Cost-Effectiveness and Estimated Health Benefits of Treating Patients with Vitamin D in Pre-Dialysis.

Background The optimal timing of treatment with vitamin D therapy for patients with chronic kidney disease (CKD), vitamin D insufficiency, and secondary hyperparathyroidism (SHPT) is a pressing question in nephrology with economic and patient outcome implications. Objective The objective of this study was to estimate the cost-effectiveness of earlier vitamin D treatment in CKD patients not on dialysis with vitamin D insufficiency and SHPT. Design A cost-effectiveness analysis based on a Markov model of CKD progression was developed from the Medicare perspective. The model follows a hypothetical cohort of 1000 Stage 3 or 4 CKD patients over a 5-year time horizon. The intervention was vitamin D therapy initiated in CKD stages 3 or 4 through CKD stage 5/end-stage renal disease (ESRD) versus initiation in CKD stage 5/ESRD only. The outcomes of interest were cardiovascular (CV) events averted, fractures averted, time in CKD stage 5/ESRD, mortality, quality-adjusted life years (QALYs), and costs associated with clinical events and CKD stage. Results Vitamin D treatment in CKD stages 3 and 4 was a dominant strategy when compared to waiting to treat until CKD stage 5/ESRD. Total cost savings associated with treatment during CKD stages 3 and 4, compared to waiting until CKD stage 5/ESRD, was estimated to be $19.9 million. The model estimated that early treatment results in 159 averted CV events, 5 averted fractures, 269 fewer patient-years in CKD stage 5, 41 fewer deaths, and 191 additional QALYs. Conclusions Initiating vitamin D therapy in CKD stages 3 or 4 appears to be cost-effective, largely driven by the annual costs of care by CKD stage, CV event costs, and risks of hypercalcemia. Further research demonstrating causal relationships between vitamin D therapy and patient outcomes is needed to inform decision making regarding vitamin D therapy timing.

Leaveism in English and Welsh police forces: baseline reference values.

BACKGROUND: Leaveism is a recently coined term for alternative attendance behaviours to sickness absence and sickness presence. Initial studies suggest that leaveism might mask the true extent of sickness in organizations and represent a response to perceived job insecurity, the belief that sickness absence could harm promotion prospects, and low job gratification. AIMS: To generate baseline reference values for leaveism in English and Welsh police forces to facilitate benchmarking and risk-reduction activities. METHODS: Officers represented by the Police Federation of England and Wales contributed survey data on the incidence of three leaveism dimensions in the year to February 2016. We applied descriptive statistics to characterize leaveism and Pearson's χ2 tests to examine differences in incidence rates by socio- and occupational-demographic factors. RESULTS: Annual leave or rest days were used to take time off from work due to physical health complaints by 8499/14 451 (59%) of respondents and psychological health complaints by 5983/14 326 (42%) (dimension 1). Work was taken home that could not be completed in normal working hours by 7515/14 959 (50%) of respondents (dimension 2), and 5974/14 963 (40%) reported having worked while on annual leave in order to catch up with work (dimension 3). Incidence rates on dimensions 2 and 3 differed markedly by rank, with higher ranks reporting higher rates. CONCLUSIONS: These sector-wide findings suggest that leaveism is a cause for concern. Further research is required to identify sector-specific causes of leaveism with a view to informing interventions to tackle the problem.

Use of Chronic Care Management Codes for Medicare Beneficiaries: a Missed Opportunity?

BACKGROUND: Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions. OBJECTIVE: Characterize use of the Chronic Care Management (CCM) code in New England in 2015. DESIGN: Retrospective observational analysis. PARTICIPANTS: All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015. INTERVENTION: None. MAIN MEASURES: The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services. KEY RESULTS: Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model. CONCLUSIONS: The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare's most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.

Benefit Type and Care Source in Relation to Mammography Screening and Breast Cancer Stage at Diagnosis Among DoD Beneficiaries.

BACKGROUND: Type of insurance and out-of-pocket costs influence the use of medical care. Specifically, type of insurance can impact an individual's likelihood of receiving a screening mammogram. Additionally, variation in tumor stage at diagnosis exists for patients with different types of insurance. It is not clear whether different benefit types and care sources differ in breast cancer care and outcomes among Department of Defense (DoD) beneficiaries. METHODS: The objective of this study was to examine differences in screening mammography and tumor stage at diagnosis between different benefit types (TRICARE Prime vs. non-Prime) and among different care sources (direct care, purchased care, and both) in the DoD Military Health System. Study subjects were women 40 to 64 years of age, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess differences by benefit type and care source in receipt of screening mammography before diagnosis and tumor stage at diagnosis. FINDINGS: A total of 2,668 women were included in this study. Patients with Prime were more likely to receive a screening mammography and have an earlier tumor stage than those with non-Prime. Women with direct care were more likely to have an earlier tumor stage but less likely to receive a screening mammogram than those with purchased care. DISCUSSION: In an equal access health care system, the use of mammography screening and tumor stage at diagnosis may differ by benefit type and care source among DoD beneficiaries. To our knowledge, this was the first study to assess mammography screening and tumor stage differences by benefit type and care source in the Military Health System. Although underlying reasons for the differences are not clear, they may be related to out-of-pocket costs, distance from medical treatment facilities, and frequency of doctor visits for other medical problems. Further research is needed to assess these differences and related factors among DoD beneficiaries.

Specifying a State Guaranteed Health Benefits package for Kazakhstan: lessons for emerging economies and middle-income countries.

The Government of Kazakhstan is engaged in a "root and branch" modernisation of the health care sector. One aspect of the raft of modernisation programmes was to revisit the State Guaranteed Health Benefits Package, with the aim to review citizen entitlements to healthcare. This paper reviews the ongoing evolution of the planning of the health benefits package in Kazakhstan, with the main challenges encountered, and critical lessons learned, to be considered for similar attempts elsewhere. The main conclusions are that: the design process requires a blend of technical and socio-political analysis, because it attracts public interest, and therefore political risks; the scale and burden of analysis need to be kept to manageable proportions; and the relationship between the benefits package and funding modalities needs to be carefully managed by the State, to ensure access to declared entitlements to all members, including the most vulnerable, while keeping the package financially feasible. © 2017 The Authors. International Journal of Health Planning and Management published by John Wiley & Sons, Ltd.

Pharmacy Benefits Management in the Veterans Health Administration Revisited: A Decade of Advancements, 2004-2014.

Over the past decade, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Services (PBM) has enhanced its formulary management activities and added programs to ensure that the national drug plan continues to meet the pharmacy needs of veterans and to promote safe and appropriate drug therapy in the face of rising medication expenditures. This article describes the broad range of services provided by the VA PBM that work in partnership to deliver a high-quality and sustainable pharmacy benefit for veterans. In support of formulary management, VA PBM pharmacists prepare extensive clinical guidance documents (e.g., drug monographs and criteria for use) that are used by physicians and pharmacists with operational and clinical oversight of the VA national formulary. The VA PBM has utilized various contracting techniques and continually evaluates drug utilization data to identify opportunities for potential savings. Remarkably, since before 2004, the average acquisition cost for a 1-month supply of medication has remained fairly stable at approximately $13-$15. Two new VA PBM programs are the VA Center for Medication Safety (VA MedSAFE) and the Clinical Pharmacy Practice Office (CPPO). VA MedSAFE is a comprehensive pharmacovigilance program focused on the detection, assessment, and prevention of adverse drug events, and CPPO is dedicated to improving safe and appropriate medication use by supporting and expanding clinical pharmacy practice. Moving forward, the VA PBM will consider new initiatives to stay at the forefront of providing quality care while maintaining economic viability. DISCLOSURES: No outside funding supported this research. This work was supported by VA Pharmacy Benefits Management Services (VA PBM), Hines, Illinois, and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. Glassman is co-director of the VA Center for Medication Safety, which is part of the VA PBM. He is also part of the Medical Advisory Panel for the VA PMB. All other authors are employed by the VA PBM. The views expressed in this article are those of the authors, and no official endorsement by the U.S. Department of Veteran Affairs or the U.S. government is intended or should be inferred. Study concept and design were contributed by Valentino, Cunningham, Good, Aspinall, and Sales. Calabrese and Ourth took the lead in data collection, along with Good, Cunningham, Aspinall, Sales, Burk, Moore, Neuhauser, and Golterman. Data interpretation was performed by Burk, Newhauser, and Golterman, along with Glassman, Calabrese, Moore, and Ourth. The manuscript was written by Aspinall and Sales, along with Burk, Newhauser, Golterman, Ourth, and Cunningham. Good, Glassman, and Moore revised the manuscript, along with Calabrese, Valentino, and Aspinall.

In the United States, "Opt-Out" States Show No Increase in Access to Anesthesia Services for Medicare Beneficiaries Compared with Non-"Opt-Out" States.

In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of "opt-out" states likely experienced smaller growth in anesthesia utilization rates compared with non-"opt-out" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.

Health and economic benefits of public financing of epilepsy treatment in India: An agent-based simulation model.

OBJECTIVE: An estimated 6-10 million people in India live with active epilepsy, and less than half are treated. We analyze the health and economic benefits of three scenarios of publicly financed national epilepsy programs that provide: (1) first-line antiepilepsy drugs (AEDs), (2) first- and second-line AEDs, and (3) first- and second-line AEDs and surgery. METHODS: We model the prevalence and distribution of epilepsy in India using IndiaSim, an agent-based, simulation model of the Indian population. Agents in the model are disease-free or in one of three disease states: untreated with seizures, treated with seizures, and treated without seizures. Outcome measures include the proportion of the population that has epilepsy and is untreated, disability-adjusted life years (DALYs) averted, and cost per DALY averted. Economic benefit measures estimated include out-of-pocket (OOP) expenditure averted and money-metric value of insurance. RESULTS: All three scenarios represent a cost-effective use of resources and would avert 800,000-1 million DALYs per year in India relative to the current scenario. However, especially in poor regions and populations, scenario 1 (which publicly finances only first-line therapy) does not decrease the OOP expenditure or provide financial risk protection if we include care-seeking costs. The OOP expenditure averted increases from scenarios 1 through 3, and the money-metric value of insurance follows a similar trend between scenarios and typically decreases with wealth. In the first 10 years of scenarios 2 and 3, households avert on average over US$80 million per year in medical expenditure. SIGNIFICANCE: Expanding and publicly financing epilepsy treatment in India averts substantial disease burden. A universal public finance policy that covers only first-line AEDs may not provide significant financial risk protection. Covering costs for both first- and second-line therapy and other medical costs alleviates the financial burden from epilepsy and is cost-effective across wealth quintiles and in all Indian states.

Beneficios para la salud digestiva del salvado de trigo; evidencias científicas / Positive effects of wheat bran for digestive health; scientific evidence

El salvado de trigo (ST) es un alimento muy rico en fibra insoluble, constituida principalmente por arabinoxilanos y, en menor proporción, celulosa y β-glucanos, así como por vitaminas, minerales y compuestos polifenólicos antioxidantes. El ST interviene en la regulación de la fisiología y la salud digestivas: retrasa el vaciado gástrico, acelera el tránsito intestinal e incrementa la masa fecal. El incremento de la masa fecal es mayor con el consumo de ST que con otros cereales como la avena o las verduras y frutas. No obstante, el ácido fítico presente en el salvado puede reducir la absorción de algunos minerales (Ca, Mg, Fe y Zn), debido a la formación de complejos. Diferentes estudios han comprobado que el consumo de salvado tiene efecto protector frente a varias enfermedades: cardiovasculares, obesidad y algunas gastrointestinales, como estreñimiento, enfermedad diverticular y cáncer colorrectal, entre otras. En España, el consumo de fibra (18 g/día en promedio) está muy por debajo del recomendado 30 g/día, por lo que el aumento del consumo de alimentos con salvado de trigo ayudaría a alcanzar esta recomendación y a reducir la incidencia de enfermedades asociadas a una baja ingesta de fibra (AU)

Wheat bran (ST) is very rich in insoluble fiber, consisting mainly arabinoxylans and, to a lesser extent, cellulose and β-glucans, as well as vitamins, minerals and antioxidants polyphenolic. The ST is involved in the regulation of gastrointestinal physiology and health: delayed gastric emptying and intestinal transit speeds and increases fecal bulk. The ST has an effect on faecal bulking greater than other grains such as oats or vegetables and fruits. However, phytic acid present in the bran may reduce the absorption of certain minerals (Ca, Mg, Fe and Zn), due to formation phytate-mineral complexes. Different studies have shown that consumption of bran has protective effect against different diseases: cardiovascular, obesity and some gastrointestinal diseases, including constipation, diverticular disease and colorectal cancer, among others. In Spain the consumption of fiber (18 g/day on average) is below the recommended (30 g/day), so the increased consumption of foods with wheat bran help achieve this recommendation and reduce the incidence of diseases associated a low intake of fiber (AU)

Achieving medication adherence through value-based insurance design.

Key findings. Five main features of value-based insurance design plans were found to be associated with higher rates of medication adherence: (1) Plans that provide more generous coverage (2) Plans that target high-risk patients (3) Plans that offer wellness programs (4) Plans that do not offer disease management programs (5) Plans that make the benefit available only for medication order by mail.

Estimating the incremental net health benefit of requirements for cardiovascular risk evaluation for diabetes therapies.

PURPOSE: To evaluate the advantages and disadvantages of pre-approval requirements for safety data to detect cardiovascular (CV) risk contained in the December 2008 U.S. Food and Drug Administration (FDA) guidance for developing type 2 diabetes drugs compared with the February 2008 FDA draft guidance from the perspective of diabetes population health. METHODS: We applied the incremental net health benefit (INHB) framework to quantify the benefits and risks of investigational diabetes drugs using a common survival metric (life-years [LYs]). We constructed a decision analytic model for clinical program development consistent with the requirements of each guidance and simulated diabetes drugs, some of which had elevated CV risk. Assuming constant research budgets, we estimate the impact of increased trial size on drugs investigated. We aggregate treatment benefit and CV risks for each approved drug over a 35-year horizon under each guidance. RESULTS: The quantitative analysis suggests that the December 2008 guidance adversely impacts diabetes population health. INHB was -1.80 million LYs, attributable to delayed access to diabetes therapies (-0 .18 million LYs) and fewer drugs (-1.64 million LYs), but partially offset by reduced CV risk exposure (0.02 million LYs). Results were robust in sensitivity analyses. CONCLUSION: The health outcomes impact of all potential benefits and risks should be evaluated in a common survival measure, including health gain from avoided adverse events, lost health benefits from delayed or for gone efficacious products, and impact of alternative policy approaches. Quantitative analysis of the December 2008 FDA guidance for diabetes therapies indicates that negative impact on patient health will result.

Benefits and risks in the broader incorporation of ultrasound in medical education / Riesgos y beneficios de una mayor incorporación de la ecografía en la educación médica

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Influence of insurance benefit criteria on the administration rate of osteoporosis drugs in postmenopausal females.

BACKGROUND: Preventive measures need to be implemented to lower the incidence of osteoporotic fractures. Osteoporotic fractures increase morbidity and mortality as well as impose a socioeconomic burden; however, current research is limited to the administration rates of osteoporosis drugs for Korean postmenopausal females. METHODS: This study represents a nationwide, observational, and cross-sectional survey that investigates the administration rates of osteoporosis drugs based upon a bone mineral density (BMD) test performed on Korean postmenopausal patients who visited outpatient orthopedic clinics. BMD test results were examined in postmenopausal female patients (50 to 80 years of age); subsequently, the patients were classified into an osteoporosis group, osteopenia group, and normal group. The administration rates of osteoporosis drugs and bisphosphonates were then analyzed. The osteoporosis group was subdivided into a T-score less than -3.0 group and a T-score between -3.0 and -2.5 group that were separately analyzed. RESULTS: Based on the lumbar spine BMD, the rate of administration of osteoporosis drugs in the osteoporosis group was 42.1%, which was significantly higher compared to the osteopenia group or normal group. A significantly low bone mineral density was observed in patients who were administered bisphosphonates. Based on the lumbar spine BMD, the administration rate of osteoporosis drugs in the group with a T-score between -3.0 and -2.5 (34.2%) was significantly lower than the group with a T-score less that -3.0 (46.2%). The bisphosphonate administration rate was also significantly low; however, the administration rate for osteoporosis drugs was significantly lower than that of the osteopenia group. CONCLUSIONS: Only about 40% of Korean postmenopausal female patients with osteoporosis were administered osteoporosis drugs. The administration rate in patients with a T-score between -3.0 and -2.5 was particularly low and active treatment to prevent osteoporotic fractures is required in this group.

Influence of Insurance Benefit Criteria on the Administration Rate of Osteoporosis Drugs in Postmenopausal Females

BACKGROUND: Preventive measures need to be implemented to lower the incidence of osteoporotic fractures. Osteoporotic fractures increase morbidity and mortality as well as impose a socioeconomic burden; however, current research is limited to the administration rates of osteoporosis drugs for Korean postmenopausal females. METHODS: This study represents a nationwide, observational, and cross-sectional survey that investigates the administration rates of osteoporosis drugs based upon a bone mineral density (BMD) test performed on Korean postmenopausal patients who visited outpatient orthopedic clinics. BMD test results were examined in postmenopausal female patients (50 to 80 years of age); subsequently, the patients were classified into an osteoporosis group, osteopenia group, and normal group. The administration rates of osteoporosis drugs and bisphosphonates were then analyzed. The osteoporosis group was subdivided into a T-score less than -3.0 group and a T-score between -3.0 and -2.5 group that were separately analyzed. RESULTS: Based on the lumbar spine BMD, the rate of administration of osteoporosis drugs in the osteoporosis group was 42.1%, which was significantly higher compared to the osteopenia group or normal group. A significantly low bone mineral density was observed in patients who were administered bisphosphonates. Based on the lumbar spine BMD, the administration rate of osteoporosis drugs in the group with a T-score between -3.0 and -2.5 (34.2%) was significantly lower than the group with a T-score less that -3.0 (46.2%). The bisphosphonate administration rate was also significantly low; however, the administration rate for osteoporosis drugs was significantly lower than that of the osteopenia group. CONCLUSIONS: Only about 40% of Korean postmenopausal female patients with osteoporosis were administered osteoporosis drugs. The administration rate in patients with a T-score between -3.0 and -2.5 was particularly low and active treatment to prevent osteoporotic fractures is required in this group.

Therapeutic potential of resveratrol in obesity and type 2 diabetes: new avenues for health benefits?

The number of people suffering from metabolic disorders is dramatically increasing worldwide. The need for new therapeutic strategies to combat this growing epidemic of metabolic diseases is therefore also increasing. In 2003, resveratrol was discovered to be a small molecule activator of sirtuin 1 (SIRT1), an important molecular target regulating cellular energy metabolism and mitochondrial homeostasis. Rodent studies have clearly demonstrated the potential of resveratrol to improve various metabolic health parameters. To date, however, only limited clinical data are available that have systematically examined the health benefits of resveratrol in metabolically challenged humans. This short review will give an overview of the currently available clinical studies examining the effects of resveratrol on obesity and type 2 diabetes from a human perspective.