Assuntos
Infecções por Mycoplasma , Mycoplasma genitalium , Técnicas de Amplificação de Ácido Nucleico/métodos , Infecções Sexualmente Transmissíveis , Uretrite , Cervicite Uterina , Adolescente , Adulto , Feminino , Humanos , Masculino , Infecções por Mycoplasma/diagnóstico , Infecções por Mycoplasma/epidemiologia , Infecções por Mycoplasma/microbiologia , Mycoplasma genitalium/genética , Mycoplasma genitalium/isolamento & purificação , Técnicas de Amplificação de Ácido Nucleico/economia , Prevalência , Utilização de Procedimentos e Técnicas/economia , RNA Ribossômico 16S/isolamento & purificação , RNA Ribossômico 23S/isolamento & purificação , Sensibilidade e Especificidade , Infecções Sexualmente Transmissíveis/diagnóstico , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/microbiologia , Manejo de Espécimes/métodos , Estados Unidos/epidemiologia , Uretrite/diagnóstico , Uretrite/epidemiologia , Uretrite/microbiologia , Cervicite Uterina/diagnóstico , Cervicite Uterina/epidemiologia , Cervicite Uterina/microbiologiaAssuntos
Antibacterianos , Cuidados de Baixo Valor , Uso Excessivo dos Serviços de Saúde , Cuidados Pré-Operatórios , Utilização de Procedimentos e Técnicas , Urinálise , Doenças Urológicas , Adulto , Antibacterianos/economia , Antibacterianos/uso terapêutico , Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/epidemiologia , Resistência Microbiana a Medicamentos/efeitos dos fármacos , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Masculino , Uso Excessivo dos Serviços de Saúde/economia , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Cuidados Pré-Operatórios/estatística & dados numéricos , Prevalência , Utilização de Procedimentos e Técnicas/economia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Estados Unidos/epidemiologia , Urinálise/economia , Urinálise/métodos , Urinálise/estatística & dados numéricos , Doenças Urológicas/epidemiologia , Doenças Urológicas/terapia , Doenças Urológicas/urinaRESUMO
BACKGROUND: Observational studies show that digital breast tomosynthesis (DBT) combined with digital mammography (DM) can reduce recall rates and increases rates of breast cancer detection. The objective of this study was to examine the cost-effectiveness of DBT plus DM versus DM alone in British Columbia and to identify parameters that can improve the efficiency of breast cancer screening programs. METHODS: We conducted an economic analysis based on data from a cohort of screening participants in the BC Cancer Breast Screening Program. The decision model simulated lifetime costs and outcomes for participants in breast cancer screening who were aged 40-74 years between 2012 and 2017. We analyzed rates of health care resource utilization, health state costs and estimated incremental cost-effectiveness ratios (ICERs), to measure incremental cost differences per quality-adjusted life years (QALYs) gained from the addition of DBT to DM-based screening, from the government payer's perspective. RESULTS: The model simulated economic outcomes for 112 249 screening participants. We found that the ICER was highly sensitive to recall rate reductions and insensitive to parameters related to cancer detection. If DBT plus DM can reduce absolute recall rates by more than 2.1%, the base-case scenario had an ICER of $17 149 per QALY. At a willingness-to-pay threshold of $100 000 per QALY, more than 95% of the probabilistic simulations favoured the adoption of DBT plus DM versus DM alone. The ICER depended heavily on the ability of DBT plus DM to reduce recall rates. INTERPRETATION: The addition of DBT to DM would be considered cost-effective owing to the low positive predictive value of screening with DM alone. Reductions in false-positive recall rates should be monitored closely.
Assuntos
Neoplasias da Mama , Mama/diagnóstico por imagem , Detecção Precoce de Câncer , Mamografia , Adulto , Idoso , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/economia , Neoplasias da Mama/epidemiologia , Colúmbia Britânica/epidemiologia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Mamografia/economia , Mamografia/métodos , Valor Preditivo dos Testes , Utilização de Procedimentos e Técnicas/economia , Anos de Vida Ajustados por Qualidade de VidaRESUMO
BACKGROUND: Clinical guidelines increasingly recommended ambulatory blood pressure monitoring (ABPM) for hypertension diagnosis and management. Yet, ABPM is used infrequently in the United States, possibly because of low insurance coverage and high patient costs. We sought to analyze out-of-pocket payments (OPPs) for ABPM among privately insured patients. METHODS: We conducted a retrospective analysis using IBM® MarketScan® commercial claims of beneficiaries aged ≥18 years receiving ABPM from January 2012 to December 2018. The date of first ABPM claim (Healthcare Common Procedure Coding System codes 93784, 93786, 93788, or 93790) was considered the index date. Patients with 12 months of continuous enrollment preindex and 30-day postindex were included. Per beneficiary OPP was calculated by aggregating all ABPM-related OPPs within the 30-day postindex window (ABPM episode). RESULTS: Of 22,317 beneficiaries receiving ABPM, 62% had $0 OPP and 38% had OPP >$0. Among the latter, median OPP per beneficiary for an ABPM episode was $23 (interquartile range [IQR], $14, $32), driven primarily by full ABPM claims (median, $22; IQR, $14, $24). Among individual components, scan analysis and report claims (median, $25; IQR, $13, $49) had the greatest OPP. The median OPP per ABPM episode did not change substantively from 2012 through 2018. CONCLUSIONS: Among commercially insured in the United States, nearly 4-in-10 have an OPP for ABPM. Though most OPPs are relatively modest, some patients incur substantial OPP. Our findings highlight the need for policymakers to ensure adequate ABPM coverage in the commercial insurance marketplace.
Assuntos
Monitorização Ambulatorial da Pressão Arterial/economia , Gastos em Saúde/estatística & dados numéricos , Hipertensão , Seguro Saúde/estatística & dados numéricos , Monitorização Ambulatorial da Pressão Arterial/métodos , Monitorização Ambulatorial da Pressão Arterial/estatística & dados numéricos , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/economia , Hipertensão/epidemiologia , Revisão da Utilização de Seguros , Cobertura do Seguro/tendências , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Setor Privado/economia , Setor Privado/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/economia , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
16S ribosomal-ribonucleic acid polymerase chain reaction (PCR) and targeted PCR aid microbiological diagnosis in culture-negative clinical samples. Despite routine clinical use, there remains a paucity of data on their effectiveness across a variety of clinical sample types, and cost-effectiveness. In this 4 year multicentre retrospective observational study, all clinical samples referred for 16S PCR and/or targeted PCR from a laboratory network serving seven London hospitals were identified. Laboratory, clinical, prescribing, and economic variables were analysed. 78/607 samples were 16S PCR positive; pus samples were most frequently positive (29/84; p < 0.0001), and CSF least (8/149; p = 0.003). 210/607 samples had targeted PCR (361 targets requested across 23 organisms) with 43/361 positive; respiratory samples (13/37; p = 0.01) had the highest detection rate. Molecular diagnostics provided a supportive microbiological diagnosis for 21 patients and a new diagnosis for 58. 14/91 patients with prescribing information available and a positive PCR result had antimicrobial de-escalation. For culture-negative samples, mean cost-per-positive 16S PCR result was £568.37 and £292.84 for targeted PCR, equating to £4041.76 and £1506.03 respectively for one prescription change. 16S PCR is more expensive than targeted PCR, with both assisting in microbiological diagnosis but uncommonly enabling antimicrobial change. Rigorous referral pathways for molecular tests may result in significant fiscal savings.
Assuntos
Técnicas Microbiológicas , Técnicas de Diagnóstico Molecular , Reação em Cadeia da Polimerase , Utilização de Procedimentos e Técnicas , RNA Ribossômico 16S/genética , Técnicas de Tipagem Bacteriana , Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/etiologia , Análise Custo-Benefício , Humanos , Laboratórios , Londres , Técnicas Microbiológicas/economia , Técnicas Microbiológicas/métodos , Técnicas de Diagnóstico Molecular/economia , Técnicas de Diagnóstico Molecular/métodos , Reação em Cadeia da Polimerase/economia , Reação em Cadeia da Polimerase/métodos , Utilização de Procedimentos e Técnicas/economia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Reino UnidoRESUMO
Importance: Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013. Objective: To assess the association of a large commercial payer's utilization management policy with the use of hypofractionated radiotherapy among women with early-stage breast cancer and its associated cost. Design, Setting, and Participants: A retrospective, adjusted difference-in-differences economic analysis was conducted using administrative claims data from January 1, 2012, to June 1, 2018, of women 18 years or older with early-stage breast cancer who were eligible for hypofractionated radiotherapy according to 2011 guidelines from the American Society for Radiation Oncology and were continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. Women who received mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy were excluded. A utilization management policy was used to encourage the use of hypofractionated radiotherapy among women in fully insured and Medicare Advantage (fully insured) plans. Under the new policy, claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. This policy did not apply to women in self-insured or Medicare supplemental insurance (self-insured) plans, allowing these groups to serve as a comparison group. Main Outcomes and Measures: The primary outcome was use of hypofractionated radiotherapy, and the secondary outcome was the cost of this type of radiotherapy. Results: Of 10â¯540 eligible women, 3619 (34.3%) were in fully insured plans and thus subject to the policy. There were no meaningful differences between the fully insured and self-insured groups in mean (SD) age at the start of radiotherapy (63.8 [8.6] vs 65.0 [8.9] years), mean (SD) Charlson Comorbidity Index score (3.0 [1.5] vs 3.2 [1.6]), or practice setting (outpatient hospital setting, 2982 of 3619 [82.4%] vs 5600 of 6921 [80.9%]). The policy was associated with an increase in use of hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-in-difference, 4.2%; 95% CI, 0.0%-8.4%; P = .05) and a nonsignificant decrease in radiotherapy-associated expenditures (-$2275 relative to self-insured patients; P = .09). Spillover analyses revealed a significantly higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-in-difference, 8.5%; 95% CI, 3.6%-13.5%; P < .001) compared with those who were not exposed. Conclusions and Relevance: This study suggests that a payer's utilization management policy was associated with direct and spillover increases in the use of hypofractionated radiotherapy, even after accounting for a long-term secular trend in the uptake of hypofractionated radiotherapy in the control groups. Utilization management may promote evidence-based cancer care.
Assuntos
Neoplasias da Mama/radioterapia , Utilização de Procedimentos e Técnicas , Idoso , Neoplasias da Mama/economia , Neoplasias da Mama/patologia , Feminino , Gastos em Saúde , Humanos , Reembolso de Seguro de Saúde , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas/economia , Hipofracionamento da Dose de RadiaçãoRESUMO
BACKGROUND: Lymphatic filariasis (LF) is endemic in 72 countries of Africa, Asia, Oceania, and the Americas. An estimated 25 million men live with the disabling effects of filarial hydrocele. Hydrocele can be corrected with surgery with few complications. For most men, hydrocelectomy reduces or corrects filarial hydrocele and permits them to resume regular activities of daily living and gainful employment. METHODOLOGY AND PRINCIPAL FINDINGS: This study measures the economic loss due to filarial hydrocele and the benefits of hydrocelectomy and is based on pre- and post-operative surveys of patients in southern Malawi. We find the average number of days of work lost due to filarial hydrocele and daily earnings for men in rural Malawi. We calculate average annual lost earnings and find the present discounted value for all years from the time of surgery to the end of working life. We estimate the total costs of surgery. We compare the benefit of the work capacity restored to the costs of surgery to determine the benefit-cost ratio. For men younger than 65 years old, the average annual earnings loss attributed to hydrocele is US$126. The average discounted present value of lifetime earnings loss for those men is US$1684. The average budgetary cost of the hydrocelectomy is US$68. The ratio of the benefit of surgery to its costs is US$1684/US$68 or 24.8. Sensitivity analysis demonstrates that the results are robust to variations in cost of surgery and length of working life. CONCLUSION: The lifetime benefits of hydrocelectomy-to the man, his family, and his community-far exceed the costs of repairing the hydrocele. Scaling up subsidies to hydrocelectomy campaigns should be a priority for governments and international aid organizations to prevent and alleviate disability and lost earnings that aggravate poverty among the many millions of men with filarial hydrocele.
Assuntos
Filariose Linfática/complicações , Utilização de Procedimentos e Técnicas/economia , Procedimentos Cirúrgicos Operatórios/economia , Hidrocele Testicular/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Humanos , Malaui , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto JovemRESUMO
The aim of this study was to identify the economic screening strategies for esophageal squamous cell carcinoma (ESCC) in high-risk regions. We used a validated ESCC health policy model for comparing different screening strategies for ESCC. Strategies varied in terms of age at initiation and frequency of screening. Model inputs were derived from parameter calibration and published literature. We estimated the effects of each strategy on the incidence of ESCC, costs, quality-adjusted life-year (QALY), and incremental cost-effectiveness ratios (ICERs). Compared with no screening, all competing screening strategies decreased the incidence of ESCC from 0.35% to 72.8%, and augmented the number of QALYs (0.002-0.086 QALYs per person) over a lifetime horizon. The screening strategies initiating at 40 years of age and repeated every 1-3 years, which gained over 70% of probabilities that was preferred in probabilistic sensitivity analysis at a $1,151/QALY willingness-to-pay threshold. Results were sensitive to the parameters related to the risks of developing basal cell hyperplasia/mild dysplasia. Endoscopy screening initiating at 40 years of age and repeated every 1-3 years could substantially reduce the disease burden and is cost-effective for the general population in high-risk regions.
Assuntos
Simulação por Computador , Detecção Precoce de Câncer/métodos , Neoplasias Esofágicas/prevenção & controle , Carcinoma de Células Escamosas do Esôfago/prevenção & controle , Esofagoscopia/normas , Modelos Econômicos , Carcinoma de Células Escamosas de Cabeça e Pescoço/prevenção & controle , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , China/epidemiologia , Análise Custo-Benefício , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/estatística & dados numéricos , Doenças do Esôfago/diagnóstico , Doenças do Esôfago/epidemiologia , Doenças do Esôfago/cirurgia , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/epidemiologia , Carcinoma de Células Escamosas do Esôfago/diagnóstico , Carcinoma de Células Escamosas do Esôfago/economia , Carcinoma de Células Escamosas do Esôfago/epidemiologia , Esofagoscopia/economia , Feminino , Geografia Médica , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Lesões Pré-Cancerosas/diagnóstico , Lesões Pré-Cancerosas/epidemiologia , Lesões Pré-Cancerosas/cirurgia , Utilização de Procedimentos e Técnicas/economia , Anos de Vida Ajustados por Qualidade de Vida , Risco , Carcinoma de Células Escamosas de Cabeça e Pescoço/diagnóstico , Carcinoma de Células Escamosas de Cabeça e Pescoço/economia , Carcinoma de Células Escamosas de Cabeça e Pescoço/epidemiologia , Adulto JovemRESUMO
Heparin-induced thrombocytopenia (HIT) is a rare adverse drug reaction. The anti-PF4 antibody assay (ELISA) is utilized to assist in the clinical evaluation of HIT due to its high negative predictability and wide-spread availability. However, it also associated with false positive results. The 4T score can assist in predicting an individual's risk for HIT and the need for further laboratory testing. This was a single-center prospective observational cohort study. Orders for HIT testing were sent via page to a clinical pharmacist to calculate a 4T score. If low risk, the pharmacist contacted the ordering prescriber to recommend discontinuation of laboratory testing. During the study, a clinical support tool was implemented to assist prescribers with ordering HIT tests. The study was divided into a pharmacist intervention group and a control group. A total of 303 pages were received. One hundred nine were missed due to unavailability of the pharmacist at time of page. A pharmacist reviewed 194 pages and intervened on 132. One hundred seven were scored as low risk, 70 as intermediate risk and 9 as high risk. Pharmacist intervention resulted in discontinuing 64 ELISA and 11 serotonin release assay tests. The clinical support tool resulted in a yearly decrease of HIT testing by 27%. Laboratory cost savings totaled $11,000 but did not include avoidance of laboratory technician or drug cost. Pharmacist involvement in the clinical assessment of HIT and the use of a support tool resulted in the reduction of HIT tests in low risk patients.
Assuntos
Anticorpos/análise , Heparina/efeitos adversos , Farmacêuticos , Fator Plaquetário 4/imunologia , Utilização de Procedimentos e Técnicas , Trombocitopenia , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Redução de Custos/métodos , Feminino , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas/economia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Papel Profissional , Melhoria de Qualidade , Gestão de Riscos/métodos , Trombocitopenia/sangue , Trombocitopenia/induzido quimicamente , Trombocitopenia/diagnóstico , Trombocitopenia/prevenção & controle , Estados UnidosRESUMO
Asia is the largest and most populated continent in the world, with a high burden of kidney failure. In this Policy Forum article, we explore dialysis care and dialysis funding in 17 countries in Asia, describing conditions in both developed and developing nations across the region. In 13 of the 17 countries surveyed, diabetes is the most common cause of kidney failure. Due to great variation in gross domestic product per capita across Asian countries, disparities in the provision of kidney replacement therapy (KRT) exist both within and between countries. A number of Asian nations have satisfactory access to KRT and have comprehensive KRT registries to help inform practices, but some do not, particularly among low- and low-to-middle-income countries. Given these differences, we describe the economic status, burden of kidney failure, and cost of KRT across the different modalities to both governments and patients and how changes in health policy over time affect outcomes. Emerging trends suggest that more affluent nations and those with universal health care or access to insurance have much higher prevalent dialysis and transplantation rates, while in less affluent nations, dialysis access may be limited and when available, provided less frequently than optimal. These trends are also reflected by an association between nephrologist prevalence and individual nations' incomes and a disparity in the number of nephrologists per million population and per thousand KRT patients.
Assuntos
Falência Renal Crônica/terapia , Diálise Renal/estatística & dados numéricos , Ásia/epidemiologia , Efeitos Psicossociais da Doença , Países Desenvolvidos/economia , Países em Desenvolvimento/economia , Nefropatias Diabéticas/economia , Nefropatias Diabéticas/epidemiologia , Nefropatias Diabéticas/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde , Hospitais Privados/economia , Hospitais Privados/estatística & dados numéricos , Hospitais Públicos/economia , Hospitais Públicos/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Falência Renal Crônica/economia , Falência Renal Crônica/epidemiologia , Transplante de Rim/economia , Transplante de Rim/estatística & dados numéricos , Prevalência , Utilização de Procedimentos e Técnicas/economia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Diálise Renal/economia , Cobertura Universal do Seguro de Saúde/estatística & dados numéricosRESUMO
PURPOSE: This study examined postoperative heart failure (HF) and respiratory failure (RF) complications and related healthcare utilization for one year following cardiac surgery. METHODS: This study identified adult patients undergoing isolated coronary artery bypass graft (CABG) and/or valve procedures from the Cerner Health Facts® database. It included patients experiencing postoperative HF or RF complications. We quantified healthcare utilization using the frequency of inpatient admissions, emergency department (ED) visits with or without hospital admission, and outpatient visits. We then determined direct hospital costs from the determined healthcare utilization. We analyzed trends over time for both HF and RF and evaluated the association between surgery type and HF complication. RESULTS: Of 10,298 patients with HF complications, 1,714 patients (16.6%) developed persistent HF; of the 10,385 RF patients, 175 (1.7%) developed persistent RF. Healthcare utilization for those with persistent complications over the one-year period following index hospital discharge comprised an average number of the following visit types: Inpatient (1.49 HF; 1.55 RF), Outpatient (2.02, 0.51), ED without hospital admission (0.33, 0.13), ED + Inpatient (0.08, 0.06). Per patient annual costs related to persistent complications of HF and RF were $20,857 and $30,745, respectively. There was a significant association between cardiac surgical type and the incidence of HF, with risk for isolated valve procedures (adjusted OR 2.60; 95% CI: 2.35-2.88) and CABG + valve procedures (adjusted OR 2.38; 95% CI: 2.17-2.61) exceeding risk for isolated CABG procedures. CONCLUSIONS: This study demonstrates that HF and RF complication rates post cardiac surgery are substantial, and complication-related healthcare utilization over the first year following surgery results in significant incremental costs. Given the need for both payers and providers to focus on healthcare cost reduction, this study fills an important gap in quantifying the mid-term economic impact of postoperative cardiac surgical complications.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Custos e Análise de Custo , Insuficiência Cardíaca/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Insuficiência Respiratória/epidemiologia , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Utilização de Procedimentos e Técnicas/economia , Insuficiência Respiratória/economia , Estados UnidosRESUMO
BACKGROUND: We conducted a study to examine regional variation in the utilization of inpatient electroconvulsive therapy (ECT) across the United States, and its impact on length of hospital stay and cost. METHODS: Analysis of the Nationwide Inpatient Sample databases to compare patient and hospital characteristics, and regional variation of ECT administration across different regions of the United States. RESULTS: The study included 41,055 inpatients who had ECT from 4,411 hospitals. Electroconvulsive therapy use is significantly higher in the Midwest. A higher proportion of females (65.2%) than males received ECT across the United States. Medicaid beneficiaries were less likely to undergo ECT compared with patients with Medicare (52.2%) or private insurance (32%). Electroconvulsive therapy was used mainly for mood disorders (84.3%). There were marked reductions of inpatient costs ($25,298 to $38,244) and average hospital stay (16 days) when ECT was initiated within the first 5 days of admission compared with later during the hospitalization. CONCLUSIONS: There is a wide variability of utilization of ECT, depending on the region, type of hospital, and type of insurance carrier. The utilization of ECT services is reduced across the United States. Appropriate utilization of this effective treatment can greatly help patients who are not responding to standard therapeutics, reduce overall health care cost and length of stay, and, most importantly, alleviate suffering.
Assuntos
Eletroconvulsoterapia/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Transtornos do Humor/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Adulto , Idoso , Eletroconvulsoterapia/economia , Feminino , Hospitalização/economia , Humanos , Pacientes Internados/estatística & dados numéricos , Seguro Saúde/economia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Medicaid/economia , Medicare/economia , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Transtornos do Humor/economia , Utilização de Procedimentos e Técnicas/economia , Fatores Sexuais , Estados UnidosRESUMO
BACKGROUND: American Society of Radiation Oncology Choosing Wisely campaign recommends hypofractionated radiation and against routine use of intensity-modulated radiation therapy (IMRT) in early-stage estrogen receptor-positive breast cancer. We analyzed guideline recommendation adherence and financial implications in a modern Medicare cohort of women treated across the southeastern United States. METHODS: Our study population comprised Medicare patients over 65 years of age with breast cancer diagnosis from 12 cancer centers in the Southeast United States with stage 0-II breast treated with lumpectomy from 2012 to 2015. Hypofractionation was defined as 4 or fewer weeks of radiation treatments. Factors associated with utilization of hypofractionation and IMRT were identified using Poisson regression. Median costs during radiation treatments were compared for hypofractionation and IMRT. RESULTS: In older women (median age 71), 75% were treated with conventional fractionation, and 20% received IMRT. Hypofractionated women were more likely to have a positive estrogen(ER) or progestorone(PR) receptor status, lower comorbidity scores, and be treated at a high volume center (all P < 0.05). IMRT was utilized in 20% of patients and was more common in women treated with conventional fractionation (P < 0.001). Positive ER/PR status (P < 0.001) and utilization of hormonal blockade (P = 0.02) were associated with increased utilization of IMRT. CONCLUSION: In an older cohort of patients with early-stage breast cancer, a majority were treated with conventional fractionated radiation, while approximately 20% were treated with IMRT. Both of which were associated with increased cost relative to hypofractionation.
Assuntos
Neoplasias da Mama , Utilização de Procedimentos e Técnicas , Hipofracionamento da Dose de Radiação/normas , Radioterapia de Intensidade Modulada , Idoso , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/patologia , Neoplasias da Mama/radioterapia , Feminino , Fidelidade a Diretrizes , Humanos , Medicare/estatística & dados numéricos , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/economia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Radioterapia de Intensidade Modulada/economia , Radioterapia de Intensidade Modulada/métodos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: We investigated whether the recent growth in home dialysis use was proportional among all racial/ethnic groups and also whether there were changes in racial/ethnic differences in home dialysis outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This observational cohort study of US Renal Data System patients initiating dialysis from 2005 to 2013 used logistic regression to estimate racial/ethnic differences in home dialysis initiation over time, and used competing risk models to assess temporal changes in racial/ethnic differences in home dialysis outcomes, specifically: (1) transfer to in-center hemodialysis (HD), (2) mortality, and (3) transplantation. RESULTS: Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were white, 28% black, 13% Hispanic, and 4% Asian. In the earliest era (2005-2007), 8.0% of white patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [95% CI], 0.86 to 1.05), whereas lower proportions of black [5.2%; aOR, 0.71; 95% CI, 0.66 to 0.76] and Hispanic (5.7%; aOR, 0.83; 95% CI, 0.86 to 0.93) patients did so. Over time, home dialysis use increased in all groups and racial/ethnic differences decreased (2011-2013: 10.6% of whites, 8.3% of blacks [aOR, 0.81; 95% CI, 0.77 to 0.85], 9.6% of Hispanics [aOR, 0.94; 95% CI, 0.86 to 1.00], 14.2% of Asians [aOR, 1.04; 95% CI, 0.86 to 1.12]). Compared with white patients, the risk of transferring to in-center HD was higher in blacks, similar in Hispanics, and lower in Asians; these differences remained stable over time. The mortality rate was lower for minority patients than for white patients; this difference increased over time. Transplantation rates were lower for blacks and similar for Hispanics and Asians; over time, the difference in transplantation rates between blacks and Hispanics versus whites increased. CONCLUSIONS: From 2005 to 2013, as home dialysis use increased, racial/ethnic differences in initiating home dialysis narrowed, without worsening rates of death or transfer to in-center HD in minority patients, as compared with white patients.
Assuntos
Hemodiálise no Domicílio/economia , Hemodiálise no Domicílio/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/economia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Sistema de Pagamento Prospectivo , Adulto , Negro ou Afro-Americano , Idoso , Asiático , Estudos de Coortes , Etnicidade , Feminino , Hispânico ou Latino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , População BrancaRESUMO
INTRODUCTION: Vertigo and dizziness are symptoms with a significant burden in the hospital and involve several specialties. There are few guidelines of radiological tests for these symptoms. AIMS: To know which profile of patients with vertigo and dizziness has neuroimaging tests, quantify and describe the radiological findings. To analyze the cost-utility of CT and MRI in the study of these patients. PATIENTS AND METHODS: Descriptive study, we selected patients referred to the hospital for vertigo and dizziness. We analyze demographic and clinical characteristics and quantify the neuroimaging tests requested. We describe the radiological findings, assess their relevance in the diagnosis and detail the cost-benefit. RESULTS: We identified 493 patients, those with neuroimaging test (60%) are older, depressed and frequented the emergency department because of vertigo. The most requested test was the cranial CT scan (5% identifies the cause of the symptom). MRI of the inner ear and cerebellopontine angle was the test that presented the most significant findings (17.7%). The 286 image tests requested for vertigo cost 56,741 euros. The cost for a positive test was 1,576 euros. CONCLUSIONS: A large number of head CT and MRI are made in patients with vertigo and dizziness. A clinical suspicion is recommended from the anamnesis and exploration to make a good selection of test to request. In more than 90% of cases, radiological findings are not shown in relation to vertigo.
TITLE: Que aporta la neuroimagen en pacientes con vertigo y mareo? Analisis coste-utilidad.Introduccion. Vertigo y mareo son sintomas que suponen una carga significativa en el hospital e involucran a varias especialidades. Existen pocas guias sobre la solicitud de pruebas radiologicas ante estos sintomas. Objetivos. Conocer que perfil de pacientes con vertigo y mareo tiene realizadas pruebas de neuroimagen, cuantificar y describir los hallazgos radiologicos, y analizar el coste-utilidad de la tomografia computarizada (TC) y la resonancia magnetica (RM) en pacientes con estos sintomas. Pacientes y metodos. Estudio descriptivo en el que se seleccionan pacientes remitidos al hospital por vertigo y mareo. Se analizan caracteristicas demograficas y clinicas y se cuantifican las pruebas de neuroimagen solicitadas. Se describen los hallazgos radiologicos, se valora su relevancia en el diagnostico y se detalla el coste. Resultados. Se identifica a 493 pacientes, el 60% tiene realizada una prueba de neuroimagen; son pacientes de mas edad, depresivos y que han acudido a urgencias por vertigo. La prueba mas realizada fue la TC de craneo sin contraste (el 5% identifica la causa del sintoma). La que presento mas hallazgos significativos fue la RM de la base del craneo (17,7%). Las 286 pruebas de imagen solicitadas por vertigo costaron 56.741 euros. El gasto para obtener un diagnostico radiologico fue de 1.576 euros. Conclusiones. Se realiza un gran numero de TC y RM de cabeza en pacientes con vertigo y mareo. Es recomendable tener un diagnostico de sospecha previo a partir de la anamnesis y la exploracion para hacer una buena seleccion de las pruebas que hay que solicitar. En mas del 90% de los casos no se muestran hallazgos radiologicos en relacion con el vertigo.
Assuntos
Tontura/diagnóstico por imagem , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Vertigem/diagnóstico por imagem , Adulto , Idoso , Encéfalo/diagnóstico por imagem , Meios de Contraste/economia , Análise Custo-Benefício , Diagnóstico Diferencial , Tontura/economia , Tontura/etiologia , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Imageamento por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Neuroimagem/economia , Neuroimagem/métodos , Osso Petroso/diagnóstico por imagem , Utilização de Procedimentos e Técnicas/economia , Estudos Retrospectivos , Base do Crânio/diagnóstico por imagem , Espanha , Tomografia Computadorizada por Raios X/economia , Procedimentos Desnecessários/economia , Vertigem/economia , Vertigem/etiologiaRESUMO
BACKGROUND: Potassium hydroxide preparations (KOH) and tissue examinations for ova and parasites (O&P) are cost-effective office-based tests. No studies have quantified their utilization and economic impact. METHODS: The objective is to determine the billing patterns and costs of office-based diagnostic procedures in the Medicare population. We conducted a cross sectional study using the Part B National Summary Data File (2000-2016) and the Physician and Other Supplier Public Use File (2012-2015) released by the Centers for Medicare & Medicaid Services. RESULTS: In 2016, the total number of claims among all providers was 28,432 (KOH) and 52,182 (O&P), representing a decrease since 2000 (KOH, -41.8%; O&P, -43.4%). The total claims for in-office procedures by dermatologists per 10,000 beneficiaries decreased between 2012 and 2015 (KOH, -18.8%; O&P, -26.6%). Fewer dermatologists submitted claims for the tests (KOH, -11.3%; O&P, -16.6%). The total single (SB) and multiple (MB) biopsy claims by dermatologists per 10,000 beneficiaries decreased between 2012 and 2015 (SB, -1.8%; MB, -2.7%). The 2016 aggregate payments (% change since 2000) for KOH and O&P were $163,127.75 (-60.4%) and $299,074.18 (-61.6%), respectively; for SB and MB, they were $240,047,487.98 (+142.3%) and $38,214,117.22 (+79.2%), respectively. CONCLUSION: Fewer dermatologists submit claims for KOH and O&P each year. Future studies should evaluate whether this is due to a loss of cost-efficacy, and secondly, if it is related to decreased reimbursement, burdensome in-office laboratory regulations, or changing provider preferences.
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Medicare/estatística & dados numéricos , Visita a Consultório Médico/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Dermatopatias Parasitárias/diagnóstico , Biópsia/economia , Biópsia/estatística & dados numéricos , Técnicas de Laboratório Clínico/economia , Técnicas de Laboratório Clínico/estatística & dados numéricos , Estudos Transversais , Dermatologia/economia , Dermatologia/estatística & dados numéricos , Humanos , Hidróxidos/economia , Indicadores e Reagentes , Medicare/economia , Visita a Consultório Médico/economia , Compostos de Potássio/economia , Utilização de Procedimentos e Técnicas/economia , Pele/parasitologia , Dermatopatias Parasitárias/economia , Dermatopatias Parasitárias/parasitologia , Estados UnidosRESUMO
OBJECTIVES: To assess the cost-effectiveness of increased consistent HIV testing among MSM in the Netherlands. METHODS: Among MSM testing at sexually transmitted infection clinics in the Netherlands in 2014-2015, approximately 20% tested consistently every 6 months. We examined four scenarios with increased percentage of MSM testing every 6 months: a small and a moderate increase among all MSM; a small and a moderate increase only among MSM with at least 10 partners in the preceding 6 months. We used an agent-based model to calculate numbers of HIV infections and AIDS cases prevented with increased HIV testing. These numbers were used in an economic model to calculate costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) due to increased testing, over 2018-2027, taking a healthcare payer perspective. RESULTS: A small increase in the percentage testing every 6 months among all MSM resulted in 490 averted HIV infections and an average ICER of &OV0556;27â900/QALY gained. A moderate increase among all MSM, resulted in 1380 averted HIV infections and an average ICER of &OV0556;36â700/QALY gained. Both were not cost-effective, with a &OV0556;20â000 willingness-to-pay threshold. Increasing the percentage testing every 6 months only among MSM with at least 10 partners in the preceding 6 months resulted in less averted HIV infections than increased testing among all MSM, but was on average cost-saving. CONCLUSION: Increased HIV testing can prevent considerable numbers of new HIV infections among MSM, but may be cost-effective only if targeted at high-risk individuals, such as those with many partners.
Assuntos
Análise Custo-Benefício , Testes Diagnósticos de Rotina/métodos , Transmissão de Doença Infecciosa/economia , Infecções por HIV/diagnóstico , Homossexualidade Masculina , Utilização de Procedimentos e Técnicas/economia , Adolescente , Adulto , Testes Diagnósticos de Rotina/economia , Transmissão de Doença Infecciosa/prevenção & controle , Infecções por HIV/economia , Infecções por HIV/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Países Baixos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Adulto JovemRESUMO
AIMS: Guidelines recommend testing HbA1c every 3-6 months in people with diabetes. In the United Kingdom (UK), primary care clinics are financially incentivized to monitor HbA1c at least annually and report proportions of patients meeting targets on 31 March. We explored the hypothesis that this reporting deadline may be associated with over-frequent or delayed HbA1c testing. METHODS: This analysis used HbA1c results from 100 000 people with diabetes during 2005-2014 in the Clinical Practice Research Datalink UK primary care database. Logistic regression was used to explore whether the four months prior to the deadline for quality reporting (December to March) or individual's previous HbA1c were aligned with retesting HbA1c within 60 days or > 1 year from the previous test, and identify other factors associated with the timing of HbA1c testing. RESULTS: Retesting HbA1c within 60 days or > 1 year was more common in December to March compared with other months of the year (odds ratio 1.06, 95% confidence interval 1.04-1.08 for retesting within 60 days). Those with higher HbA1c were more likely to have a repeat test within 60 days and less likely to have a repeat test > 1 year from the previous test. CONCLUSIONS: We have found that retesting HbA1c within 60 days and > 1 year from the previous test was more common in December to March compared with the other months of the year. This work suggests that both practice-centred administrative factors and patient-centred considerations may be influencing diabetes care in the UK.
Assuntos
Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 2/sangue , Hemoglobinas Glicadas/análise , Atenção Primária à Saúde/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Adulto , Idoso , Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Utilização de Procedimentos e Técnicas/economia , Reembolso de Incentivo , Reino Unido/epidemiologiaAssuntos
Anti-Inflamatórios/administração & dosagem , Stents Farmacológicos , Furoato de Mometasona/administração & dosagem , Seios Paranasais/cirurgia , Cuidados Pós-Operatórios/métodos , Padrões de Prática Médica/tendências , Utilização de Procedimentos e Técnicas/tendências , Implantes Absorvíveis , Anti-Inflamatórios/economia , Anti-Inflamatórios/uso terapêutico , Análise Custo-Benefício , Stents Farmacológicos/economia , Stents Farmacológicos/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Furoato de Mometasona/economia , Furoato de Mometasona/uso terapêutico , Obstrução Nasal/economia , Obstrução Nasal/etiologia , Obstrução Nasal/prevenção & controle , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Padrões de Prática Médica/economia , Utilização de Procedimentos e Técnicas/economia , Aderências Teciduais/economia , Aderências Teciduais/etiologia , Aderências Teciduais/prevenção & controle , Estados UnidosRESUMO
BACKGROUND: Robotic-assisted surgery (RAS) with its advantages continues to gain popularity among surgeons. This study analyzed the increased costs of RAS in common surgical procedures using the National Inpatient Sample. METHODS: Retrospective analysis of the 2012-2014 Healthcare Cost and Utilization Project-NIS was performed for the following laparoscopic/robotic procedures: cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy (TAH). Patients with additional concurrent procedures were excluded. Costs were compared between the laparoscopic procedures and their RAS counterparts. Total costs and charges for cholecystectomy (the most common procedure in the dataset) were compared based on the payer and characteristics of hospital (region, rural/urban, bed size, and ownership). RESULTS: A total of 91,630 surgeries (87,965 laparoscopic, 3665 robotic) were analyzed. The average cost for the laparoscopic group was $10,227 ± $4986 versus $12,340 ± $5880 for the robotic cases (p < 0.001). The overall and percentage increases for laparoscopic versus robotic for each procedure were as follows: cholecystectomy $9618 versus $10,944 (14%), ventral hernia repair $10,739 versus $13,441 (25%), right colectomy $12,516 versus $15,027 (20%), left colectomy $14,157 versus $17,493 (24%), sigmoidectomy $13,504 versus $16,652 (23%), abdominoperineal resection $17,708 versus $19,605 (11%), and TAH $9368 versus $9923 (6%). Hysterectomy was the only procedure performed primarily using RAS and it was found to have the lowest increase in costs. Increased costs were associated with even higher increases in charges, especially in investor-owned private hospitals. CONCLUSION: RAS is more costly when compared to conventional laparoscopic surgery. Additional costs may be lower in centers that perform a higher volume of RAS. Further analysis of long-term outcomes (including reoperations and readmissions) is needed to better compare the life-long treatment costs for both surgical approaches.