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2.
Am Surg ; 85(10): 1079-1082, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657298

RESUMO

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Especialidades Cirúrgicas/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Feminino , Cirurgia Geral/estatística & dados numéricos , Humanos , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Razão de Chances , Sistema de Registros , Estudos Retrospectivos , Cirurgiões/classificação , Cirurgia Torácica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
5.
Med Care Res Rev ; : 1077558719849356, 2019 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-31117877

RESUMO

Chief executive officer (CEO) compensation is highly scrutinized, with nonprofit organizations often receiving additional attention due to their tax-exempt status. Understanding hospital CEO compensation is of increasing importance as health care costs remain high and strong leadership is required to implement new health policies. This study documents CEO compensation at nonprofit hospitals in the United States for 2010 and 2015. We compare hospital CEO compensation with CEO compensation in other institution types, including nonhospital health care. We also explore changes in hospital CEO compensation over time and differences across states. We find CEOs at hospitals earn substantially less than CEOs of publicly traded companies though more than presidents of nonprofit institutions of higher education. Additionally, we find that the relationship between CEO compensation and hospital size was weaker in 2015 than in 2010, and substantial variation in CEO compensation exists across states.

6.
PLoS One ; 14(4): e0215876, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31002706

RESUMO

BACKGROUND: Health care is believed to be suffered from a "cost disease," in which a heavy reliance on labor limits opportunities for efficiencies stemming from technological improvement. Although recent evidence shows that U.S. hospitals have experienced a positive trend of productivity growth, skilled nursing facilities are relatively "low-tech" compared to hospitals, leading some to worry that productivity at skilled nursing facilities will lag behind the rest of the economy. OBJECTIVE: To assess productivity growth among skilled nursing facilities (SNFs) in the treatment of conditions which frequently involve substantial post-acute care after hospital discharge. METHODS: We constructed an analytic file with the records of Medicare beneficiaries that were discharged from acute-care hospitals to SNFs with stroke, hip fracture, or lower extremity joint replacement (LEJR) between 2006 and 2014. We populated each record for 90 days starting at the time of SNF admission, detailing for each day the treatment site and all associated costs. We used ordinary least square regression to estimate growth in SNF productivity, measured by the ratio of "high-quality SNF stays" to total treatment costs. The primary definition of a high-quality stay was a stay that ended with the return of the patient to the community within 90 days after SNF admission. We controlled for patient demographics and comorbidities in the regression analyses. RESULTS: Our sample included 1,076,066 patient stays at 14,394 SNFs with LEJR, 315,546 patient stays at 14,154 SNFs with stroke, and 739,608 patient stays at 14,588 SNFs with hip fracture. SNFs improved their productivity in the treatment of patients with LEJR, stroke, and hip fracture by 1.1%, 2.2%, and 2.0% per year, respectively. That pattern was robust to a number of alternative specifications. Regressions on year dummies showed that the productivity first decreased and then increased, with a lowest point in 2011. Over the study period, quality continued to rise, but dominated by higher costs at first. Costs then started to decrease, driving productivity to grow. CONCLUSION: There has been substantial productivity growth in recent years among SNFs in the U.S. in the treatment of post-acute-care-intensive conditions.


Assuntos
Artroplastia de Quadril/economia , Eficiência Organizacional/economia , Fraturas do Quadril/economia , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Acidente Vascular Cerebral/economia , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/métodos , Feminino , Fraturas do Quadril/cirurgia , Fraturas do Quadril/terapia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Estados Unidos
7.
PLoS One ; 14(3): e0213647, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30908492

RESUMO

OBJECTIVES: To measure value in the delivery of inpatient care and to quantify its variation across U.S. regions. DATA SOURCES / STUDY SETTING: A random (20%) sample of 33,713 elderly fee-for-service Medicare beneficiaries treated in 2,232 hospitals for a heart attack in 2013. STUDY DESIGN: We estimate a production function for inpatient care, defining output as stays with favorable patient outcomes in terms of survival and readmission. The regression model includes hospital inputs measured by treatment costs, as well as patient characteristics. Region-level effects in the production function are used to estimate the productivity and value of the care delivered by hospitals within regions. DATA COLLECTION / EXTRACTION METHODS: Medicare claims and enrollment files, linked to the Dartmouth Atlas of Health Care and Inpatient Prospective Payment System Impact Files. PRINCIPAL FINDINGS: Hospitals in the hospital referral region at the 90th percentile of the value distribution delivered 54% more high-quality stays than hospitals at the 10th percentile could have delivered, after adjusting for treatment costs and patient severity. CONCLUSIONS: Variation in the delivery of high-value inpatient care points to opportunities for better quality and lower costs.


Assuntos
Custos de Cuidados de Saúde , Pesquisa sobre Serviços de Saúde , Hospitalização/economia , Pacientes Internados , Readmissão do Paciente , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Economia Hospitalar , Planos de Pagamento por Serviço Prestado/economia , Feminino , Geografia , Hospitais/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Mortalidade , Sistema de Pagamento Prospectivo/economia , Qualidade da Assistência à Saúde , Risco , Resultado do Tratamento , Estados Unidos
8.
Am J Manag Care ; 24(12): e380-e385, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30586486

RESUMO

OBJECTIVES: To assess the value to society of improved survival from novel immuno-oncology (I-O) treatments. STUDY DESIGN: Case studies of ipilimumab for the treatment of advanced unresectable melanoma and nivolumab for advanced previously treated squamous non-small cell lung cancer (NSCLC). METHODS: Published data and survival analysis were used to estimate survival gains. We valued the gains using an economic model developed for application to discrete changes in life expectancy. We estimated aggregate utilization and value to society using cancer registry data and literature. We assessed the share of social value that flowed to the pharmaceutical manufacturer as sales revenue based on publicly available prices. RESULTS: For advanced melanoma, our analysis estimated an average real-world life expectancy (discounted at a 3% rate) of 32.4 months with ipilimumab versus 14.2 months with an existing standard of care. Treatment of advanced NSCLC with nivolumab generated a life expectancy of 28.1 months versus 14.3 months with an existing standard of care. Depending on model assumptions, the value of these survival gains ranged from $232,000 to $697,000 for a patient with melanoma and from $180,000 to $586,000 for one with NSCLC. Using a midpoint value to aggregate across treated patients over a 5-year window, the total value to society was estimated at $1.9 billion for ipilimumab in advanced melanoma and $1.7 billion for nivolumab in NSCLC. Less than 30% of the total value flowed to the pharmaceutical manufacturer in the form of profit. CONCLUSIONS: The novel I-O treatments studied here generate substantial survival gains and, thus, social value. Less than half of this value accrued to the pharmaceutical manufacturer as sales revenue.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Ipilimumab/uso terapêutico , Neoplasias Pulmonares/tratamento farmacológico , Melanoma/tratamento farmacológico , Nivolumabe/uso terapêutico , Neoplasias Cutâneas/tratamento farmacológico , Adulto , Carcinoma Pulmonar de Células não Pequenas/economia , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Análise Custo-Benefício , Feminino , Humanos , Ipilimumab/economia , Estimativa de Kaplan-Meier , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/mortalidade , Masculino , Melanoma/economia , Melanoma/mortalidade , Modelos Econômicos , Nivolumabe/economia , Neoplasias Cutâneas/economia , Neoplasias Cutâneas/mortalidade , Análise de Sobrevida , Resultado do Tratamento
9.
Matern Child Health J ; 22(12): 1751-1760, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30066300

RESUMO

Objectives To examine the association between having a patient-centered medical home (PCMH) and healthcare expenditures and quality of care for children with special health care needs (CSHCN). Methods We conducted a cross-sectional analysis of 8802 CSHCN using the 2008-2012 Medical Expenditure Panel Survey. A PCMH indicator was constructed from survey responses. Inverse probability treatment weighting was applied to balance the cohort. CSHCN's annual health care expenditures and quality were analyzed using two-part and logistic models, respectively. Results Covariate-adjusted annual total expenditures were similar between CSHCN with and without a PCMH ($4267 vs. $3957, p = 0.285). CSHCN with a PCMH had higher odds of incurring expenditure (OR 1.66, 95% CI 1.22-2.25)-in particular, office-based services and prescriptions (OR 1.46 and 1.36, 95% CI 1.24-1.72 and 1.17-1.58, respectively)-compared to those without a PCMH, without shifting expenditures. When examined in detail, PCMH was associated with lower odds of accessing office-based mental health services (OR 0.80, 95% CI 0.66-0.96), leading to lower expenditures ($106 vs. $137; p = 0.046). PCMH was associated with higher odds of post-operation and immunization visits (OR 1.23 and 1.22, 95% CI 1.05-1.45 and 1.004-1.48, respectively) without changing expenditures. Parents of CSHCN with a PCMH were more likely to report having the best health care quality (OR 2.33, p < 0.001). Conclusions CSHCN who had a PCMH experienced better health care quality and were more likely to access preventive services, with unchanged expenditures. However, they were less likely to use mental health services in office-based settings. As the effects of PCMH varied across services for CSHCN, more research is warranted.


Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Crianças com Deficiência/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Determinação de Necessidades de Cuidados de Saúde/economia , Assistência Centrada no Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde , Criança , Estudos Transversais , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Assistência Centrada no Paciente/economia , Estados Unidos
10.
Am J Manag Care ; 24(8 Spec No.): SP322-SP328, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30020747

RESUMO

OBJECTIVES: To model the impacts of restrictive formulary designs on outcomes for patients with HIV and to demonstrate the costs of restricting access to novel HIV regimens with better safety and efficacy profiles. STUDY DESIGN: We modified an epidemiological model of HIV incidence, progression, and treatment to simulate the effects of 5 formulary scenarios on patient outcomes in the United States. METHODS: Using a cohort of HIV-susceptible individuals, we followed patients through HIV infection, disease progression, and death. Patients transitioned in and out of treatment states once infected. Treatment discontinuation, efficacy, and the rate of adverse events (AEs; renal failure and bone fracture) in each formulary scenario depended on the treatment path and regimens included. Outcomes of interest included all-cause cumulative deaths, annual rates of AEs, and costs associated with treating those AEs. RESULTS: All outcomes of interest were more favorable in less restrictive formulary scenarios that provided fewer barriers to appropriate treatments. By 2025, more restrictive formularies would have resulted in 171,500 more cumulative bone and renal events among treated patients with HIV compared with an open formulary. This corresponds to AE treatment costs of $3.65 billion in more restrictive formularies compared with $1.43 billion in an open formulary. Finally, compared with an open formulary, there would be an additional 16,200 cumulative deaths in more restrictive formularies. CONCLUSIONS: Less restrictive formulary designs, which allow patients with HIV to initiate potentially safer and more efficacious regimens based on their proclivity to AEs, yield better outcomes and reduce costs.

11.
J Am Heart Assoc ; 7(6)2018 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-29523525

RESUMO

BACKGROUND: Previous research has found that patients with acute cardiovascular conditions treated in teaching hospitals have lower 30-day mortality during dates of national cardiology meetings. METHODS AND RESULTS: We analyzed 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (overall, ST-segment-elevation myocardial infarction, and non-ST-segment-elevation myocardial infarction) from January 1, 2007, to November 31, 2012, in major teaching hospitals during dates of a major annual interventional cardiology meeting (Transcatheter Cardiovascular Therapeutics) compared with identical nonmeeting days in the ±5 weeks. Treatment differences were assessed. We used a database of US physicians to compare interventional cardiologists who practiced and did not practice during meeting dates ("stayers" and "attendees," respectively) in terms of demographic characteristics and clinical and research productivity. Unadjusted and adjusted 30-day mortality rates were lower among patients admitted during meeting versus nonmeeting dates (unadjusted, 15.3% [482/3153] versus 16.7% [5208/31 556] [P=0.04]; adjusted, 15.4% versus 16.7%; difference -1.3% [95% confidence interval, -2.7% to -0.1%] [P=0.05]). Rates of interventional cardiologist involvement were similar between dates (59.5% versus 59.8% of hospitalizations; P=0.88), as were percutaneous coronary intervention rates (30.2% versus 29.1%; P=0.20). Mortality reductions were largest among patients with non-ST-segment-elevation myocardial infarction not receiving percutaneous coronary intervention (16.9% versus 19.5% adjusted 30-day mortality; P=0.008). Compared with stayers, attendees were of similar age and sex, but had greater publications (18.9 versus 6.3; P<0.001), probability of National Institutes of Health funding (5.3% versus 0.4%; P<0.001), and clinical trial leadership (10.3% versus 3.9%; P<0.001), and they performed more percutaneous coronary interventions annually (85.6 versus 63.3; P<0.001). CONCLUSIONS: Hospitalization with acute myocardial infarction during Transcatheter Cardiovascular Therapeutics meeting dates was associated with lower 30-day mortality, predominantly among patients with non-ST-segment-elevation myocardial infarction who were medically managed.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Cardiologistas/tendências , Serviço Hospitalar de Cardiologia/tendências , Congressos como Assunto/tendências , Hospitais de Ensino/tendências , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Intervenção Coronária Percutânea/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Idoso , Bases de Dados Factuais , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
12.
Value Health ; 20(2): 217-223, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-28237198

RESUMO

BACKGROUND: Previous research indicates that patients value therapies that provide durable or tail-of-the-curve survival gains, but it is unclear whether physicians share these preferences. OBJECTIVE: To compare patient and physician preferences for treatments with a positive probability of durable survival gains relative to those with fixed survival gains. METHODS: Patients with advanced stage melanoma or lung cancer and the oncologists who treated these patients were surveyed. The primary end point was the share of respondents who selected a therapy with a variable survival profile, with some patients experiencing long-term durable survival and others experiencing much shorter survival, compared to a therapy with a fixed survival duration. Parameter estimation by sequential testing was applied to calculate the length of nonvarying survival that would make respondents indifferent between that survival and therapy with durable survival. RESULTS: The sample comprised 165 patients (lung = 84, melanoma = 81) and 98 physicians. For lung cancer, 65.5% of patients preferred the therapy with a variable survival profile, compared with 40.8% of physicians (Δ = 24.7%; P < 0.001). For melanoma, these figures were 63.0% for patients and 29.7% for physicians (Δ = 33.3%; P < 0.001). Patients' indifference point implied that therapies with a variable survival profile are preferred unless the treatment with fixed survival had 13.6 months (melanoma) or 11.6 months (lung) longer mean survival; physicians would prescribe treatments with a fixed survival if the treatment had 7.5 months (melanoma) or 1.0 month (lung) shorter survival than the variable survival profile. CONCLUSIONS: Patients place a high value on therapies that provide a chance of durable or "tail-of-the-curve" survival, whereas physicians do not. Value frameworks should incorporate measures of tail-of-the-curve survival gains into their methodologies.


Assuntos
Preferência do Paciente , Médicos/psicologia , Sobrevida , Adulto , Feminino , Humanos , Neoplasias Pulmonares/terapia , Masculino , Melanoma/terapia , Pessoa de Meia-Idade , Inquéritos e Questionários , Aquisição Baseada em Valor
13.
J Vasc Surg ; 65(3): 783-792.e4, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28027805

RESUMO

OBJECTIVE: Prevalence of end-stage renal disease, modality of treatment, and type of hemodialysis vascular access used varies widely by race/ethnicity in the United States, but outcomes of hemodialysis vascular access by race/ethnicity are poorly described. The objective of this study is to evaluate variations in outcomes of hemodialysis vascular access in the elderly by race/ethnicity. METHODS: Medicare outpatient, inpatient, and carrier files were queried from 2006 to 2011 for beneficiaries that were age ≥66 years and dialysis-dependent at time of index fistula/graft creation, qualified for Medicare by age only, and were continuously enrolled in Medicare 12 months before and after index fistula/graft creation. Primary outcome measures were early vascular access failure and 12-month failure-free survival, specifically, the variation in the difference between fistula and graft in non-White vs White race/ethnicity groups. RESULTS: Fistulas comprised a smaller proportion of index procedures performed in Blacks (65.9%; P < .001) and Asians (71.4%; P < .001), compared with Whites (78.0%) with no difference in Hispanics (78.7%; P = .59). Incidence of early failure after graft vs fistula was Whites, 34.9% vs 43.5% (P < .001), Blacks, 32.9% vs 49.1% (P < .001), Asians, 30.8% vs 40.5% (P = .014), and Hispanics 35.2% vs 43.2% (P = .005). The difference in early failure after fistula vs graft in Blacks was significantly larger than the difference in Whites (P < .001). The 12-month failure-free survival after index graft vs fistula was Whites 41.9% vs 38.9% (P = .008), Blacks 48.5% vs 37.3% (P < .001), Asians 51.6% vs 45.2% (P = .98), and Hispanics 51.9% vs 42.2% (P < .001). The difference in 12-month failure-free survival after graft vs fistula in Blacks and in Hispanics was larger than the difference in Whites (P < .001 and P = .02, respectively). CONCLUSIONS: Outcomes of fistulas vs grafts in the elderly vary significantly by race/ethnicity. The decreased risk of early failure after graft vs fistula creation is larger in Blacks compared with Whites. The higher failure-free survival at 12 months after graft vs fistula creation is larger in Blacks compared with Whites and trends toward being larger in Hispanics compared with Whites.


Assuntos
Afro-Americanos , Derivação Arteriovenosa Cirúrgica , Americanos Asiáticos , Implante de Prótese Vascular , Grupo com Ancestrais do Continente Europeu , Hispano-Americanos , Falência Renal Crônica/terapia , Diálise Renal , Fatores Etários , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/tendências , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/tendências , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/etnologia , Masculino , Medicare , Diálise Renal/efeitos adversos , Diálise Renal/tendências , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Falha de Tratamento , Estados Unidos/epidemiologia
14.
Pediatrics ; 139(1)2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28028202

RESUMO

BACKGROUND AND OBJECTIVES: Many children with special health care needs (CSHCN) receive health care at home from family members, but the extent of this care is poorly quantified. This study's goals were to create a profile of CSHCN who receive family-provided health care and to quantify the extent of such care. METHODS: We analyzed data from the 2009-2010 National Survey of Children with Special Health Care Needs, a nationally representative sample of 40 242 parents/guardians of CSHCN. Outcomes included sociodemographic characteristics of CSHCN and their households, time spent by family members providing health care at home to CSHCN, and the total economic cost of such care. Caregiving hours were assessed at (1) the cost of hiring an alternative caregiver (the "replacement cost" approach), and (2) caregiver wages (the "foregone earnings" approach). RESULTS: Approximately 5.6 million US CSHCN received 1.5 billion hours annually of family-provided health care. Replacement with a home health aide would have cost an estimated $35.7 billion or $6400 per child per year in 2015 dollars ($11.6 billion or $2100 per child per year at minimum wage). The associated foregone earnings were $17.6 billion or $3200 per child per year. CSHCN most likely to receive the greatest amount of family-provided health care at home were ages 0 to 5 years, were Hispanic, lived below the federal poverty level, had no parents/guardians who had finished high school, had both public and private insurance, and had severe conditions/problems. CONCLUSIONS: US families provide a significant quantity of health care at home to CSHCN, representing a substantial economic cost.


Assuntos
Cuidadores/estatística & dados numéricos , Doença Crônica/economia , Doença Crônica/enfermagem , Crianças com Deficiência/estatística & dados numéricos , Adolescente , Cuidadores/economia , Criança , Pré-Escolar , Efeitos Psicossociais da Doença , Feminino , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/estatística & dados numéricos , Humanos , Renda/estatística & dados numéricos , Lactente , Masculino , Inquéritos e Questionários , Fatores de Tempo , Estados Unidos , Revisão da Utilização de Recursos de Saúde/economia
15.
J Health Econ ; 51: 1-12, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27992772

RESUMO

Approval of new drugs is increasingly reliant on "surrogate endpoints," which correlate with but imperfectly predict clinical benefits. Proponents argue surrogate endpoints allow for faster approval, but critics charge they provide inadequate evidence. We develop an economic framework that addresses the value of improvement in the predictive power, or "quality," of surrogate endpoints, and clarifies how quality can influence decisions by regulators, payers, and manufacturers. For example, the framework shows how lower-quality surrogates lead to greater misalignment of incentives between payers and regulators, resulting in more drugs that are approved for use but not covered by payers. Efficient price-negotiation in the marketplace can help align payer incentives for granting access based on surrogates. Higher-quality surrogates increase manufacturer profits and social surplus from early access to new drugs. Since the return on better quality is shared between manufacturers and payers, private incentives to invest in higher-quality surrogates are inefficiently low.


Assuntos
Biomarcadores , Aprovação de Drogas/métodos , Cobertura do Seguro , Análise Custo-Benefício , Aprovação de Drogas/economia , Custos de Medicamentos , Indústria Farmacêutica/economia , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/normas , Modelos Econométricos , Resultado do Tratamento
16.
Artigo em Inglês | MEDLINE | ID: mdl-28012020

RESUMO

When a pharmaceutical manufacturer experiences a safety problem, negative impacts on profitability can spread to its competitors. Reduced consumer confidence, product recalls, and litigation are limited to the responsible manufacturer only if that manufacturer can be clearly linked to the safety problem. We analyze the impact of "accountability" for safety problems on manufacturer entry decisions and investments to mitigate risk. Consistent with prior research, we find investment levels increase with accountability in a duopoly market, and that accountability can thus enhance market viability and improve consumer welfare. However, we also analyze the impact of accountability on entry of a competitor, after the originator's exclusivity has expired. Accountability promotes the development of a robust market by raising expected profits, particularly for an entrant with a relatively low likelihood of a safety problem. Yet entry need not improve consumer welfare, and may benefit the incumbent in our model. In contrast to the traditional entry deterrence mechanism, when accountability is sufficiently low, increased incumbent investment encourages entry. Our analysis has important implications for biologic drugs, insofar as pathways for entry by "biosimilars" have been established in Europe and the United States, and informs pharmacovigilance and other accountability policies for biologics.

17.
PLoS One ; 11(11): e0166858, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27870907

RESUMO

Some models of vaccination behavior imply that an individual's willingness to vaccinate could be negatively correlated with the vaccination rate in her community. The rationale is that a higher community vaccination rate reduces the risk of contracting the vaccine-preventable disease and thus reduces the individual's incentive to vaccinate. At the same time, as for many health-related behaviors, individuals may want to conform to the vaccination behavior of peers, counteracting a reduced incentive to vaccinate due to herd immunity. Currently there is limited empirical evidence on how individual vaccination decisions respond to the vaccination decisions of peers. In the fall of 2014, we used a rapid survey technology to ask a large sample of U.S. adults about their willingness to use a vaccine for Ebola. Respondents expressed a greater inclination to use the vaccine in a hypothetical scenario with a high community vaccination rate. In particular, an increase in the community vaccination rate from 10% to 90% had the same impact on reported utilization as a nearly 50% reduction in out-of-pocket cost. These findings are consistent with a tendency to conform with vaccination among peers, and suggest that policies promoting vaccination could be more effective than has been recognized.


Assuntos
Vacinação/psicologia , Vacinação/estatística & dados numéricos , Adulto , Tomada de Decisões , Feminino , Gastos em Saúde , Inquéritos Epidemiológicos , Humanos , Imunidade Coletiva , Masculino , Pessoa de Meia-Idade , Estados Unidos
19.
Value Health ; 19(4): 451-9, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27325337

RESUMO

OBJECTIVES: The objective of this study was to compare patient and physician preferences for different antithrombotic therapies used to treat nonvalvular atrial fibrillation (NVAF). METHODS: Patients diagnosed with NVAF and physicians treating such patients completed 12 discrete choice questions comparing NVAF therapies that varied across five attributes: stroke risk, major bleeding risk, convenience (no regular blood testing/dietary restrictions), dosing frequency, and patients' out-of-pocket cost. We used a logistic regression to estimate the willingness-to-pay (WTP) value for each attribute. RESULTS: The 200 physicians surveyed were willing to trade off $38 (95% confidence interval [CI] $22 to $54] in monthly out-of-pocket cost for a 1% (absolute) decrease in stroke risk, $14 (95% CI $8 to $21) for a 1% decrease in major bleeding risk, and $34 (95% CI $9 to $60) for more convenience. The WTP value among 201 patients surveyed was $30 (95% CI $18 to $42) for reduced stroke risk, $16 (95% CI $9 to $24) for reduced bleeding risk, and -$52 (95% CI -$96 to -6) for convenience. The WTP value for convenience among patients using warfarin was $9 (95% CI $1 to $18) for more convenience, whereas patients not currently on warfarin had a WTP value of -$90 (95% CI -$290 to -$79). Both physicians' and patients' WTP value for once-daily dosing was not significantly different from zero. On the basis of survey results, 85.0% of the physicians preferred novel oral anticoagulants (NOACs) to warfarin. NOACs (73.0%) were preferred among patients using warfarin, but warfarin (78.2%) was preferred among patients not currently using warfarin. Among NOACs, both patients and physicians preferred apixaban. CONCLUSIONS: Both physicians and patients currently using warfarin preferred NOACs to warfarin. Patients not currently using warfarin preferred warfarin over NOACs because of an apparent preference for regular blood testing/dietary restrictions.


Assuntos
Fibrilação Atrial/economia , Atitude do Pessoal de Saúde , Fibrinolíticos/economia , Preferência do Paciente/estatística & dados numéricos , Médicos/psicologia , Adulto , Idoso , Anticoagulantes , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Atitude Frente a Saúde , Comportamento de Escolha , Custos e Análise de Custo , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente/psicologia , Pacientes/psicologia , Projetos Piloto , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/prevenção & controle , Inquéritos e Questionários , Varfarina/economia , Varfarina/uso terapêutico , Adulto Jovem
20.
Med Care Res Rev ; 73(3): 329-48, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26537525

RESUMO

We investigated the effect of changes to state AIDS Drug Assistance Programs (ADAP) policies, which govern access to antiretroviral therapy (ART), on clinical and economic outcomes among low-income people living with HIV/AIDS. Retrospective analyses of ART access were conducted on state ADAP policies, using data from ADAP Monitoring Reports and Kaiser Family Foundation from 2006 to 2010. We found stricter eligibility requirements reduce the number of HIV-positive individuals with ART access through ADAP, and decreased ART use increases mortality by 2.67 quality-adjusted life years (QALYs) per beneficiary. If the ADAP income eligibility cutoff were decreased by 50 percentage points in each state, 4,626 individuals would lose ART access nationwide. Based on a $22,143 cost/QALY, this policy would save $274 million in health care expenditures (2012 dollars), but result in 12,352 QALYs lost, valued at $1.2 billion. Therefore, states should exercise caution in restricting programs that increase ART access for low-income people living with HIV/AIDS.


Assuntos
Fármacos Anti-HIV/economia , Infecções por HIV/tratamento farmacológico , Assistência Médica , Governo Estadual , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/economia , Política de Saúde/economia , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Assistência Médica/economia , Assistência Médica/estatística & dados numéricos , Pobreza , Estudos Retrospectivos , Estados Unidos
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