Costs of integrating cervical cancer screening at an HIV clinic in Kenya.

OBJECTIVE: To estimate the societal-level costs of integrating cervical cancer screening into HIV clinics in Nairobi, Kenya. METHODS: A cross-sectional micro-costing study was performed at Coptic Hope Center for Infectious Diseases and Kenyatta National Hospital, Kenya, between July 1 and October 31, 2014. To estimate direct medical, non-medical, and indirect costs associated with screening, a time-and-motion study was performed, and semi-structured interviews were conducted with women aged at least 18 years attending the clinic for screening during the study period and with clinic staff who had experience relevant to cervical cancer screening. RESULTS: There were 148 patients and 23 clinic staff who participated in interviews. Visual inspection with acetic acid was associated with the lowest estimated marginal per-screening costs ($3.30), followed by careHPV ($18.28), Papanicolaou ($24.59), and Hybrid Capture 2 screening ($31.15). Laboratory expenses were the main cost drivers for Papanicolaou and Hybrid Capture 2 testing ($11.61 and $16.41, respectively). Overhead and patient transportation affected the costs of all methods. Indirect costs were cheaper for single-visit screening methods ($0.43 per screening) than two-visit screening methods ($2.88 per screening). CONCLUSIONS: Integrating cervical cancer screening into HIV clinics would be cost-saving from a societal perspective compared with non-integrated screening. These findings could be used in cost-effectiveness analyses to assess incremental costs per clinical outcome in an integrated setting.

The clinical and cost burden of coronary calcification in a Medicare cohort: An economic model to address under-reporting and misclassification.

BACKGROUND: Coronary artery calcification (CAC) is a well-established risk factor for the occurrence of adverse ischemic events. However, the economic impact of the presence of CAC is unknown. OBJECTIVES: Through an economic model analysis, we sought to estimate the incremental impact of CAC on medical care costs and patient mortality for de novo percutaneous coronary intervention (PCI) patients in the 2012 cohort of the Medicare elderly (≥65) population. METHODS: This aggregate burden-of-illness study is incidence-based, focusing on cost and survival outcomes for an annual Medicare cohort based on the recently introduced ICD9 code for CAC. The cost analysis uses a one-year horizon, and the survival analysis considers lost life years and their economic value. RESULTS: For calendar year 2012, an estimated 200,945 index (de novo) PCI procedures were performed in this cohort. An estimated 16,000 Medicare beneficiaries (7.9%) were projected to have had severe CAC, generating an additional cost in the first year following their PCI of $3500, on average, or $56 million in total. In terms of mortality, the model projects that an additional 397 deaths would be attributable to severe CAC in 2012, resulting in 3770 lost life years, representing an estimated loss of about $377 million, when valuing lost life years at $100,000 each. CONCLUSIONS: These model-based CAC estimates, considering both moderate and severe CAC patients, suggest an annual burden of illness approaching $1.3 billion in this PCI cohort. The potential clinical and cost consequences of CAC warrant additional clinical and economic attention not only on PCI strategies for particular patients but also on reporting and coding to achieve better evidence-based decision-making.

How does use of a prescription monitoring program change pharmacy practice?

OBJECTIVES: To assess differences in prescription monitoring program (PMP) use between two states with different PMP accessibility (Connecticut [CT] and Rhode Island [RI]), to explore use of PMPs in pharmacy practice, and to examine associations between PMP use and pharmacists' responses to suspected diversion or "doctor shopping." DESIGN: Descriptive nonexperimental study. SETTING: CT and RI from March through August 2011. PARTICIPANTS: Licensed pharmacists in CT and RI. INTERVENTION: Anonymous surveys e-mailed to pharmacists MAIN OUTCOME MEASURES: PMP use, use of patient reports in pharmacy practice, and responses to suspected doctor shopping or diversion. RESULTS: Responses from 294 pharmacists were received (CT: 198; RI: 96). PMP users were more likely to use the PMP to detect drug abuse (CT: 79%; RI: 21.9%; P < 0.01) and doctor shopping (67%; 7%; P < 0.01). When faced with suspicious medication use behavior, PMP users were less likely than nonusers to discuss their concerns with the patient (adjusted odds ratio 0.48 [95% CI 0.25-0.92]) but as likely to contact the provider (0.86 [0.21-3.47]), refer the patient back to the prescriber (1.50 [0.79-2.86]), and refuse to fill the prescription (0.63 [0.30-1.30]). PMP users were less likely to state they were out of stock of the drug (0.27 [0.12-0.60]) compared with nonusers. Pharmacists reported high interest in attending continuing education on safe dispensing (72.8%). CONCLUSION: Pharmacists are important participants in the effort to address prescription drug misuse and abuse. Current PMP use with prevailing systems had limited influence on pharmacy practice. Findings point to future research and needed practice and education innovations to improve patient safety and safer opioid dispensing for pharmacists.

How does use of a prescription monitoring program change medical practice?

OBJECTIVES: The objectives of this study were to test for differences in prescription monitoring program (PMP) use between two states, Connecticut (CT) and Rhode Island (RI), with a different PMP accessibility; to explore use of PMP reports in clinical practice; and to examine associations between PMP use and clinician's responses to suspected diversion or "doctor shopping" (i.e., multiple prescriptions from multiple providers). DESIGN, SETTING, SUBJECTS: From March to August 2011, anonymous surveys were emailed to providers licensed to prescribe Schedule II medications in CT (N = 16,924) and RI (N = 5,567). OUTCOME MEASURES: PMP use, use of patient reports in clinical practice, responses to suspected doctor shopping, or diversion. RESULTS: Responses from 1,385 prescribers were received: 998 in CT and 375 in RI. PMP use was greater in CT, where an electronic PMP is available (43.9% vs 16.3%, χ(2) = 85.2, P < 0.0001). PMP patient reports were used to screen for drug abuse (36.2% CT vs 10.0% RI, χ(2) = 60.9, P < 0.0001) and detect doctor shopping (43.9% CT vs 18.5% RI, χ(2) = 68.3, P < 0.0001). Adjusting for potential confounders, responses by PMP users to suspicious medication use behavior were more likely to entail clinical response (i.e., refer to another provider odds ratio, OR, 1.75 [95% confidence interval, CI, 1.10, 2.80]; screen for drug abuse OR 1.93 [1.39, 2.68]; revisit pain/treatment agreement OR 1.97 [1.45, 2.67]; conduct urine screen OR 1.82 [1.29, 2.57]; refer to substance abuse treatment OR 1.30 [0.96, 1.75]) rather than legal intervention (OR 0.45 [0.21, 0.94]) or inaction (OR 0.09 [0.01, 0.70]). CONCLUSIONS: Prescribers' use of an electronic PMP may influence medical practice, especially opioid abuse detection, and is associated with clinical responses to suspected doctor shopping or diversion.

Life after the ban: an assessment of US syringe exchange programs' attitudes about and early experiences with federal funding.

OBJECTIVES: We aimed to determine whether syringe exchange programs (SEPs) currently receive or anticipate pursuing federal funding and barriers to funding applications following the recent removal of the long-standing ban on using federal funds for SEPs. METHODS: We conducted a telephone-administered cross-sectional survey of US SEPs. Descriptive statistics summarized responses; bivariate analyses examined differences in pursuing funding and experiencing barriers by program characteristics. RESULTS: Of the 187 SEPs (92.1%) that responded, 90.9% were legally authorized. Three received federal funds and 116 intended to pursue federal funding. Perceived federal funding barriers were common and included availability and accessibility of funds, legal requirements such as written police support, resource capacity to apply and comply with funding regulations, local political and structural organization, and concern around altering program culture. Programs without legal authorization, health department affiliation, large distribution, or comprehensive planning reported more federal funding barriers. CONCLUSIONS: Policy implementation gaps appear to render federal support primarily symbolic. In practice, funding opportunities may not be available to all SEPs. Increased technical assistance and legal reform could improve access to federal funds, especially for SEPs with smaller capacity and tenuous local support.