Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy

Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.

Sex Differences in Financial Barriers and the Relationship to Recovery After Acute Myocardial Infarction

BACKGROUND

Financial barriers to health care are associated with worse outcomes following acute myocardial infarction (AMI). Yet, it is unknown whether the prevalence of financial barriers and their relationship with post-AMI outcomes vary by sex among young adults.

METHODS AND RESULTS

We assessed sex differences in patient-reported financial barriers among adults aged <55 years with AMI using data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study. We examined the prevalence of financial barriers and their association with health status 12 months post-AMI. Among 3437 patients, more women than men reported financial barriers to medications (22.3% vs 17.2%; P=0.001), but rates of financial barriers to services were similar (31.3% vs 28.9%; P=0.152). In multivariable linear regression models adjusting for baseline health, psychosocial status, and clinical characteristics, compared with no financial barriers, women and men with financial barriers to services and medications had worse mental functional status (Short Form-12 mental health score: mean difference [MD]=-3.28 and -3.35, respectively), greater depressive symptomatology (Patient Health Questionnaire-9: MD, 2.18 and 2.16), lower quality of life (Seattle Angina Questionnaire-Quality of Life: MD, -4.98 and -7.66), and higher perceived stress (Perceived Stress Score: MD, 3.76 and 3.90; all P<0.05). There was no interaction between sex and financial barriers.

CONCLUSIONS

Financial barriers to care are common in young patients with AMI and associated with worse health outcomes 1 year post-AMI. Whereas women experienced more financial barriers than men, the association did not vary by sex. These findings emphasize the importance of addressing financial barriers to recovery post-AMI in young adults.

Estimating the costs for the treatment of abortion complications in two public referral hospitals: a cross-sectional study in Ouagadougou, Burkina Faso

BACKGROUND

Treatment costs of induced abortion complications can consume a substantial amount of hospital resources. This use of hospitals scarce resources to treat induced abortion complications may affect hospitals' capacities to deliver other health care services. In spite of the importance of studying the burden of the treatment of induced abortion complications, few studies have been conducted to document the costs of treating abortion complications in Burkina Faso. Our objective was to estimate the costs of six abortion complications including incomplete abortion, hemorrhage, shock, infection/sepsis, cervix or vagina laceration, and uterus perforation treated in two public referral hospital facilities in Ouagadougou and the cost saving of providing safe abortion care services.

METHODS

The distribution of abortion-related complications was assessed through a review of postabortion care-registers combined with interviews with key informants in maternity wards and in hospital facilities. Two structured questionnaires were used for data collection following the perspective of the hospital. The first questionnaire collected information on the units and the unit costs of drugs and medical supplies used in the treatment of each complication. The second questionnaire gathered information on salaries and overhead expenses. All data were entered in a spreadsheet designed for studying abortion, and analyses were performed on Excel 2007.

RESULTS

Across six types of abortion complications, the mean cost per patient was USD45.86. The total cost to these two public referral hospital facilities for treating the complications of abortion was USD22,472.53 in 2010 equivalent to USD24,466.21 in 2015. Provision of safe abortion care services to women who suffered from complications of unsafe induced abortion and who received care in these public hospitals would only have cost USD2,694, giving potential savings of more than USD19,778.53 in that year.

CONCLUSIONS

The treatment of the complications of abortion consumes a significant proportion (up to USD22,472.53) of the two public hospitals resources in Burkina Faso. Safe abortion care services may represent a cost beneficial alternative, as it may have saved USD19,778.53 in 2010.

Cost of diabetic foot disease to the National Health Service in England

AIM

To estimate the annual cost of diabetic foot care in a universal healthcare system.

METHODS

National datasets and economic modelling were used to estimate the cost of diabetic foot disease to the National Health Service in England in 2010-2011. The cost of hospital admissions specific to foot disease or amputation was estimated from Hospital Episode Statistics and national tariffs. Multivariate regression analysis was used to estimate the impact of foot disease on length of stay in admissions that were not specific to foot disease or amputation. Costs in other areas were estimated from published studies and data from individual hospitals.

RESULTS

The cost of diabetic foot care in 2010-2011 is estimated at £580 m, almost 0.6% of National Health Service expenditure in England. We estimate that more than half this sum (£307 m) was spent on care for ulceration in primary and community settings. Of hospital admissions with recorded diabetes, 8.8% included ulcer care or amputation. Regression analysis suggests that foot disease was associated with a 2.51-fold (95% CI 2.43-2.59) increase in length of stay.The cost of inpatient ulcer care is estimated at £219 m, and that of amputation care at £55 m.

CONCLUSIONS

The cost of diabetic foot disease is substantial. Ignorance of the cost of current care may hinder commissioning of effective services for prevention and management in both community and secondary care.

Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge?

BACKGROUND

Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.

OBJECTIVE

To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).

DESIGN

A quasi-experimental cohort study using consecutive convenience sampling.

PATIENTS

Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.

INTERVENTION

The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.

MAIN MEASURES

We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.

KEY RESULTS

Compared to matched internal controls (N = 321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P = 0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.

CONCLUSIONS

This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.

Cost minimization analysis of two treatment regimens for low-risk rhabdomyosarcoma in children: a report from the Children's Oncology Group

BACKGROUND

Recent Children's Oncology Group trials for low-risk rhabdomyosarcoma attempted to reduce therapy while maintaining excellent outcomes. D9602 delivered 45 weeks of outpatient vincristine and dactinomycin (VA) for patients in Subgroup A. ARST0331 reduced the duration of therapy to 22 weeks but added four doses of cyclophosphamide to VA for patients in Subset 1. Failure-free survival was similar. We undertook a cost minimization comparison to help guide future decision-making.

PROCEDURE

Addressing the costs of treatment from the healthcare perspective we modeled a simple decision-analytic model from aggregate clinical trial data. Medical care inputs and probabilities were estimated from trial reports and focused chart review. Costs of radiation, surgery and off-therapy surveillance were excluded. Unit costs were obtained from literature and national reimbursement and inpatient utilization databases and converted to 2012 US dollars. Model uncertainty was assessed with first-order sensitivity analysis.

RESULTS

Direct medical costs were $46,393 for D9602 and $43,261 for ARST0331 respectively, making ARST0331 the less costly strategy. Dactinomycin contributed the most to D9602 total costs but varied with age (42-69%). Chemotherapy administration costs accounted for the largest proportion of ARST0331 total costs (39-57%). ARST0331 incurred fewer costs than D9602 under most alternative distributive models and alternative clinical practice assumptions.

CONCLUSIONS

Cost analysis suggests that ARST0331 may incur fewer costs than D9602 from the healthcare system's perspective. Attention to the services driving the costs provides directions for future efficiency improvements. Future studies should prospectively consider the patient and family's perspective.

Postabortion care in Pakistan

The current law in Pakistan permits abortion only under narrow circumstances. As a result, women resort to clandestine and unsafe abortion procedures, which often lead to complications. This report summarizes findings from a study that examined the conditions under which women obtain abortion in Pakistan; the incidence, coverage and quality of facility-based postabortion care (PAC); and the extent to which recommended standards for PAC have been implemented in health facilities.

A multicenter randomized controlled trial of aftercare services for severe mental illness: study protocol

BACKGROUND

Severe mental illness is responsible for a significant proportion of burden of diseases in Iranian population. People with severe mental illnesses are more likely to have high rates of non-attendance at follow-up visits, and lack of an active follow-up system, particularly in the country's urban areas that has resulted in the revolving door phenomenon of rehospitalizations. Therefore, there is an increasing need for implementation of effective and cost-effective aftercare services.

METHOD/DESIGN

This is a randomized control trial with the primary hypothesis that aftercare services delivered to patients with severe mental illnesses in outpatient department and patient's home by a community care team would be more effective when compared to treatment as usual (TAU) in reducing length of hospital stay and any psychiatric hospitalization. Patients were recruited from three psychiatric hospitals in Iran. After obtaining informed written consent, they were randomly allocated into aftercare intervention and control (TAU) groups. Aftercare services included treatment follow-up (through either home care or telephone follow-up prompts for outpatient attendance), family psychoeducation, and patient social skills training that were provided by community mental health teams. Patients were followed for 12 months after discharge. The primary outcome measures were length of hospital stay and any hospitalization in the 12 month follow-up. Secondary outcome measures included patients' clinical global impression, global functioning, quality of life, and patient's satisfaction. The trial also allowed an assessment of direct cost-effectiveness of the aftercare services.

DISCUSSION

This paper presents a protocol for an RCT of aftercare services delivered to patients with severe mental illnesses within patients' home or outpatient department. The findings of this study can influence policy and program planning for people with severe mental illnesses in Iran.

TRIAL REGISTRATION

IRCT201009052557N2.

[Total knee and hip prosthesis: variables associated with costs]

BACKGROUND

The elevated prevalence of osteoarthritis in Western countries, the high costs of hip and knee arthroplasty, and the wide variations in the clinical practice have generated considerable interest in comparing the associated costs before and after surgery.

OBJECTIVE

To determine the influence of a number of variables on the costs of total knee and hip arthroplasty surgery during the hospital stay and during the one-year post-discharge.

METHODS

A prospective multi-center study was performed in 15 hospitals from three Spanish regions. Relationships between the independent variables and the costs of hospital stay and postdischarge follow-up were analyzed by using multilevel models in which the "hospital" variable was used to group cases. Independent variables were: age, sex, body mass index, preoperative quality of life (SF-12, EQ-5 and Womac questionnaires), surgery (hip/knee), Charlson Index, general and local complications, number of beds and economic-institutional dependency of the hospital, the autonomous region to which it belongs, and the presence of a caregiver.

RESULTS

The cost of hospital stay, excluding the cost of the prosthesis, was 4,734 Euros, and the post-discharge cost was 554 Euros. With regard to hospital stay costs, the variance among hospitals explained 44-46% of the total variance among the patients. With regard to the post-discharge costs, the variability among hospitals explained 7-9% of the variance among the patients.

CONCLUSIONS

There is considerable potential for reducing the hospital stay costs of these patients, given that more than 44% of the observed variability was not determined by the clinical conditions of the patients but rather by the behavior of the hospitals.

The future cost of stroke in Ireland: an analysis of the potential impact of demographic change and implementation of evidence-based therapies

BACKGROUND AND PURPOSE

this paper examines the impact of demographic change from 2007 to 2021 on the total cost of stroke in Ireland and analyses potential impacts of expanded access to stroke unit care and thrombolytic therapy on stroke outcomes and costs.

METHODS

total costs of stroke are estimated for the projected number of stroke cases in 2021 in Ireland. Analysis also estimates the potential number of deaths or institutionalised cases averted among incident stroke cases in Ireland in 2007 at different rates of access to stroke unit care and thrombolytic therapy. Drawing on these results, total stroke costs in Ireland in 2007 are recalculated on the basis of the revised numbers of incident stroke patients estimated to survive stroke, and of the numbers estimated to reside at home rather than in a nursing home in the context of expanded access to stroke units or thrombolytic therapy.

RESULTS

future costs of stroke in Ireland are estimated to increase by 52-57% between 2007 and 2021 on the basis of demographic change. The projected increase in aggregate stroke costs for all incident cases in 1 year in Ireland due to the delivery of stroke unit care and thrombolytic therapy can be offset to some extent by reductions in nursing home and other post-acute costs.

Transitional care management services: everything you need to know

Tired of providing medical services without reimbursement? Learn how to document and code for Transitional Care Management, and start receiving reimbursement for services you may have been providing gratis.

Unintended pregnancy and unsafe abortion in the Philippines: context and consequences

Despite advances in reproductive health law, many Filipino women experience unintended pregnancies, and because abortion is highly stigmatized in the country, many who seek abortion undergo unsafe procedures. This report provides a summary of reproductive health indicators in the Philippines—in particular, levels of contraceptive use, unplanned pregnancy and unsafe abortion—and describes the sociopolitical context in which services are provided, the consequences of unintended pregnancy and unsafe abortion,and recommendations for improving access to reproductive health services.

[Utilization of health care resources and cost associated to fasciectomy in Dupuytren's disease in Spain]

OBJECTIVE

To estimate the healthcare resource utilization and their associated costs secondary to fasciectomy of Dupuytren s disease (DD) treated under usual medical practice in Spain.

METHODS

This multicenter, observational, retrospective cohort study, extracted data through the revision of medical records of three tertiary public hospitals. Each center should recruit 40 patients operated for DD, as principal diagnose of Minimum Data Set, in which the surgical procedure conducted was fasciectomy, during 2007-2009. To collect all the resources used during surgery, a specific chart form was designed. Demographic (age, gender, occupational status), clinical (stage of contracture and comorbilities) and healthcare utilization (hospitalizations, medical visits, tests, drugs) data were collected under medical routine. Comparisons between stage of contracture grouped (I: stage N, 1 & 2; II: stage 3 & 4) and centers were made.

RESULTS

A total of 123 subjects (52% group I; 86.2% men; 35.8% active workers) were identified. 81.3% of patients presented at least one comorbidity, being hypertension the most frequent. 28.4% of patients were operated in ambulatory surgery and 71.6% hospitalized. All the patients had follow-up visits after surgery, 27% needed physical therapy, 88% performed preoperative tests and 8% visit the emergency room after surgery. Healthcare mean (SD) costs were as follows: fasciectomy €1,074 (0); hospitalizations €978 (743); ambulatory €186 (10); follow-up visits €260 (173); emergency rooms €13 (53); tests €78(43); drugs €7 (9); physical therapy €46 (134). Mean total costs were €2,250 (839). There were no significant differences between study groups grouped by stage of contracture. However, the center and the severity of the CD seem explanatory variables of cost, p<0.05.

CONCLUSIONS

Healthcare resources utilization for surgical treatment of Dupuytren's disease may cost €2,250 (839) per fasciectomy treated under usual medical practice.

Ductal carcinoma in situ (DCIS): posttreatment follow-up care among Latina and non-Latina White women

BACKGROUND

There is a lack of information about posttreatment care among patients with ductal carcinoma in situ (DCIS). This study compares posttreatment care by ethnicity-language and physician specialty among Latina and White women with DCIS.

METHODS

Latina and White women diagnosed with DCIS between 2002 and 2005 identified through the California Cancer Registry completed a telephone survey in 2006. Main outcomes were breast surveillance, lifestyle counseling, and follow-up physician specialty.

KEY RESULTS

Of 742 women (396 White, 349 Latinas), most (90 %) had at least one clinical breast exam (CBE). Among women treated with breast-conserving surgery (BCS; N = 503), 76 % had received at least two mammograms. While 92 % of all women had follow-up with a breast specialist, Spanish-speaking Latinas had the lowest specialist follow-up rates (84 %) of all groups. Lifestyle counseling was low with only 53 % discussing exercise, 43 % weight, and 31 % alcohol in relation to their DCIS. In multivariable analysis, Spanish-speaking Latinas with BCS had lower odds of receiving the recommended mammography screening in the year following treatment compared to Whites (OR 0.5; 95 % CI, 0.2-0.9). Regardless of ethnicity-language, seeing both a specialist and primary care physician increased the odds of mammography screening and CBE (OR 1.6; 95 % CI, 1.2-2.3 and OR 1.9; 95 % CI, 1.3-2.8), as well as having discussions about exercise, weight, and alcohol use, compared to seeing a specialist only.

CONCLUSIONS

Most women reported appropriate surveillance after DCIS treatment. However, our results suggest less adequate follow-up for Spanish-speaking Latinas, possibly due to language barriers or insurance access.

IMPLICATIONS FOR CANCER SURVIVORS

Follow-up with a primary care provider in addition to a breast specialist increases receipt of appropriate follow-up for all women.

Unintended pregnancy and abortion in Uganda

Unintended pregnancy is common in Uganda, leading to high levels of unplanned births, unsafe abortions, and maternal injury and death. Because most pregnancies that end in abortion are unwanted, nearly all ill health and mortality resulting from unsafe abortion is preventable. This report summarizes evidence on the context and consequences of unintended pregnancy and unsafe abortion in Uganda, points out gaps in knowledge, and highlights steps that can be taken to reduce levels of unintended pregnancy and unsafe abortion, and, in turn, the high level of maternal mortality.

Post-acute care and vertical integration after the Patient Protection and Affordable Care Act

The anticipated changes resulting from the passage of the Patient Protection and Affordable Care Act-including the proposed adoption of bundled payment systems and the promotion of accountable care organizations-have generated considerable controversy as U.S. healthcare industry observers debate whether such changes will motivate vertical integration activity. Using examples of accountable care organizations and bundled payment systems in the American post-acute healthcare sector, this article applies economic and sociological perspectives from organization theory to predict that as acute care organizations vary in the degree to which they experience environmental uncertainty, asset specificity, and network embeddedness, their motivation to integrate post-acute care services will also vary, resulting in a spectrum of integrative behavior.