Estimated Medicare Part B Savings From Inflationary Rebates.

This study uses annual Medicare Part B spending data to examine the potential savings from the drug pricing reforms in the Inflation Reduction Act of 2022.

Whole Grain Intakes Are Associated with Healthcare Cost Savings Following Reductions in Risk of Colorectal Cancer and Total Cancer Mortality in Australia: A Cost-of-Illness Model.

Whole grain consumption has been associated with the reduced risk of several chronic diseases with significant healthcare monetary burden, including cancer. Colorectal cancer (CRC) is one of the most common cancers globally, with the highest rates reported in Australia. Three servings of whole grains provide a 15% reduction in total cancer and 17% reduction in CRC risk; however, 70% of Australians fall short of this level of intake. The aim of this study was to assess the potential savings in healthcare costs associated with reductions in the relative risk of CRC and total cancer mortality following the whole grain Daily Target Intake (DTI) of 48 g in Australia. A three-step cost-of-illness analysis was conducted using input parameters from: (1) estimates of current and targeted whole grain intakes among proportions (5%, 15%, 50%, and 100%) of the Australian adult (≥20 years) population; (2) estimates of reductions in relative risk (with 95% confidence intervals) of CRC and total cancer mortality associated with specific whole grain intake from meta-analysis studies; and (3) estimates of annual healthcare costs of CRC and all cancers from disease expenditure national databases. A very pessimistic (5% of population) through to universal (100% of population) adoption of the recommended DTI in Australia were shown to potentially yield savings in annual healthcare costs equal to AUD 1.9 (95% CI 1.2-2.4) to AUD 37.2 (95% CI 24.1-48.1) million for CRC and AUD 20.3 (95% CI 12.2-27.0) to AUD 405.1 (95% CI 243.1-540.1) million for total cancers. As treatment costs for CRC and other cancers are increasing, and dietary measures exchanging whole grains for refined grains are not cost preclusive nor does the approach increase energy intake, there is an opportunity to facilitate cost-savings along with reductions in disease for Australia. These results suggest specific benefits of encouraging Australians to swap refined grains for whole grains, with greater overall adherence to suggestions in dietary guidelines.

Safety assessment of intraparenchymal central nervous system biopsies: Single institution healthcare value review.

The study objective was to evaluate a single institution experience with adult stereotactic intracranial biopsies and review any projected cost savings as a result of bypassing intensive care unit (ICU) admission and limited routine head computed tomography (CT). The authors retrospectively reviewed all stereotactic intracranial biopsies performed at a single institution between February 2012 and March 2019. Primary data collection included ICU length of stay (LOS), hospital LOS, ICU interventions, need for reoperation, and CT use. Secondarily, location of lesion, postoperative hematoma, neurological deficit, pathology, and preoperative coagulopathy data were collected. There were 97 biopsy cases (63% male). Average age, ICU LOS, and total hospital stay were 58.9 years (range; 21-92 years), 2.3 days (range; 0-40 days), and 8.8 days (range 1-115 days), respectively. Seventy-five (75 of 97) patients received a postoperative head CT. No patients required medical or surgical intervention for complications related to biopsy. Eight patients required transfer from the ward to the ICU (none directly related to biopsy). Nine patients transferred directly to the ward postoperatively (none required transfer to ICU). Of the patients who did not receive CT or went directly to the ward, none had extended LOS or required transfer to ICU for neurosurgical concerns. Eliminating routine head CT and ICU admission translates to approximately $584,971 in direct cost savings in 89 cases without a postoperative ICU requirement. These practice changes would save patients' significant hospitalization costs, decrease healthcare expenditures, and allow for more appropriate hospital resource use.

Reducing administrative costs in US health care: Assessing single payer and its alternatives.

OBJECTIVE: Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them. DATA SOURCES: Literature review and national utilization and expenditure data. STUDY DESIGN: We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing. DATA EXTRACTION: For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters. PRINCIPAL FINDINGS: Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies. CONCLUSION: Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.

Return on Investment: Medical Savings of an Employer-Sponsored Digital Intensive Lifestyle Intervention, Weight Loss.

OBJECTIVE: This study aimed to determine the medical cost impact and return on investment (ROI) of a large, commercial, digital, weight-management intensive lifestyle intervention (ILI) program (Real Appeal). METHODS: Participants in this program were compared with a control group matched by age, sex, geographic region, health risk, baseline medical costs, and chronic conditions. Medical costs were defined as the total amount paid for all medical expenses, inclusive of both the insurers' and the study participants' responsibility. RESULTS: In the 3 years following program registration, the intent-to-treat (ITT) cohort had significantly lower medical expenditures than the matched controls, with an average of -$771 or 12% lower costs (P = 0.002). Among 4,790 ITT participants, a total savings of $3,693,090 compared with total program costs of $1,639,961 translated into a 2.3:1 ROI. Program completers (n = 3,990), who attended more sessions than the overall ITT group, had greater mean weight loss (-4.4%), greater cost savings (-$956 or 14%), and an ROI of 2.0:1 over the 3-year time frame compared with matched controls. CONCLUSIONS: The findings demonstrated that the digital weight-management ILI was associated with a significantly positive ROI. Employers and payers willing to cover the cost of an ILI that produces both weight loss and demonstrated cost benefits can improve health and save money for their population with overweight or obesity.

Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State.

BACKGROUND: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS: A total of 417,861 Medicare medical and surgical patients. MEASURES: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

Robotic total knee arthroplasty: A missed opportunity for cost savings in Bundled Payment for Care Improvement initiatives?

BACKGROUND: The use of robotic total knee arthroplasty has become increasingly prevalent. Proponents of robotic total knee arthroplasty tout its potential to not only improve outcomes, but also to reduce costs compared with traditional total knee arthroplasty. Despite its potential to deliver on the value proposition, whether robotic total knee arthroplasty has led to improved outcomes and cost savings within Medicare's Bundled Payment for Care Improvement initiative remains unexplored. METHODS: Medicare beneficiaries who underwent total knee arthroplasty designated under Medicare severity diagnosis related group 469 or 470 in the year 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals participating in the Bundled Payment for Care Improvement were identified using the Bundled Payment for Care Improvement analytic file. We calculated risk-adjusted, price-standardized payments for the surgical episode from admission through 90-days postdischarge. Outcomes, utilization, and spending were assessed relative to variation between robotic and traditional total knee arthroplasty. RESULTS: Overall, 198,371 patients underwent total knee arthroplasty (traditional total knee arthroplasty: n= 194,020, 97.8% versus robotic total knee arthroplasty: n = 4,351, 2.2%). Among the 3,272 hospitals that performed total knee arthroplasty, only 300 (9.3%) performed robotic total knee arthroplasty. Among the 183 participating in the Bundled Payment for Care Improvement, only 40 (19%) hospitals performed robotic total knee arthroplasty. Risk-adjusted 90-day episode spending was $14,263 (95% confidence interval $14,231-$14,294) among patients who underwent traditional total knee arthroplasty versus $13,676 (95% confidence interval $13,467-$13,885) among patients who had robotic total knee arthroplasty. Patients who underwent robotic total knee arthroplasty had a shorter length of stay (traditional total knee arthroplasty: 2.3 days, 95% confidence interval: 2.3-2.3 versus robotic total knee arthroplasty: 1.9 days, 95% confidence interval: 1.9-2.0), as well as a lower incidence of complications (traditional total knee arthroplasty: 3.3%, 95% confidence interval: 3.2-3.3 versus robotic total knee arthroplasty: 2.7%, 95% confidence interval: 2.3-3.1). Of note, patients who underwent robotic total knee arthroplasty were less often discharged to a postacute care facility than patients who underwent traditional total knee arthroplasty (traditional total knee arthroplasty: 32.4%, 95% confidence interval: 32.3-32.5 versus robotic total knee arthroplasty: 16.8%, 95% confidence interval 16.1-17.6). Both Bundled Payment for Care Improvement and non-Bundled Payment for Care Improvement hospitals with greater than 50% robotic total knee arthroplasty utilization had lower spending per episode of care versus spending at hospitals with less than 50% robotic total knee arthroplasty utilization. CONCLUSION: Overall 90-day episode spending for robotic total knee arthroplasty was lower than traditional total knee arthroplasty (Δ $-587, 95% confidence interval: $-798 to $-375). The decrease in spending was attributable to shorter length of stay, fewer complications, as well as lower utilization of postacute care facility. The cost savings associated with robotic total knee arthroplasty was only realized when robotic total knee arthroplasty volume surpassed 50% of all total knee arthroplasty volume. Hospitals participating in the Bundled Payment for Care Improvement may experience cost-saving with increased utilization of robotic total knee arthroplasty.

Utilization fraction of rhinoplasty instrument sets: Model for efficient use of surgical instruments.

OBJECTIVES: Recognize the avoidable costs incurred due to overpacking of rhinoplasty instrument trays. Reduce rhinoplasty instrument trays by including only instruments used frequently. Establish methods to reduce trays prepared for other otolaryngologic procedures. METHODS: This is a prospective study. The study evaluates the specific use of instruments opened for rhinoplasty procedures at the New York Eye & Ear Infirmary of Mount Sinai. Instruments were counted in 10 rhinoplasty cases. Usage rate was calculated for each instrument. Additionally, all instruments used in at least 20% of cases were noted. This "20%" threshold was used to create new rhinoplasty tray inventories more reflective of actual instrument usage. Some instruments above the 20% threshold were included in multiples (i.e. two Adson Brown forceps vs. one curved iris scissor). RESULTS: 189 instruments were opened, and 32 instruments were used on average in each rhinoplasty. 55 instruments were used in at least 20% of cases. The 55 "high usage" instruments were used to create new, reduced rhinoplasty tray inventory lists. Based on our analysis, a new rhinoplasty tray inventory was created comprised of 68 instruments, a 64% reduction from 189. CONCLUSION: Instruments are sterilized and packed in gross excess for rhinoplasty procedures. Previously published figures estimate re-sterilization costs of $0.51 to $0.77 per instrument. Reduction in instruments opened from 189 to 68 is expected to lead to cost savings ranging from $62 to $93 per case, yielding a savings between $6200 and $9300 per 100 cases performed. LEVEL OF EVIDENCE: II-3.

Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Reducing the cost of robotic hysterectomy: assessing the safety and efficacy of using prograsp forceps in lieu of needle holder for vaginal cuff closure.

Robotic-assisted surgery is criticized for its high cost. As surgeons get more experienced in robotic surgery, modifications to existing techniques are tried to reduce surgical costs. Vaginal cuff closure using prograsp forceps in lieu of needle holder can be safe and cost-effective in patients undergoing robotic-assisted hysterectomy. The objective of this study is to compare the safety, efficacy, and cost effectiveness of using prograsp forceps in lieu of needle holder for suturing the vaginal cuff after robotic-assisted hysterectomy. This was a single-institution retrospective review of patients who underwent robotic-assisted hysterectomy for benign and malignant conditions from October 2015 to August 2018. Patients were stratified based on whether prograsp forceps or needle holder was used for suturing vaginal cuff. Data obtained included demographic, surgical data, and postoperative outcomes. Mann-Whitney U test and Chi-square test were used to compare qualitative and quantitative data, respectively. 367 patients underwent robotic-assisted hysterectomies during this period. 75 patients belonged to the needle holder cohort; 292 patients had vaginal cuff closure using prograsp forceps. Vault closure time was comparable between the groups (6.4 vs. 6.6 p = 0.33). There were no significant differences in the postoperative vault-related complications between groups. There was no instrument damage in either group. Using prograsp saved 220 USD in instrument-related charges. This study shows that using prograsp in lieu of needle holder for suturing is safe, there is no increase in operative time or complications, and there is a cost advantage.

Robotic-assisted repair of complex ventral hernia: can it pay off?

Pressure on health care providers is growing due to capping of remuneration for medical services in most Western European countries. We wanted to investigate, if robotic-assisted ventral hernia repair is reasonable from an economic point of view in our setting. Patients undergoing open or robotic-assisted repair for complex abdominal wall hernia using a Transversus Abdominis Release (TAR) between September 2017 and January 2019 were included. Procedure-related costs were calculated exact to the minute and cost unit accounting for the postoperative in-patient stay was done. Abdominal wall reconstruction using the TAR-technique was done in a total of 26 (10 female) patients via an open (n = 10) or robotic-assisted (n = 16) approach. No significant difference was seen in regard to age, BMI and ASA scores between subgroups. Time for operation was longer (253.5 vs 211.5 min; p = 0.0322), while postoperative hospital stay was shorter for patients operated with a robotic-assisted approach (4.5 vs 12.5 days; p < 0.005). Procedure-related costs were 2.7-fold higher when a robotic-assisted reconstruction was done (EUR 5397 vs. 1989), while total costs for in-patient stay were about 60% lower (EUR 2715 vs 6663). Currently, revenues by national insurance account for a total of EUR 9577 leading to a profit of EUR 1465 and 925 for the robotic-assisted and open myofascial release, respectively. In addition, 30-day re-admission rate was in favor of the robotic-assisted approach as well (6.3% vs 20%). From an economic point of view, robotic-assisted TAR for complex ventral hernia repair is a viable option in our setting. Higher procedure-related costs are offset by a significant shorter hospital stay. The economic advantage goes along with improvement in outcome of patients.

Robot-assisted sialolithotomy with sialoendoscopy: a review of safety, efficacy and cost.

OBJECTIVE: Review the safety, efficacy and cost of robot-assisted sialolithotomy with sialoendoscopy (RASS) for large submandibular gland hilar sialoliths. STUDY DESIGN: Retrospective case series. METHODS: Patients ≥18 years diagnosed with submandibular hilar sialolithiasis between 1/1/2015 and 7/31/2018 who underwent RASS were identified. Procedure success, post-operative complications, procedure duration, and costs associated with the procedure were reviewed. RESULTS: 33 patients fit inclusion criteria. 94% of patients had successful sialolith removal. Mean sialolith size was 8.9 mm. 15.1% had transient tongue paresthesia. 0% had permanent tongue paresthesia compared to a 2% rate of lingual nerve damage cited in the literature for combined approach sialolithotomy (CAS). The average total cost was $16,921. Insurance paid 100%, 90-99%, 70-89.9%, and 40-69.9% of the expected reimbursement in 43.8%, 18.7%, 18.7% and 12.5% of patients respectively. 6% of patients self-paid. Compared to CAS, the cost of reusable robotic arms and drapes totaled $475, though these costs were included in the standardized operative cost per minute and were not forwarded to the patient. The mean procedure time was 62 minutes. Compared to published mean procedure times for CAS, the reduced operative time may account for a savings of $3332-$6069. CONCLUSION: RASS is a safe modality for submandibular hilar sialolith removal with a high success rate, low risk for temporary tongue paresthesia, and lower rate of permeant lingual nerve damage compared to CAS. Compared with CAS, RASS may result in a net reduction of operative room costs given its shorter procedure time.

Costs of Definitive Chemoradiation, Surgery, and Adjuvant Radiation Versus De-Escalated Adjuvant Radiation per MC1273 in HPV+ Cancer of the Oropharynx.

PURPOSE: De-escalated treatment for human papillomavirus (HPV)+ oropharynx squamous cell carcinoma (OPSCC) has shown promising initial results. Health-care policy is increasingly focusing on high-value care. This analysis compares the cost of care for HPV+ OPSCC treated with definitive chemoradiation (CRT), surgery and adjuvant radiation (RT), and surgery and de-escalated CRT on MC1273. METHODS AND MATERIALS: MC1273 is a prospective, phase 2 study evaluating adjuvant CRT to 30 to 36 Gy plus docetaxel for HPV+ OPSCC after surgery for high-risk patients. Matched standard-of-care control groups were retrospectively identified for patients treated with definitive CRT or adjuvant RT. Standardized costs were evaluated before radiation, during treatment (during RT), and at short-term (6 month) and long-term (7-24 month) follow-up periods. RESULTS: A total of 56 definitive CRT, 101 adjuvant RT, and 66 MC1273 patients were included. The CRT arm had more T3-4 disease (63% vs 17-21%) and higher N2c-N3 disease (52% vs 20-24%) vs both other groups. The total treatment costs in the CRT, adjuvant RT, and MC1273 groups were $47,763 (standard deviation [SD], $19,060], $57,845 (SD, $17,480), and $46,007 (SD, $9019), respectively, and the chemotherapy and/or RT costs were $39,936 (SD, $18,480), $26,603 (SD, $12,542), and $17,864 (SD, $3288), respectively. The per-patient, per-month, average short-term follow-up costs were $3860 (SD, $10,525), $1072 (SD, $996), and $972 (SD, $833), respectively, and the long-term costs were $978 (SD, $2294), $485 (SD, $1156), and $653 (SD, $1107), respectively. After adjustment for age, T-stage, and N-stage, treatment costs remained lower for CRT and MC1273 versus adjuvant RT ($45,450 and $47,114 vs $58,590, respectively; P < .001), whereas the total per-patient, per-month follow-up costs were lower in the MC1273 study group and adjuvant RT versus CRT ($853 and $866 vs $2030, respectively; P = .03). CONCLUSIONS: MC1273 resulted in 10% and 20% reductions in global costs compared with standard-of-care adjuvant RT and definitive CRT treatments. Substantial cost savings may be an added benefit to the already noted low toxicity and maintained quality of life of treatment per MC1273.

Provider networks and health plan premium variation.

OBJECTIVE: To examine how plan premiums are associated with physician network breadth, hospital network breadth, and hospital network quality on the Affordable Care Act's Health Insurance Marketplaces in all 50 states and the DC in 2016. DATA SOURCES: Data on plan premiums and characteristics came from 2016 Robert Wood Johnson Foundation Health Insurance Exchange (HIX) Compare. Provider network information was obtained from Vericred. Hospital characteristics were obtained from CMS Hospital Compare and the American Hospital Association (AHA) survey. STUDY DESIGN: We analyzed how plan premiums were associated with variations in physician network breadth, hospital network breadth, and hospital network quality using ordinary least square regressions with state-rating area fixed effects and carrier fixed effects. PRINCIPAL FINDINGS: Plan premiums were positively associated with physician network breadth and hospital network breadth. We find the following statistically significant results: a one standard deviation increase in physician network breadth was linked to a premium increase of 2.8 percent or $101 per year; a one standard deviation increase in hospital network breadth was linked to a premium increase of 2.4 percent or $86 per year. There was no significant association between premiums and hospital network quality, as measured by hospital star ratings and the inclusion of teaching hospitals or the top-20 hospitals nationwide. CONCLUSIONS: Physician network breadth and hospital network breadth contributed positively to plan premiums. The roles of the two types of provider network breadth are quantitatively similar. Premiums appear to be insensitive to hospital network quality.

[Effects of a multifactorial intervention for improving frailty on risk of long-term care insurance certification, death, and long-term care cost among community-dwelling older adults: A quasi-experimental study using propensity score matching].

Objectives　To examine the effects of a multifactorial intervention for improving frailty-comprising resistance exercise and nutritional and psychosocial programs-on the risk of long-term care insurance (LTCI) certification, death, and long-term care (LTC) cost among community-dwelling older adults.Methods　Seventy-seven individuals (47 in 2011 and 30 in 2013) from the Hatoyama Cohort Study (742 individuals) participated in a multifactorial intervention. Non-participants were from the same cohort (including people who were invited to participate in the multifactorial intervention but declined). We performed propensity score matching with a ratio of 1 : 2 (intervention group vs. non-participant group). Afterward, 70 individuals undergoing the multifactorial intervention and 140 non-participants were selected. The risk of LTCI certification and/or death and the mean LTC cost during the follow-up period (32 months) were compared using the Cox proportional hazards model and generalized linear model (gamma regression model).Results　The incidence of new LTCI certification (per 1,000 person-years) tended to be lower in the intervention group than in the non-participant group (1.8 vs. 3.6), but this was not statistically significant as per the Cox proportional hazards model (hazard ratio=0.51, 95% confidence interval [CI]=0.17-1.54). Although the incidence of LTC cost was not significant, the mean cumulative LTC cost during the 32 months and the mean LTC cost per unit during the follow-up period (1 month) were 375,308 JPY and 11,906 JPY/month, respectively, in the intervention group and 1,040,727 JPY and 33,460 JPY/month, respectively, in the non-participant group. Cost tended to be lower in the intervention group than in the non-participant group as per the gamma regression model (cumulative LTC cost: cost ratio=0.36, 95%CI=0.11-1.21, P=0.099; LTC cost per unit follow-up period: cost ratio=0.36, 95%CI=0.11-1.12, P=0.076).Conclusions　These results suggest that a multifactorial intervention comprising resistance exercise, nutritional, and psychosocial programs is effective in lowering the incidence of LTCI certification, consequently saving LTC cost, although the results were not statistically significant. Further research with a stricter study design is needed.

Cost-Effectiveness of Testing and Treatment for Hepatitis B Virus and Hepatitis C Virus Infections: An Analysis by Scenarios, Regions, and Income.

OBJECTIVES: Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups. METHODS: We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination). RESULTS: Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results. CONCLUSIONS: Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.

Machine Learning Improves the Identification of Individuals With Higher Morbidity and Avoidable Health Costs After Acute Coronary Syndromes.

OBJECTIVES: Traditional risk scores improved the definition of the initial therapeutic strategy in acute coronary syndrome (ACS), but they were not designed for predicting long-term individual risks and costs. In parallel, attempts to directly predict costs from clinical variables in ACS had limited success. Thus, novel approaches to predict cardiovascular risk and health expenditure are urgently needed. Our objectives were to predict the risk of major/minor adverse cardiovascular events (MACE) and estimate assistance-related costs. METHODS: We used a 2-step approach that: (1) predicted outcomes with a common pathophysiological substrate (MACE) by using machine learning (ML) or logistic regression (LR) and compared with existing risk scores; (2) derived costs associated with noncardiovascular deaths, dialysis, ambulatory-care-sensitive-hospitalizations (ACSH), strokes, and MACE. With consecutive ACS individuals (n = 1089) from 2 cohorts, we trained in 80% of the population and tested in 20% using a 4-fold cross-validation framework. The 29-variable model included socioeconomic, clinical/lab, and coronarography variables. Individual costs were estimated based on cause-specific hospitalization from the Brazilian Health Ministry perspective. RESULTS: After up to 12 years follow-up (mean = 3.3 ± 3.1; MACE = 169), the gradient-boosting machine model was superior to LR and reached an area under the curve (AUROC) of 0.891 [95% CI 0.846-0.921] (test set), outperforming the Syntax Score II (AUROC = 0.635 [95% CI 0.569-0.699]). Individuals classified as high risk (>90th percentile) presented increased HbA1c and LDL-C both at <24 hours post-ACS and 1-year follow-up. High-risk individuals required 33.5% of total costs and showed 4.96-fold (95% CI 3.71-5.48, P < .00001) greater per capita costs compared with low-risk individuals, mostly owing to avoidable costs (ACSH). This 2-step approach was more successful for finding individuals incurring high costs than predicting costs directly from clinical variables. CONCLUSION: ML methods predicted long-term risks and avoidable costs after ACS.

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

Contexte: L'initiative de récupération améliorée après la chirurgie (RAAC) est un projet international d'amélioration de la qualité en chirurgie. On en sait peu sur les retombées économiques, tant à court qu'à long terme, de la mise en œuvre de multiples lignes directrices de RAAC. Méthodes: Nous avons réalisé une analyse du rendement sur l'investissement (RSI) visant la mise en œuvre de multiples lignes directrices de RAAC (pour les opérations colorectales, pancréatiques, hépatiques ou d'oncologie gynécologique et la cystectomie) dans 9 hôpitaux albertains sur un horizon temporel de 30, 180 et 365 jours. L'incidence de la RAAC sur l'utilisation des services de santé (durée du séjour à l'hospitalisation initiale, nombre de réadmissions, durée du séjour à la réhospitalisation et nombre de visites à l'urgence, en consultation externe, chez un spécialiste et chez un omnipraticien) a été évaluée à l'aide d'un modèle multiniveau de régressions binomiales négatives à effets mixtes multivariés. Les bénéfices nets et le RSI ont été estimés à l'aide d'un processus de modélisation analytique décisionnelle. Tous les coûts ont été rapportés en dollars canadiens de 2019. Résultats: Les économies nettes du système de santé allaient de 26,35 $ à 3606,44 $ par patient, et le RSI variait de 1,05 à 7,31; chaque dollar investi dans l'initiative de RAAC a donc généré un retour sur l'investissement de 1,05 $ à 7,31 $. Les probabilités d'économie grâce au RAAC allaient de 86,5% à 99,9%. Les retombées générées augmentaient avec un horizon temporel à plus long terme, ce qui suggère que l'utilisation unique d'un horizon temporel de 30 jours aurait mené à une sousestimation des bénéfices. Conclusion: Les résultats montrent que la mise en œuvre de multiples lignes directrices de RAAC a permis des économies en Alberta. En vue d'obtenir un RSI optimal, il est important de tenir compte d'une grande variété d'utilisations des services de santé, des retombées à long terme, des économies d'échelle, de l'efficacité productive et de l'efficience des allocations pour la pérennité, la mise à l'échelle et la diffusion des projets de mise en œuvre de RAAC.