40% (hospitalizations were reduced by approximately 80%, emergency department visits by > 60%, and outpatient clinical visits by nearly 40%; P < .001). Based on economic modeling, total cost savings of $129 740 or per-patient cost savings of $210 over 90 days could be attributed to the use of nutritional QIP strategies. Total cost savings equated to nearly twice the initial investment for QIP intervention; that is, the per-dollar return on investment was $1.82. CONCLUSIONS: For older adults living in the community in Colombia, the use of our nutritional QIP improved health outcomes while lowering costs of healthcare and was thus cost-effective.

Pursuing Elimination of Hepatitis C in Egypt: Cost-Effectiveness and Economic Evaluation of a Country-Wide Program.

INTRODUCTION: Hepatitis C virus (HCV) is a global public health crisis. Egypt presents the highest HCV global prevalence. Recently, three different HCV screening/testing/therapy programs were implemented: In 2014 (wave 1), major decisions on HCV therapy were enacted, accompanied by a 99% discount for the HCV therapy sofosbuvir. In 2016 (wave 2), a first testing program was launched to identify patients for free treatment. In 2018 (wave 3), population-wide screening was conducted using a WHO-prequalified finger prick rapid diagnostic test (RDT) to identify/treat all Egyptians with HCV. The financial advantages of HCV screening programs (wave 1-3 results) were estimated vs a baseline period of limited Egyptian HCV testing/therapeutic intervention (2008-2014). METHODS: Using published evidence and model-based estimates from real-world data, we evaluated the direct costs of the different HCV programs, accompanied by a conservative simulation of major HCV health consequences (i.e., liver-related deaths/life years lost) and related indirect costs. Total economic consequences of each HCV program were compared to each other and baseline from a societal perspective. Future costs and health effects were discounted by 3.5% per year. RESULTS: Discounted total costs (in US dollars) were $1,057 billion (baseline), $913 million (wave 1), $457 million (wave 2), and $396 million (wave 3). Discounted HCV-related life years lost were 418,000 (baseline), 377,000 (wave 1), 142,000 (wave 2), and 62,000 (wave 3). With each successive Egyptian HCV screening/testing/therapy wave, total costs and HCV-related mortality were reduced. CONCLUSION: Use of the community-applied, WHO-prequalified RDT was the most dominant approach to cost-effectiveness. These results provide rationale for worldwide scalability of similar HCV elimination programs.

Robotic hysterectomy compared with laparoscopic hysterectomy: is it still more costly to perform?

To establish the economic value of simple robotic hysterectomy vs laparoscopic hysterectomy and assess the impact of surgeon's experience. Retrospective cohort study. University-affiliated US regional healthcare system. Reproductive and post-menopausal women undergoing hysterectomy for benign indications. Robotic or laparoscopic hysterectomy. Between January 2018 and December 2019, a total of 985 simple laparoscopic and robotic hysterectomies were performed by 47 different gynecologists. Overall, the mean payment, direct cost, and profit were comparable (p value > 0.05) among simple robotic and laparoscopic hysterectomy. However, the mean operative time was significantly shorter for robotic hysterectomy compared to laparoscopic hysterectomy (106 min vs 127 min, respectively, p < 0.05). Operative time decreased as a surgeon's annual robotic case volume increased. Per-minute profitability of robotic hysterectomy increased significantly when a surgeon performed greater than 45 cases annually (p = 0.04). This effect became most pronounced when a surgeon performed 60 or more cases per year (p = 0.01). Simple robotic hysterectomy has shorter operative time compared to laparoscopic hysterectomy, with direct costs being similar. Robotic hysterectomy has higher per-minute profit compared to laparoscopic hysterectomy when a surgeon performs > 45 cases per year.

Budget Impact Analysis of a Home-Based Nutrition Program for Adults at Risk for Malnutrition.

BACKGROUND: Hospital-based, nutrition-focused interventions have significantly lowered the cost-associated burden of poor nutrition through a reduction in healthcare resource utilization (HCRU). However, for patients at risk for poor nutrition who receive nutritional care at home, limited evidence exists on the economic impact of nutrition-focused interventions. OBJECTIVE: To estimate the 30-day cost-savings associated with an at-home nutrition-focused quality improvement program in the postacute care setting for patients at risk for poor nutrition from the perspective of a hospital system. METHODS: We compared the HCRU of 1546 patients enrolled in a quality improvement program during 1 year versus 7413 patients in a pre-program historical cohort who received care during the 1 year before the quality improvement program implementation. The analysis included the number of 30-day hospitalizations, emergency department and outpatient visits for both cohorts, and the associated costs. The main analysis included the fixed and variable costs for the program, and the costs of oral nutritional supplement and delivery. The costs for hospitalization, emergency department, and outpatient visit costs were based on the 2013 Healthcare Cost and Utilization Project and Medical Expenditure Panel Survey. RESULTS: Based on the 2013 survey, the baseline costs for hospitalization, emergency department, and outpatient visit costs were $18,296, $1312, and $535, respectively. Our health economic analysis about the 30-day overall HCRU has shown that the quality improvement program group resulted in a total cost-savings of $2,408,668 for the 1546 patients in the program and a net savings of $1558 per patient compared with the costs for the pre-quality improvement program historical cohort. CONCLUSION: The use of a nutrition-focused quality improvement program led to significant 30-day cost-savings, by reducing HCRU for adults who received nutritional-based care at home. The improvements in HCRU highlight the importance of implementing nutrition-focused quality improvement programs for hospital systems that provide care for patients who are at risk for poor nutrition across a variety of care settings.

Cost of ownership assessment for a da Vinci robot based on US real-world data.

BACKGROUND: Despite growth of robotic surgery, published literature lacks assessment of the cost of ownership (CoO) of a da Vinci robot by surgical service line and the associated benefit such data provides. METHODS: Based on real-world data (RWD) from 14 US hospitals and ≈6000 da Vinci robotic cases, CoO was assessed using all relevant fixed and variable cost components, calculated by surgical service line. RESULTS: At a representative hospital with an efficient robotic program (n = 424 cases), the weighted average fixed cost per case was $984. Weighted average variable cost per case was $8025 (range: $3325 for Cholecystectomy-multiport, to $16 986 for Rectal Resection). Assessing weighted average by case, main variable cost drivers were non-da Vinci supplies (49.5%), staff costs (28.6%), and da Vinci supplies (21.9%). CONCLUSIONS: Case mix, annual robotic case volumes, and cut-to-close/patient-in-room time by surgical service line represent core variables influencing robotic program CoO, which help drive profitable program management.

Event simulation and external validation applied in published health economic models for obesity: a systematic review.

INTRODUCTION: This study aims to determine methodological variations in the event simulation approaches of published health economic decision models, in the field of obesity, and to investigate whether their predictiveness and validity were investigated via external event validation techniques, which investigate how well the model reproduces reality. AREAS COVERED: A systematic review identified a total of 87 relevant papers, of which 72 that simulated obesity-associated events were included. Most frequently simulated events were coronary heart disease (≈ 83%), type 2 diabetes (≈ 74%), and stroke (≈ 66%). Only for ten published model-based health economic assessments in obesity an external event validation was performed (14%; 10 of 72), and only for one the predictiveness and validity of the event simulation was investigated in a cohort of obese subjects. EXPERT COMMENTARY: We identified a wide range of obesity related event simulation approaches. Published obesity models lack information on the predictive quality and validity of the applied event simulation approaches. Further work on comparing and validating these event simulation approaches is required to investigate their predictiveness and validity, which will offer guidance future modelling in the field of obesity.

Budget Impact of a Comprehensive Nutrition-Focused Quality Improvement Program for Malnourished Hospitalized Patients.

BACKGROUND: Nutrition interventions can alleviate the burden of malnutrition by improving patient outcomes; however, evidence on the economic impact of medical nutrition intervention remains limited. A previously published nutrition-focused quality improvement program targeting malnourished hospitalized patients showed that screening patients with a validated screening tool at admission, rapidly administering oral nutritional supplements, and educating patients on supplement adherence result in significant reductions in 30-day unplanned readmissions and hospital length of stay. OBJECTIVES: To assess the potential cost-savings associated with decreased 30-day readmissions and hospital length of stay in malnourished inpatients through a nutrition-focused quality improvement program using a web-based budget impact model, and to demonstrate the clinical and fiscal value of the intervention. METHODS: The reduction in readmission rate and length of stay for 1269 patients enrolled in the quality improvement program (between October 13, 2014, and April 2, 2015) were compared with the pre-quality improvement program baseline and validation cohorts (4611 patients vs 1319 patients, respectively) to calculate potential cost-savings as well as to inform the design of the budget impact model. Readmission rate and length-of-stay reductions were calculated by determining the change from baseline to post-quality improvement program as well as the difference between the validation cohort and the post-quality improvement program, respectively. RESULTS: As a result of improved health outcomes for the treated patients, the nutrition-focused quality improvement program led to a reduction in 30-day hospital readmissions and length of stay. The avoided hospital readmissions and reduced number of days in the hospital for the patients in the quality improvement program resulted in cost-savings of $1,902,933 versus the pre-quality improvement program baseline cohort, and $4,896,758 versus the pre-quality improvement program in the validation cohort. When these costs were assessed across the entire patient population enrolled in the quality improvement program, per-patient net savings of $1499 when using the baseline cohort as the comparator and savings per patient treated of $3858 when using the validated cohort as the comparator were achieved. CONCLUSION: The nutrition-focused quality improvement program reduced the per-patient healthcare costs by avoiding 30-day readmissions and through reduced length of hospital stay. These clinical and economic outcomes provide a rationale for merging patient care and financial modeling to advance the delivery of value-based medicine in a malnourished hospitalized population. The use of a novel web-based budget impact model supports the integration of comparative effectiveness analytics and healthcare resource management in the hospital setting to provide optimal quality of care at a reduced overall cost.

Systematic review and overview of health economic evaluation models in obesity prevention and therapy.

INTRODUCTION: Given the increasing clinical and economic burden of obesity, it is of major importance to identify cost-effective approaches for obesity management. Areas covered: This study aims to systematically review and compile an overview of published decision models for health economic assessments (HEA) in obesity, in order to summarize and compare their key characteristics as well as to identify, inform and guide future research. Of the 4,293 abstracts identified, 87 papers met our inclusion criteria. A wide range of different methodological approaches have been identified. Of the 87 papers, 69 (79%) applied unique /distinctive modelling approaches. Expert commentary: This wide range of approaches suggests the need to develop recommendations /minimal requirements for model-based HEA of obesity. In order to reach this long-term goal, further research is required. Valuable future research steps would be to investigate the predictiveness, validity and quality of the identified modelling approaches.

Effectiveness and cost-effectiveness of erlotinib versus gefitinib in first-line treatment of epidermal growth factor receptor-activating mutation-positive non-small-cell lung cancer patients in Hong Kong.

OBJECTIVE: To compare the effectiveness and cost-effectiveness of erlotinib versus gefitinib as first-line treatment of epidermal growth factor receptor-activating mutation-positive non-small-cell lung cancer patients. DESIGN. Indirect treatment comparison and a cost-effectiveness assessment. SETTING: Hong Kong. PATIENTS: Those having epidermal growth factor receptor-activating mutation-positive non-small-cell lung cancer. INTERVENTIONS: Erlotinib versus gefitinib use was compared on the basis of four relevant Asian phase-III randomised controlled trials: one for erlotinib (OPTIMAL) and three for gefitinib (IPASS; NEJGSG; WJTOG). The cost-effectiveness assessment model simulates the transition between the health states: progression-free survival, progression, and death over a lifetime horizon. The World Health Organization criterion (incremental cost-effectiveness ratio <3 times of gross domestic product/capita:

Early health economic evaluation of the future potential of next generation artificial vision systems for treating blindness in Germany.

The next generation of artificial vision devices (AVDs), which is currently developed in pre-clinical settings, has the potential to improve the vision of blind patients with retinitis pigmentosa (RP) in a manner that they will be categorized as visual impaired but no more as blind. This unprecedented vision improvement will result in a mentionable quality of life gain which poses the question at which costs the next generation AVDs are to be regarded as cost-effective, from a German healthcare payer perspective. In order to answer this research question a Markov model was developed to simulate and to compare the costs and effects of next generation AVDs versus best supportive care (BSC). Applying the base case settings resulted in incremental costs of 107,925, in 2.03 incremental quality-adjusted life years (QALYs) and in a cost-effectiveness ratio of 53,165 per QALY gained. Probabilistic and deterministic sensitivity analyses as well as scenario analyses for the effect size and the AVD costs were performed in order to investigate the robustness of results. In these scenario analyses a strong variation of the cost-effectiveness results was obtained ranging from 23,512 (best case) to 176,958 (worst case) per QALY gained by AVD therapy. This early health economic evaluation has to handle with three main uncertainty factors: the effect size of next generation AVDs, the costs of next generation AVDs and the WTP threshold that might be applied in RP patients, which reflect the main limitations of the presented assessment. In conclusion the presented early cost-effectiveness evaluation has obtained that next generation AVDs have the potential to be a cost-effective therapy option in patients with RP in Germany. The innovative nature, the high unmet medical need and the expected unprecedented efficacy of next generation AVDs will highly likely lead to the case that even relatively high incremental cost-effectiveness ratios, that have been obtained when simulating various effect and pricing scenarios, will be regarded as acceptable from a German healthcare payer perspective.

Cost comparison of second-line treatment options for late stage non-small-cell lung cancer: cost analysis for Italy.

BACKGROUND: Lung cancer is the leading cause of cancer deaths worldwide (1.38 million cancer deaths, 18.2% of the total) and of cancer morbidity (1.61 million new cases, 12.7% of all new cancers). Currently only three second-line non-small-cell lung cancer (NSCLC) pharmacotherapies are licensed in the European Union: the chemotherapies pemetrexed and docetaxel and the epidermal growth factor receptor tyrosine kinase inhibitor erlotinib. These therapy alternatives have shown a comparable efficacy (survival benefit). In the past, cost comparisons showed that erlotinib was less costly compared to docetaxel, which in turn is cheaper than pemetrexed. Nowadays erlotinib (and docetaxel) are still less expensive than pemetrexed; but docetaxel lost patent protection (basic compound patent) at the end of 2010, so docetaxel drug costs have decreased rapidly and the question remains whether erlotinib is still the least costly therapy alternative in second-line NSCLC. MATERIAL AND METHODS: Italy was selected for base case analysis to compare the total therapy costs, estimated by combining country-specific drug costs, administration costs, and adverse event costs of erlotinib and generic docetaxel in second-line NSCLC therapy. Sensitivity analyses on central input parameters have been performed. RESULTS: The total costs of treating one patient with erlotinib therapy of €5121 are lower than the docetaxel costs of €6699 for the Italian health care setting. Although the drug costs of erlotinib are higher than generic docetaxel (incremental €3770): the costs of intravenous chemotherapy administration (incremental -€4510), and the costs of adverse event therapy (incremental -€837) lead to higher total therapy costs for docetaxel compared to the epidermal growth factor receptor tyrosine kinase inhibitor therapy erlotinib. CONCLUSION: The cost comparison findings for Italy show that erlotinib is still the less costly therapy alternative in second-line NSCLC. These results were robust to changes of central input parameters and robust to further potential price decreases for docetaxel.