Assessing Telemental Health Uptake and Associated Health Care Resource Implications among Mississippi Medicaid Enrollees with Major Depression.

Objective: Investigate the association between Telemental Health (TMH) uptake and sociodemographic characteristics, and how TMH uptake relates to health care resource utilization and Medicaid expenditures among Mississippi Medicaid enrollees with major depression. Methods: A retrospective cohort study was conducted (2019-2020), comparing those who utilized TMH and those who did not. Results: Among the 21,239 identified enrollees, 806 (3.79%) utilized TMH. The TMH cohort was more likely to be of older age, non-Hispanic White, comprehensive managed care organization enrollees, rural residents, and from areas with a higher area deprivation index, and have higher Charlson comorbidity index scores. The TMH cohort also exhibited higher mental health-related and all-cause outpatient and emergency department utilization, along with higher Medicaid expenditures. Conclusion: As the first study investigating telehealth utilization among Mississippi Medicaid enrollees, this study highlights sociodemographic disparities in telehealth adoption. Addressing barriers hindering telehealth adoption among vulnerable populations and ensuring the availability of quality data are vital for future research.

Feasibility of Remote Blood Pressure Monitoring for Detection and Management of Maternal Hypertension in a predominantly Black, Rural and Medicaid Population in Mississippi.

Background: Remote patient monitoring (RPM) has potential in hypertension management, but limited studies have focused on maternal hypertension, especially among vulnerable populations. The objective of this study was to integrate RPM into perinatal care for pregnant patients at elevated risk of hypertensive disorders to show feasibility, acceptability, and safety. Methods: A prospective pilot cohort study was conducted at the University of Mississippi Medical Center 2021-2023. Participants' blood pressure readings were remotely captured and monitored until 8-week postpartum, with timely assessment and intervention. Results: Out of 98 enrollees, 77 utilized RPM, and no maternal or neonatal deaths occurred within 60-day postpartum. High program satisfaction was reported at discharge. Conclusion: This study demonstrates the feasibility and acceptability of RPM for perinatal care in a vulnerable population. Positive outcomes were observed, including high patient satisfaction and no maternal or neonatal deaths. Further research should address patient engagement barriers and develop tailored protocols for improved clinical outcomes.

Telehealth Evaluation in the United States: Protocol for a Scoping Review.

BACKGROUND: The rapid expansion of telehealth services, driven by the COVID-19 pandemic, necessitates systematic evaluation to guarantee the quality, effectiveness, and cost-effectiveness of telehealth services and programs in the United States. While numerous evaluation frameworks have emerged, crafted by various stakeholders, their comprehensiveness is limited, and the overall state of telehealth evaluation remains unclear. OBJECTIVE: The overarching goal of this scoping review is to create a comprehensive overview of telehealth evaluation, incorporating perspectives from multiple stakeholder categories. Specifically, we aim to (1) map the existing landscape of telehealth evaluation, (2) identify key concepts for evaluation, (3) synthesize existing evaluation frameworks, and (4) identify measurements and assessments considered in the United States. METHODS: We will conduct this scoping review in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). This scoping review will consider documents, including reviews, reports, and white papers, published since January 1, 2019. It will focus on evaluation frameworks and associated measurements of telehealth services and programs in the US health care system, developed by telehealth stakeholders, professional organizations, and authoritative sources, excluding those developed by individual researchers, to collect data that reflect the collective expertise and consensus of experts within the respective professional group. RESULTS: The data extracted from selected documents will be synthesized using tools such as tables and figures. Visual aids like Venn diagrams will be used to illustrate the relationships between the evaluation frameworks from various sources. A narrative summary will be crafted to further describe how the results align with the review objectives, facilitating a comprehensive overview of the findings. This scoping review is expected to conclude by August 2024. CONCLUSIONS: By addressing critical gaps in telehealth evaluation, this scoping review protocol lays the foundation for a comprehensive and multistakeholder assessment of telehealth services and programs. Its findings will inform policy makers, health care providers, researchers, and other stakeholders in advancing the quality, effectiveness, and cost-effectiveness of telehealth in the US health care system. TRIAL REGISTRATION: OSF Registries osf.io/aytus; https://osf.io/aytus. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55209.

Economic evaluation and costs of remote patient monitoring for cardiovascular disease in the United States: a systematic review.

BACKGROUND: Remote patient monitoring (RPM) has emerged as a viable and valuable care delivery method to improve chronic disease management. In light of the high prevalence and substantial economic burden of cardiovascular disease (CVD), this systematic review examines the cost and cost-effectiveness of using RPM to manage CVD in the United States. METHODS: We systematically searched databases to identify potentially relevant research. Findings were synthesized for cost and cost-effectiveness by economic study type with consideration of study perspective, intervention, clinical outcome, and time horizon. The methodological quality was assessed using the Joanna Briggs Institute Checklist for Economic Evaluations. RESULTS: Thirteen articles with fourteen studies published between 2011 and 2021 were included in the final review. Studies from the provider perspective with a narrow scope of cost components identified higher costs and similar effectiveness for the RPM group relative to the usual care group. However, studies from payer and healthcare sector perspectives indicate better clinical effectiveness of RPM relative to usual care, with two cost-utility analysis studies suggesting that RPM relative to usual care is a cost-effective tool for CVD management even at the conservative $50,000 per Quality-Adjusted Life-Year threshold. Additionally, all model-based studies revealed that RPM is cost-effective in the long run. CONCLUSIONS: Full economic evaluations identified RPM as a potentially cost-effective tool, particularly for long-term CVD management. In addition to the current literature, rigorous economic analysis with a broader perspective is needed in evaluating the value and economic sustainability of RPM.

Palliative Care Consultation in the Intensive Care Unit Reduces Hospital Costs: A Cost-Analysis.

BACKGROUND: Palliative care aims to improve or maintain quality of life for patients with life-limiting or life-threatening diseases. Limited research shows that palliative care is associated with reduced intensive care unit length of stay and use of high-cost resources. METHODS: This was an observational, non-experimental comparison group study on all patients 18 years or older admitted to any intensive care unit (ICU) at Memorial Hermann - Texas Medical Center for 7 to 30 days from August 2013 to December 2015. Length of stay (LOS) and hospital costs were compared between the treatment group of patients with palliative care in the ICU and the control group of patients with usual care in the ICU. To adjust for confounding of the palliative care consultation on LOS and hospital cost, an inverse probability of treatment weighted method was conducted. Generalized linear models using gamma distribution and log link were estimated. All costs were converted to 2015 US dollars. RESULTS: Mean LOS was 13 days and mean total hospital costs were USD 58,378. In adjusted and weighted analysis, LOS for the treatment group was 8% longer compared to the control group. The mean total hospital cost was estimated to decrease by 21% for the treatment group versus the control group. We found a reduction of USD 33,783 in hospital costs per patient who died in the hospital and reduction of USD 9113 per patient discharged alive. CONCLUSION: Palliative care consultation was associated with a reduction in the total cost of hospital care for patients with life-limiting or life-threatening diseases.

Analysis of Suicide After Cancer Diagnosis by US County-Level Income and Rural vs Urban Designation, 2000-2016.

Importance: Studies suggest the risk of suicide among people with cancer diagnosis is higher compared with the general population. However, little is known about how suicide risk among people diagnosed with cancer might vary according to area-level income and rurality. Objective: To examine whether the risks and patterns of suicide mortality among people with a cancer diagnosis differ by US county-level median income and rural or urban status. Design, Setting, and Participants: A retrospective, population-based cohort study following up individuals who were diagnosed with cancer between January 1, 2000, and December 31, 2016, was conducted. The Surveillance, Epidemiology, and End Results Program 18 registries (SEER 18) database was used to obtain data on persons diagnosed with a first primary malignant tumor. Comparisons with the general US population were based on mortality data collected by the National Center for Health Statistics. Analyses were conducted from February 22 to October 14, 2020. Exposures: County-level median household income and urban or rural status. Main Outcomes and Measures: Standardized mortality ratios (SMRs) of suicide deaths and annual percentage changes (APCs) of SMRs. Results: The SEER 18 database included 5 362 782 persons with cancer diagnoses living in 635 counties. Most study participants were men (51.2%), White (72.2%), and older than 65 years (49.7%). Among them, 6357 persons died of suicide (SMR, 1.41; 95% CI, 1.38-1.44). People with cancer living in the lowest-income counties had a significantly higher risk (SMR, 1.94; 95% CI, 1.76-2.13) than those in the highest-income counties (SMR, 1.30; 95% CI, 1.26-1.34). Those living in rural counties also had significantly higher SMR than those in urban counties (SMR, 1.81; 95% CI, 1.70-1.92 vs SMR, 1.35; 95% CI, 1.32-1.39). For all county groups, the SMRs were the highest within the first year following cancer diagnosis. However, among people living in the lowest-income counties, the risk remained significantly high even after 10 or more years following cancer diagnosis (SMR, 1.83; 95% CI, 1.31-2.48). The comparative risk of suicide mortality within 1 year following cancer diagnosis significantly decreased over the years but then plateaued in the highest-income (2005-2015: APC, 2.03%; 95% CI, -0.97% to 5.13%), lowest-income (2010-2015: APC, 4.80%; 95% CI, -19.97% to 37.24%), and rural (2004-2015: APC, 1.83; 95% CI, -1.98% to 5.79%) counties. Conclusions and Relevance: This cohort study showed disparities in suicide risks and their patterns among people diagnosed with cancer by county-level income and rural or urban status. The findings suggest that additional research and effort to provide psychological services addressing these disparities among people with cancer may be beneficial.

Cost-utility analysis of treatment options after initial tumor necrosis factor inhibitor therapy discontinuation in patients with rheumatoid arthritis.

BACKGROUND: For patients with rheumatoid arthritis (RA) who discontinued initial treatment with tumor necrosis factor inhibitor (TNFi), 2 approaches are commonly used: cycling to another TNFi or switching to a drug with another mechanism of action. Currently, there is no consensus on which approach to use first. A report from the IBM MarketScan Research administrative claims database showed adalimumab (cycling strategy) and abatacept (switching strategy) were more commonly prescribed after the first TNFi discontinuation. OBJECTIVE: To evaluate the cost-utility of adalimumab versus abatacept in patients with RA whose initial TNFi therapy failed. METHODS: A probabilistic cost-utility microsimulation state-transition model was used. Our target population was commercially insured adults with RA, the time horizon was 10 years, and we used a payer perspective. Patients not responding to adalimumab or abatacept were moved to the next drug in a sequence of 3 and, finally, to conventional synthetic therapy. Incremental cost-utility ratios (2016 USD per quality-adjusted-life-year gained [QALY)] were calculated. Utilities were derived from a formula based on the Health Assessment Questionnaire Disability Index and age-adjusted comorbidity score. RESULTS: Switching to abatacept after the first TNFi showed an incremental cost of just more than $11,300 over 10 years and achieved a QALY benefit of 0.16 compared with adalimumab. The incremental cost-effectiveness ratio was $68,950 per QALY. Scenario analysis produced an incremental cost-effectiveness ratio range of $44,573 per QALY to $148,558 per QALY. Probabilistic sensitivity analysis showed that switching to abatacept after TNFi therapy failure had an 80.6% likelihood of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY. CONCLUSIONS: Switching to abatacept is a cost-effective strategy for patients with RA whose discontinue initial therapy with TNFi. DISCLOSURES: Funding for this project was provided by a Rheumatology Research Foundation Investigator Award (principal investigator: Maria A. Lopez-Olivo). Karpes Matusevich's work was supported by a Doctoral Dissertation Research Award from the University of Texas, School of Public Health Office of Research. Lal reports competing interests outside of the submitted work (employed by Optum). Suarez-Almazor reports competing interests outside of the submitted work (consulting fees from Pfizer, AbbVie, Eli Lilly, Agile Therapeutics, Amag Pharmaceuticals, and Gilead). Chan, Swint, and Cantor have nothing to disclose.

Treatment Sequences After Discontinuing a Tumor Necrosis Factor Inhibitor in Patients With Rheumatoid Arthritis: A Comparison of Cycling Versus Swapping Strategies.

OBJECTIVE: To evaluate the sequences of tumor necrosis factor inhibitors (TNFi) and non-TNFi used by rheumatoid arthritis (RA) patients whose initial TNFi therapy has failed, and to evaluate effectiveness and costs. METHODS: Using the Truven Health MarketScan Research database, we analyzed claims of commercially insured adult patients with RA who switched to their second biologic or targeted disease-modifying antirheumatic drug between January 2008 and December 2015. Our primary outcome was the frequency of treatment sequences. Our secondary outcomes were the time to therapy discontinuation, drug adherence, and drug and other health care costs. RESULTS: Among 10,442 RA patients identified, 36.5% swapped to a non-TNFi drug, most commonly abatacept (54.2%). The remaining 63.5% cycled to a second TNFi, most commonly adalimumab (41.2%). For subsequent switches of therapy, non-TNFi were more common. Patients who swapped to a non-TNFi were significantly older and had more comorbidities than those who cycled to a TNFi (P < 0.001). Survival analysis showed a longer time to discontinuation for non-TNFi than for TNFi (median 605 days compared with 489 days; P < 0.001) when used after initial TNFi discontinuation, but no difference in subsequent switches of therapy. Although non-TNFi were less expensive for adherent patients, cycling to a TNFi was associated with lower costs overall. CONCLUSION: Even though patients are more likely to cycle to a second TNFi than swap to a non-TNFi, those who swap to a non-TNFi are more likely to persist with the therapy. However, cycling to a TNFi is the less costly strategy.

The evaluation of comprehensive medication management for chronic diseases in primary care clinics, a Texas delivery system reform incentive payment program.

BACKGROUND: The Institute of Medicine reported that more than 1.5 million preventable adverse drug events occur annually in the United States. Comprehensive Medication Management (CMM) is the medication review process to improve clinical outcomes, enhance patient adherence, reduce drug therapy problems and reduce health care costs. University of Texas (UT) Physicians implemented a CMM program in several community-based clinics. We evaluated the effectiveness of CMM to reduce drug therapy problems and achieve medical cost savings. METHODS: This was a retrospective, observational study of CMM participants from October 2015 to September 2016. Program participants included patients aged 18 years or older who had taken more than 4 prescribed medications and were diagnosed with at least one of the following chronic diseases: hypertension, congestive heart failure, chronic obstructive pulmonary disease, asthma or diabetes. Under the CMM program, a clinical pharmacist reviewed patients' electronic health records and created action plans to resolve identified drug problems. As part of the evaluation of the clinical process, two independent physicians conducted peer review on the recommendations issued by the pharmacist in order to establish inter-rater reliability of drug therapy problems and potential consequent medical services. The drug therapy problems were identified and classified into four categories: indication, effectiveness, safety and/or compliance. The average cost of avoided medical services was obtained based on cost extrapolations from the literature, combined with hospital discharge data. Potential medical services avoided were linked to the average cost of those services to calculate the total cost savings of the program from the payers' perspective. RESULTS: By reviewing electronic health records of 3280 patients, the pharmacist identified 301 drug therapy problems and resolved 49.8% of these problems with collaboration from the patient's primary care physician or care team. The most commonly identified drug problems were related to potentially adverse drug reactions or inappropriate drug dosage. The CMM program resulted in potential cost savings of $1,143,015. CONCLUSIONS: The CMM program resolved medication therapy problems among program participants and achieved significant health care cost savings.

Systematic Review of Economic Evaluations of Cycling Versus Swapping Medications in Patients With Rheumatoid Arthritis After Failure to Respond to Tumor Necrosis Factor Inhibitors.

OBJECTIVE: To systematically review the modeling approaches and quality of economic analyses comparing cycling tumor necrosis factor inhibitors (TNFi) to swapping to a therapy with a different mode of action in patients with rheumatoid arthritis whose initial TNFi failed. METHODS: We searched electronic databases, gray literature, and references of included publications until July 2017. Two reviewers independently screened citations. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Data regarding modeling methodology were extracted. RESULTS: We included 7 articles comprising 19 comparisons. Three studies scored ≥16 of 24 on the CHEERS checklist. Most models used a lifetime horizon, took a payer perspective, employed a 6-month cycle length, and measured treatment efficacy in terms of the American College of Rheumatology improvement criteria. We noted possible sources of bias in terms of transparency and study sponsorship. In the cost-utility comparisons, the median incremental cost-effectiveness ratio was US $70,332 per quality-adjusted life-year for swapping versus cycling strategies. Rituximab was more effective and less expensive than TNFi in 7 of 11 comparisons. Abatacept (intravenous) compared to TNFi was less cost-effective than rituximab. Common influential parameters in sensitivity analyses were the rituximab dosing schedule, assumptions regarding disease progression, and the estimation of utilities. CONCLUSION: Differences in the design, key assumptions, and model structure chosen had a major impact on the individual study conclusions. Despite the existence of multiple reporting standards, there continues to be a need for more uniformity in the methodology reported in economic evaluations of cycling versus swapping strategies after TNFi in patients with rheumatoid arthritis.

Clinical Application of Genome and Exome Sequencing as a Diagnostic Tool for Pediatric Patients: a Scoping Review of the Literature.

PURPOSE: Availability of clinical genomic sequencing (CGS) has generated questions about the value of genome and exome sequencing as a diagnostic tool. Analysis of reported CGS application can inform uptake and direct further research. This scoping literature review aims to synthesize evidence on the clinical and economic impact of CGS. METHODS: PubMed, Embase, and Cochrane were searched for peer-reviewed articles published between 2009 and 2017 on diagnostic CGS for infant and pediatric patients. Articles were classified according to sample size and whether economic evaluation was a primary research objective. Data on patient characteristics, clinical setting, and outcomes were extracted and narratively synthesized. RESULTS: Of 171 included articles, 131 were case reports, 40 were aggregate analyses, and 4 had a primary economic evaluation aim. Diagnostic yield was the only consistently reported outcome. Median diagnostic yield in aggregate analyses was 33.2% but varied by broad clinical categories and test type. CONCLUSION: Reported CGS use has rapidly increased and spans diverse clinical settings and patient phenotypes. Economic evaluations support the cost-saving potential of diagnostic CGS. Multidisciplinary implementation research, including more robust outcome measurement and economic evaluation, is needed to demonstrate clinical utility and cost-effectiveness of CGS.

Long-term economic value of hypofractionated prostate radiation: Secondary analysis of a randomized trial.

PURPOSE: Moderately hypofractionated intensity modulated radiation therapy (HIMRT) for prostate cancer shortens the treatment course while providing outcomes comparable with those of conventional intensity modulated radiation therapy (CIMRT). To determine the long-term economic value of HIMRT, including the costs of managing long-term radiation toxicities, a cost minimization analysis compared CIMRT with dose-escalated HIMRT using patient-level data from a randomized trial. METHODS AND MATERIALS: Men with localized prostate cancer were randomized to CIMRT (75.6 Gy in 42 fractions over 8.4 weeks) or HIMRT (72 Gy in 30 fractions over 6 weeks). A decision tree modeled trial probabilities of maximum late bowel and urinary toxicities using patient-level data with a median follow-up of 6 years. Costs were estimated from the healthcare perspective using the 2014 national reimbursement rates for services received. Patient-level institutional costs, adjusted to 2014 dollars, verified reimbursements. A sensitivity analysis assessed model uncertainty. RESULTS: The cost for HIMRT and toxicity management was $22,957, saving $7,000 compared with CIMRT ($30,241). CIMRT was the common factor among the 5 most influential scenarios that contributed to total costs. Toxicity represented a small part (<10%) of the average total cost for patients with either grade 2-3 bowel toxicity or grade 2-3 urinary toxicity. However, toxicity management reached up to 26% of the total cost for patients with both high-grade bowel and urinary toxicities. There was no threshold at which CIMRT became the less costly regimen. Institutional costs confirmed the economic value of HIMRT ($6,000 in savings). CONCLUSIONS: HIMRT is more cost-efficient than CIMRT for treating prostate cancer, even when taking into account the costs related to late radiation toxicities. HIMRT enhances the value of prostate radiation when compared with CIMRT.

Cost-effectiveness Analysis Comparing Conventional, Hypofractionated, and Intraoperative Radiotherapy for Early-Stage Breast Cancer.

Background: Early-stage breast cancer is among the most prevalent and costly malignancies treated in the American health care system. Adjuvant radiotherapy after lumpectomy represents a substantial portion of breast cancer expenditures. The relative value of novel radiotherapeutic approaches such as intraoperative radiotherapy (IORT) and hypofractionated whole breast irradiation (HF-WBI) compared with conventionally fractionated whole breast irradiation (CF-WBI) is unknown. Therefore, we used prospectively collected outcomes from randomized clinical trials (RCTs) to compare the cost-effectiveness of these approaches. Methods: We constructed a decision-analytic model that followed women who were treated with lumpectomy for early-stage breast cancer. Recurrence, mortality, complication rates, and utilities (five-year radiation-associated quality of life scores), were extracted from RCTs. Costs were based on Medicare reimbursement rates. Cost-effectiveness from societal and health care sector perspectives was estimated considering two scenarios-the first assumes that radiation-associated disutility persists five years after treatment, and the second assumes that disutility discontinues. Lifetime outcomes were summarized using incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses evaluated the robustness of the results. Results: HF-WBI dominated CF-WBI (ie, resulted in higher quality-adjusted life-years [QALYs] and lower cost) in all scenarios. HF-WBI also had a greater likelihood of cost-effectiveness compared with IORT; under a societal perspective that assumes that radiation-associated disutility persists, HF-WBI results in an ICER of $17 024 per QALY compared with IORT with a probability of cost-effectiveness of 80% at the $100 000 per QALY willingness-to-pay threshold. If radiation-associated disutility is assumed to discontinue, the ICER is lower ($11 461/QALY), resulting in an even higher (83%) probability of relative cost-effectiveness. The ICER was most sensitive to the probability of metastasis and treatment cost. Conclusions: For women with early-stage breast cancer requiring adjuvant radiotherapy, HF-WBI is cost-effective compared with CF-WBI and IORT.

Post-GAVI sustainability of the Haemophilus influenzae type b vaccine program: The potential role of economic evaluation.

Haemophilus influenzae type b (Hib) can cause severe invasive diseases which are, however, preventable by vaccination. To increase access to Hib vaccine, GAVI - the Vaccine Alliance - has provided financial support for 73 lower income countries worldwide. At the same time, GAVI has been implementing its co-financing policy, requiring recipient countries to pay a portion of vaccine costs and to increase this amount over time. Starting in 2016, 5 countries will stop receiving GAVI funding and procure the vaccine themselves. Although the graduating countries have access to the UNICEF/GAVI tendered vaccine price for 5 more years, the uncertainty in market vaccine price may hamper the post-GAVI program sustainability. A possible increase in vaccine price would cause a significant burden on governmental budgets, discouraging countries to continue the program. As a special tool, economic evaluation (EE) can assist decision makers by identifying the maximum affordable vaccine price for countries to pay. Given that only 6 GAVI-eligible countries have such analyses published, more EEs are necessary to strengthen countries' commitment during this transition period. The information will also be useful for manufacturers to determine their pricing policy.

Primary Care Availability, Safety Net Clinics, and Health Insurance Coverage: The Association of These Access Factors With Preventable Hospitalizations.

The objective of the study was to examine the relationship between physician/safety net availability and health insurance coverage and preventable hospitalizations (PHs) in nonelderly adults in an urban area. Preventable conditions (PHs) were identified for nonelderly adults in Harris County using the Texas Health Care Information Collection hospital database. Multivariable logistic regression models examined the association of health insurance and patient proximity to physicians and safety net clinics with the risk of a PH. Safety net availability reduced PH risk by 23% (P < .05) but only among the uninsured. Lack of health insurance increased PH risk by 30% (P < .05).

Cost-effectiveness of Haemophilus influenzae type b vaccine in Vietnam.

BACKGROUND: With GAVI support, Vietnam introduced Haemophilus influenzae type b (Hib) vaccine in 2010 without evidence on cost-effectiveness. We aimed to analyze the cost-effectiveness of Hib vaccine from societal and governmental perspectives. METHOD: We constructed a decision-tree cohort model to estimate the costs and effectiveness of Hib vaccine versus no Hib vaccine for the 2011 birth cohort. The disease burden was estimated from local epidemiologic data and literature. Vaccine delivery costs were calculated from governmental reports and 2013 vaccine prices. A prospective cost-of-illness study was conducted to estimate treatment costs. The human capital approach was employed to estimate productivity loss. The incremental costs of Hib vaccine were divided by cases, deaths, and disability-adjusted life years (DALY) averted. We used the WHO recommended cost-effectiveness thresholds of an intervention being highly cost-effective if incremental costs per DALY were below GDP per capita. RESULT: From the societal perspective, incremental costs per discounted case, death and DALY averted were US$ 6252, US$ 26,476 and US$ 1231, respectively; the break-even vaccine price was US$ 0.69/dose. From the governmental perspective, the results were US$ 6954, US$ 29,449, and US$ 1373, respectively; the break-even vaccine price was US$ 0.48/dose. Vietnam's GDP per capita was US$ 1911 in 2013. In deterministic sensitivity analysis, morbidity and mortality parameters were among the most influential factors. In probabilistic sensitivity analysis, Hib vaccine had an 84% and 78% probability to be highly cost-effective from the societal and governmental perspectives, respectively. CONCLUSION: Hib vaccine was highly cost-effective from both societal and governmental perspectives. However, with GAVI support ending in 2016, the government will face a six-fold increase in its vaccine budget at the 2013 vaccine price. The variability of vaccine market prices adds an element of uncertainty. Increased government commitment and improved resource allocation decision making will be necessary to retain Hib vaccine.

Revisiting the economic efficiencies of observation units.

BACKGROUND: Recent studies cast doubt about the economic efficiency of observation units (OUs). OBJECTIVE: We aimed to reexamine the cost savings of OUs compared with inpatient care. METHODS: Claims for 15,851 patients who were admitted to inpatient or OUs between January 2009 and December 2012 following emergency room (ER) visits for chest pain were retrospectively examined. The two groups were compared for total cost of episode, length of stay (LOS), and utilization rates of diagnostic procedures, including standard exercise and echocardiography stress tests, myocardial perfusion imaging (MPI), coronary computed tomography angiography (CCTA), and computed tomography (CT) chest scans. Total costs of care and LOS were adjusted for age, gender, risk scores, and comorbidities using quantile regression. RESULTS: More than 37% of the sample was admitted to inpatient units (n = 5,890) vs 62.7% to OUs (n = 9,961). Patients admitted to inpatient units had more comorbidities and longer LOS during their ER visit (median 1.5 adjusted days; 10th percentile = 1, 90th percentile = 3) vs. median 21 adjusted hours for OUs (20, 23). The adjusted median cost of OUs was $5,411 ($4,652, $7,157) vs. $6,946 for inpatient admission ($5,978, $18,683). The estimated adjusted cost saving of OUs was $1,535 (95% CI = $1,206, $1,411) compared with inpatient admission. About 37% of patients admitted to OUs stayed longer than 24 hours. Compared with patients admitted to inpatient units, patients in OUs also received more MPI (35.8% vs. 31.5%), CT scans (13.2% vs. 10.4%), standard exercise test (45.6% vs. 33.8%) and echocardiography stress test (8% vs. 3.4%). CONCLUSION: Despite the increased proportion of patients exceeding the 24-hour LOS and the increased utilization of advanced imaging procedures, OUs are still less costly compared with inpatient admission.

Algorithm for analysis of administrative pediatric cancer hospitalization data according to indication for admission.

BACKGROUND: Childhood cancer relies heavily on inpatient hospital services to deliver tumor-directed therapy and manage toxicities. Hospitalizations have increased over the past decade, though not uniformly across childhood cancer diagnoses. Analysis of the reasons for admission of children with cancer could enhance comparison of resource use between cancers, and allow clinical practice data to be interpreted more readily. Such comparisons using nationwide data sources are difficult because of numerous subdivisions in the International Classification of Diseases Clinical Modification (ICD-9) system and inherent complexities of treatments. This study aimed to develop a systematic approach to classifying cancer-related admissions in administrative data into categories that reflected clinical practice and predicted resource use. METHODS: We developed a multistep algorithm to stratify indications for childhood cancer admissions in the Kids Inpatient Databases from 2003, 2006 and 2009 into clinically meaningful categories. This algorithm assumed that primary discharge diagnoses of cancer or cytopenia were insufficient, and relied on procedure codes and secondary diagnoses in these scenarios. Clinical Classification Software developed by the Healthcare Cost and Utilization Project was first used to sort thousands of ICD-9 codes into 5 mutually exclusive diagnosis categories and 3 mutually exclusive procedure categories, and validation was performed by comparison with the ICD-9 codes in the final admission indication. Mean cost, length of stay, and costs per day were compared between categories of indication for admission. RESULTS: A cohort of 202,995 cancer-related admissions was grouped into four categories of indication for admission: chemotherapy (N=77,791, 38%), to undergo a procedure (N=30,858, 15%), treatment for infection (N=30,380, 15%), or treatment for other toxicities (N=43,408, 21.4%). The positive predictive value for the algorithm was >95% for each category. Admissions for procedures had higher mean hospital costs, longer hospital stays, and higher costs per day compared with other admission reasons (p<0.001). CONCLUSIONS: This is the first description of a method for grouping indications for childhood cancer admission within an administrative dataset into clinically relevant categories. This algorithm provides a framework for more detailed analyses of pediatric hospitalization data by cancer type.

Cost minimization analysis of two treatment regimens for low-risk rhabdomyosarcoma in children: a report from the Children's Oncology Group.

BACKGROUND: Recent Children's Oncology Group trials for low-risk rhabdomyosarcoma attempted to reduce therapy while maintaining excellent outcomes. D9602 delivered 45 weeks of outpatient vincristine and dactinomycin (VA) for patients in Subgroup A. ARST0331 reduced the duration of therapy to 22 weeks but added four doses of cyclophosphamide to VA for patients in Subset 1. Failure-free survival was similar. We undertook a cost minimization comparison to help guide future decision-making. PROCEDURE: Addressing the costs of treatment from the healthcare perspective we modeled a simple decision-analytic model from aggregate clinical trial data. Medical care inputs and probabilities were estimated from trial reports and focused chart review. Costs of radiation, surgery and off-therapy surveillance were excluded. Unit costs were obtained from literature and national reimbursement and inpatient utilization databases and converted to 2012 US dollars. Model uncertainty was assessed with first-order sensitivity analysis. RESULTS: Direct medical costs were $46,393 for D9602 and $43,261 for ARST0331 respectively, making ARST0331 the less costly strategy. Dactinomycin contributed the most to D9602 total costs but varied with age (42-69%). Chemotherapy administration costs accounted for the largest proportion of ARST0331 total costs (39-57%). ARST0331 incurred fewer costs than D9602 under most alternative distributive models and alternative clinical practice assumptions. CONCLUSIONS: Cost analysis suggests that ARST0331 may incur fewer costs than D9602 from the healthcare system's perspective. Attention to the services driving the costs provides directions for future efficiency improvements. Future studies should prospectively consider the patient and family's perspective.

Cost analysis of PET and comprehensive lifestyle modification for the reversal of atherosclerosis.

UNLABELLED: We present a preliminary cost analysis of a combination intervention using PET and comprehensive lifestyle modification to reverse atherosclerosis. With a sensitivity of 92%-95% and specificity of 85%-95%, PET is an essential tool for high-precision diagnosis of coronary artery disease, accurately guiding optimal treatment for both symptomatic and asymptomatic patients. PET imaging provides a powerful visual and educational aid for helping patients identify and adopt appropriate treatments. However, little is known about the operational cost of using the technology for this purpose. METHODS: The analysis was done in the context of the Century Health Study for Cardiovascular Medicine (Century Trial), a 1,300-patient, randomized study combining PET imaging with lifestyle changes. Our methodology included a microcosting and time study focusing on estimating average direct and indirect costs. RESULTS: The total cost of the Century Trial in present-value terms is $9.2 million, which is equal to $7,058 per patient. Sensitivity analysis indicates that the present value of total costs is likely to range between $8.8 and $9.7 million, which is equivalent to $6,655-$7,606 per patient. CONCLUSION: The clinical relevance of the Century Trial is significant since it is, to our knowledge, the first randomized controlled trial to combine high-precision imaging with lifestyle strategies. The Century Trial is in its second year of a 5-y protocol, and we present preliminary findings. The results of this cost study, however, provide policy makers with an early estimate of the costs of implementing, at large scale, a combined intervention such as the Century Trial. Further, we believe that imaging-guided lifestyle management may have considerable potential for improving outcomes and reducing health-care costs by eliminating unnecessary invasive procedures.