Comparison of Guidelines for Evaluation of Suspected Pulmonary Embolism in Pregnancy: A Cost-effectiveness Analysis.

BACKGROUND: Pulmonary embolism (PE) remains a leading cause of maternal mortality, yet diagnosis remains challenging. International diagnostic guidelines vary significantly in their recommendations, making it difficult to determine an optimal policy for evaluation. RESEARCH QUESTION: Which societal-level diagnostic guidelines for evaluation of suspected PE in pregnancy are an optimal policy in terms of its cost-effectiveness? STUDY DESIGN AND METHODS: We constructed a complex Markov decision model to evaluate the cost-effectiveness of each identified societal guidelines for diagnosis of PE in pregnancy. Our model accounted for risk stratification, empiric treatment, diagnostic testing strategies, as well as short- and long-term effects from PE, treatment with low-molecular-weight heparin, and radiation exposure from advanced imaging. We considered clinical and cost outcomes of each guideline from a US health care system perspective with a lifetime horizon. Clinical effectiveness and costs were measured in time-discounted quality-adjusted life years (QALYs) and US dollars, respectively. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000/QALY. One-way, multiway, and probabilistic sensitivity analyses were performed. RESULTS: We identified six international societal-level guidelines. Base-case analysis showed the guideline proposed by the American Thoracic Society and Society of Thoracic Radiology (ATS-STR) yielded the highest health benefits (22.90 QALYs) and was cost-effective, with an ICER of $7,808 over the guidelines proposed by the Australian Society of Thrombosis and Haemostasis and the Society of Obstetric Medicine of Australia and New Zealand (ASTH-SOMANZ). All remaining guidelines were dominated. The ATS-STR guideline-recommended strategy yielded an expected additional 2.7 QALYs/100 patients evaluated over the ASTH-SOMANZ. Conclusions were robust to sensitivity analyses, with the ATS-STR guidelines optimal in 86% of probabilistic sensitivity analysis scenarios. INTERPRETATION: The ATS-STR guidelines for diagnosis of suspected PE in pregnancy are cost-effective and generate better expected health outcomes than guidelines proposed by other medical societies.

International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual Meeting (May 17-20, 2021 - Virtual Meeting).

COVID-19 has pushed us to think differently about health and its delivery, and following the declaration of pandemic by the World Health Organization (WHO), value chains have been largely broken and must be rebuilt and redesigned. COVID-19 brought the whole world to a standstill, and its impact on overall healthcare utilization and cost trends is undeniable; as such, the importance of public health expertise and health economics outcomes research (HEOR) to support and inform public health cannot be overstated. The virtual International Society for Pharmacoeconomics and Outcomes Research (ISPOR) meeting brought together experts and leaders in the HEOR field to explore topics that will shape healthcare decision making over the coming decades and to consider the useful lessons learnt from COVID-19 and how these will impact healthcare decisions in the post-COVID-19 era.

Enhancing Value-Based Care With a Walk-in Clinic: A Primary Care Provider Intervention to Decrease Low Acuity Emergency Department Overutilization.

Background Emergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems. Methods A retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic. Results Over the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits ($437) cost 4.9 times more than comparable PCP office visits ($91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $825,902. Conclusion Extended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.