Spatial and Temporal Analysis of COVID-19 in the Elderly Living in Residential Care Homes in Portugal.

BACKGROUND: The goal of this study is to identify geographic areas for priority actions in order to control COVID-19 among the elderly living in Residential Care Homes (RCH). We also describe the evolution of COVID-19 in RHC throughout the 278 municipalities of continental Portugal between March and December 2020. METHODS: A spatial population analysis of positive COVID-19 cases reported by the Portuguese National Health Service (NHS) among the elderly living in RCH. The data are for COVID-19 testing, symptomatic status, comorbidities, and income level by municipalities. COVID-19 measures at the municipality level are the proportion of positive cases of elderly living in RCH, positive cases per elderly living in RCH, symptomatic to asymptomatic ratio, and the share of comorbidities cases. Spatial analysis used the Kernel density estimation (KDE), space-time statistic Scan, and geographic weighted regression (GWR) to detect and analyze clusters of infected elderly. RESULTS: Between 3 March and 31 December 2020, the high-risk primary cluster was located in the regions of Braganca, Guarda, Vila Real, and Viseu, in the Northwest of Portugal (relative risk = 3.67), between 30 September and 13 December 2020. The priority geographic areas for attention and intervention for elderly living in care homes are the regions in the Northeast of Portugal, and around the large cities, Lisbon and Porto, which had high risk clusters. The relative risk of infection was spatially not stationary and generally positively affected by both comorbidities and low-income. CONCLUSION: The regions with a population with high comorbidities and low income are a priority for action in order to control COVID-19 in the elderly living in RCH. The results suggest improving both income and health levels in the southwest of Portugal, in the environs of large cities, such as Lisbon and Porto, and in the northwest of Portugal to mitigate the spread of COVID-19.

On the timing and probability of Presurgical Teledermatology: how it becomes the dominant strategy.

Health level fluctuations make the outcome of any treatment option uncertain, so that decision-makers might have to wait for more information before optimally choosing treatments, especially when time spent in treatment cannot be fully recovered later in terms of health outcome. To examine whether or not, and when decision-makers should use presurgical teledermatology, a dynamic stochastic model is applied to patients waiting for dermatology surgical intervention. The theoretical model suggests that health uncertainty discourages using teledermatology. As teledermatology becomes less cost competitive, the uncertainty becomes more dominant. The results of the model were then tested empirically with the teledermatology network covering the area served by one Portuguese regional hospital, which links the primary care centers of 24 health districts with the hospital's dermatology department via the corporate intranet of the Portuguese healthcare system. Under uncertainty and irreversibility, presurgical teledermatology becomes the dominant strategy for younger patients and with lower probability of developing skin cancer.

Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity.

INTRODUCTION: Cancer chemotherapy increases the risk of heart failure. This cost-effectiveness study analyzes cardio-oncology imaging assessment of left ventricular ejection fraction (LVEF) using a Portuguese healthcare payer perspective and a five-year time horizon. METHODS: Two cardioprotective strategies were assessed: universal cardioprotection (UCP) for all patients and cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX). A Markov model, informed by the retrospective clinical course of breast cancer patients followed in a Portuguese public hospital, was developed to assess the cost-effectiveness of LVEF cardio-oncology imaging assessment. Data on transition probabilities, costs and utilities were retrieved from both the retrospective data and published literature to assess the cost-effectiveness of LVEF echocardiographic assessment. Costs and utilities of the cardioprotective strategies were assessed over a five-year range, using probabilistic sensitivity analyses. RESULTS: In the reference case of a 63-year-old breast cancer patient treated with cardioprotection initiated on diagnosis of EF-CTX, the five-year time horizon (4.22 QALYs and €2594 cost over five years) dominated UCP (3.42 QALYS and €3758 cost over five years). Under a time horizon of five years at a willingness-to-pay threshold of €22 986, over 65.7% of simulations provided additional QALYs. Monte Carlo simulation of the Markov model had no effect on the model's conclusions. CONCLUSION: In the Portuguese public healthcare system and under specific hypotheses, from a healthcare payer perspective, EF-CTX-guided cardioprotection for patients at risk of chemotherapy-related cardiotoxicity provides more QALYs at lower cost than UCP.

Patients' out-of-pocket expenses analysis of presurgical teledermatology.

BACKGROUND: This study undertakes an economic analysis of presurgical teledermatology from a patient perspective, comparing it with a conventional referral system. Store-and-forward teledermatology allows surgical planning, saving both time and number of visits involving travel, thereby reducing patients' out-of-pocket expenses, i.e. costs that patients incur when traveling to and from health providers for treatment, visits' fees, and opportunity cost of time spent in visits. to The study quantifies the opportunity costs and direct costs of visits for adults waiting for dermatology surgery. METHOD: This study uses a retrospective assessment of 123 patients. Patients' out-of-pocket expenses of presurgical teledermatology were analyzed in the setting of a public hospital over 2 years. The teledermatology network covering the area served by the Hospital Garcia da Horta, Portugal, linked the primary care centers of 24 health districts with the hospital's dermatology department. The patients' opportunity cost of visits and direct costs of visits (transport costs, and visits' fee) of each presurgical modality (teledermatology and conventional referral), were simulated from initial primary care visit until surgical intervention. Two groups of patients, those with Squamous Cell Carcinoma and those with Basal Cell Carcinoma, were distinguished in order to compare the patients' out-of-pocket expenses according to the dermatoses. RESULTS: From a patient perspective, the conventional system was 2.12 times more expensive than presurgical teledermatology. Teledermatology allowed saving €0.74 per patient and per day of delay avoided. This saving was greater in patients with Squamous Cell Carcinoma than in patients with Basal Cell Carcinoma. Although, the probabilistic sensitivity analysis corroborates the results of the base case scenario, only a prospective study can substantiate these results. CONCLUSION: In the Portuguese public healthcare system and under specific cost hypotheses, from a patient economic perspective, teledermatology used for presurgical planning and preparation is the dominant strategy in terms of out-of-pocket expenses, outperforming the conventional referral system, especially for patients with severe dermatoses.

Spatial heterogeneity of quality, use and spending on medicare for the elderly.

The spatial variation of the relations between Medicare spending (MS), use and quality in the United States was investigated employing spatial regression. A focus of the study was whether, and to what extent, MS and use vary by service type. Employing different spatial regression designs based on Medicare regional data, the impact of the heterogeneous spatial effects of hospital readmissions on MS for the elderly at the aggregate level was examined. The results were followed up by investigation whether the effects of hospital readmissions are heterogeneous with regard to service type. It was found that poor quality indicators lead to increased MS at the aggregate level and thus higher costs per beneficiary, and that the quality effects are heterogeneous with variable impacts, both spatially and by type of medical service. The results shed new light on the relationship between quality and MS highlighting the pitfalls of global averaging models that hide the reality of a highly diversified and spatially stratified country. Reducing payments to high-spending areas and increasing payments to low-spending areas should reduce spending variability but the quality indicators of care become ambiguous and not easy to interpret.

HIV patients' decision of switching to second-line antiretroviral therapy in India.

The objective is to examine when patients should switch to second-line antiretroviral therapy (ART) under health uncertainty and in the absence of viral load monitoring. We formalize and solve the therapeutic dilemma about whether or not, and when, to switch a therapy. The model's main value-added consists in the concrete application to patients with HIV in India. In our dynamic stochastic model, health level volatility can be understood as the variation in CD4 count and the trend of health level as increases in CD4 count and, thus, decreases in the incidence of opportunistic infections and mortality. The results of the empirical application suggest that the theoretical model can explain ART treatment switch. Treatment switch depends negatively on the volatility of patients' health, and on trend of health, i.e., the greater the variation in CD4 count and the more CD4 count increase, the fewer treatment switches one expects to occur. Treatment switch also depends negatively on the degree of irreversibility. Under irreversibility, low-risk patients must begin the second-line treatment as soon as possible, which is precisely when the second-line treatment is least valuable. The existence of an option value means that ART first-line regimen may be the better choice when considering lifetime welfare. Conversely, treatment switch depends positively on the discount rate and on the correlation between the patient's health under first- and second-line treatments. This means that treatment switch is likelier to succeed in second-line treatments that are similar to the first-line treatments, implying that a decision-maker should not rely on treatment switch as a risk diversification tool.

The timing and probability of treatment switch under cost uncertainty: an application to patients with gastrointestinal stromal tumor.

BACKGROUND: Cost fluctuations render the outcome of any treatment switch uncertain, so that decision makers might have to wait for more information before optimally switching treatments, especially when the incremental cost per quality-adjusted life year (QALY) gained cannot be fully recovered later on. OBJECTIVE: To analyze the timing of treatment switch under cost uncertainty. METHODS: A dynamic stochastic model for the optimal timing of a treatment switch is developed and applied to a problem in medical decision taking, i.e. to patients with unresectable gastrointestinal stromal tumour (GIST). RESULTS: The theoretical model suggests that cost uncertainty reduces expected net benefit. In addition, cost volatility discourages switching treatments. The stochastic model also illustrates that as technologies become less cost competitive, the cost uncertainty becomes more dominant. With limited substitutability, higher quality of technologies will increase the demand for those technologies disregarding the cost uncertainty. The results of the empirical application suggest that the first-line treatment may be the better choice when considering lifetime welfare. CONCLUSIONS: Under uncertainty and irreversibility, low-risk patients must begin the second-line treatment as soon as possible, which is precisely when the second-line treatment is least valuable. As the costs of reversing current treatment impacts fall, it becomes more feasible to provide the option-preserving treatment to these low-risk individuals later on.