Comparison of economic and health implications from earlier detection of HIV infection in the United Kingdom and Poland

PURPOSE

To model the financial and survival impact of early HIV infection detection versus late and compare results between the UK and Polish setting among the newly detected patients.

PATIENTS AND METHODS

A Microsoft Excel decision model (SUNRISE) was designed to generate a set of outcomes for a defined population. Survival was modelled on the COHERE study extrapolated to a 5-year horizon as a constant hazard. Hazard rates were specific to age, sex and whether detection was early or late. The primary outcomes for each year up to 5 years were: annual costs, numbers of infected cases, hospital admissions and surviving cases. Total population was observed in UK and Poland. ISPOR Budget Impact Model - Principles of Good Practice were utilised in SUNRISE development.

RESULTS

The projected cumulative cost-savings over 5 years in Poland and UK were 5,823,479 PLN (£1,109,234) and £21,608,562 respectfully. When including the value of life-years saved projected cumulative cost-savings in Poland and UK amounted to 8,374,018 PLN (£1,595,051) and £29,834,679 respectively. Savings were insensitive to transmission rates, but were sensitive in direct proportion to the percentage shift from late to early detection. In UK, savings were in higher proportion to Poland, due to much higher overall cost of HIV treatment (whether early or late HIV detected patient).

CONCLUSION

Estimated cost savings that could be translated into identification of appropriate programmes (providing wider coverage of HIV testing, awareness building) that would lead towards higher proportion of early HIV detected patients are very sensitive to the cost of HIV test and overall HIV treatment cost.

Medicare program; revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, access to identifiable data for the Center for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015. Final rule with comment period

This major final rule with comment period addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. See the Table of Contents for a listing of the specific issues addressed in this rule.

The laboratory test utilization management toolbox

Efficiently managing laboratory test utilization requires both ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients. After the difficult clinical decision is made to define the patients that do and do not need a test, a wealth of interventions are available to the clinician and laboratorian to help guide appropriate utilization. These interventions are collectively referred to here as the utilization management toolbox. Experience has shown that some tools in the toolbox are weak and other are strong, and that tools are most effective when many are used simultaneously. While the outcomes of utilization management studies are not always as concrete as may be desired, what data is available in the literature indicate that strong utilization management interventions are safe and effective measures to improve patient health and reduce waste in an era of increasing financial pressure.

[Optimization of healthcare expenditures, centralization of laboratory determinations and laboratory information accessibility]

The optimization of money expenditure for healthcare is leading to the reorganization of the structure of medical organizations, to reducing of small establishments, to centralization of laboratory analyses with cessation of their performing in some hospitals and out patient offices. This tendency is based on medical (enlargement of laboratory tests spectrum) and economical (high productivity, relative reducing of net cost of laboratory determinations) reasons. But the repercussions of switch-over to centralization of laboratory analyses performance must be evaluated from the position of laboratory information accessibility tacking in account the need in express analyses for patient, situated on territories outlying from the centralized laboratory. Using of the portative analytical devices and therefore the possibility to perform the urgent analyses by non-laboratory personal in point of care and by patients themselves as a matter of self-testing can help to solve the problem of accessibility of laboratory tests in conditions of laboratory centralization in some regions.

FibroTest-FibroSURE™: towards a universal biomarker of liver fibrosis?

Among the noninvasive alternatives to liver biopsy, several studies have demonstrated the predictive value and superior benefit/risk ratio to biopsy of two combinations of simple serum biochemical markers in patients infected with hepatitis B and C virus. These include FibroTest (BioPredictive) for the quantitative assessment of fibrosis, and ActiTest (BioPredictive) for the quantitative assessment of necroinflammatory activity (HCV-FibroSURE, LabCorp). The possible causes of false negatives and positives are also better identified. These tests, which are now available in 12 countries, can facilitate the screening and management of the most frequent liver diseases.

Rapid tests for detection of viral markers in blood transfusion

Since the early 1990s, rapid tests have been available for detection of HIV infection. They were intended for field diagnosis, emergency and home testing. In addition, rapid tests for anti-HIV, hepatitis B surface antigen and antihepatitis C virus have been used for blood screening in many resource-poor areas to save resources and overcome lack of funding, equipment and electrical supply. The performance of rapid tests varies widely but some have sensitivity and specificity levels that meet standards established by enzyme immunoassays for anti-HIV. Compared with genomic detection of hepatitis B virus, hepatitis B surface antigen rapid tests and enzyme immunoassays have insufficient sensitivity. The clinical consequences of this performance deficit remain to be clarified. Anti-hepatitis C virus rapid tests detect chronically infected individuals who are viremic, however, further studies are required to fully assess their performance. In settings where few blood donations are collected and equipment is unavailable, rapid tests provide a flexible, technically undemanding and relatively inexpensive approach to ensuring a safer blood supply. When utilized for predonation screening in areas of high endemicity of viral markers, rapid tests provide the means to limit blood bag wasting, store only clinically usable blood and inform and counsel deferred donors. As with any laboratory assay, adequate training and sustained quality assurance programs are critical to maintain a safe supply of blood. As a means of achieving a safe blood supply, rapid tests for viral markers and nucleic acid testing have a place next to classic enzyme immunoassays in the definition of strategies that are adapted to a setting's epidemiology, the size and type of donor base, equipment, staff training and resources.

Cost-effectiveness of novel algorithms for rapid diagnosis of tuberculosis in HIV-infected individuals in Uganda

OBJECTIVE

Xpert MTB/RIF ('Xpert') and urinary lateral-flow lipoarabinomannan (LF-LAM) assays offer rapid tuberculosis (TB) diagnosis. This study evaluated the cost-effectiveness of novel diagnostic algorithms utilizing combinations of Xpert and LF-LAM for the detection of active TB among people living with HIV.

DESIGN

Cost-effectiveness analysis using data from a comparative study of LF-LAM and Xpert, with a target population of HIV-infected individuals with signs/symptoms of TB in Uganda.

METHODS

A decision-analysis model compared multiple strategies for rapid TB diagnosis:sputum smear-microscopy; sputum Xpert; smear-microscopy combined with LF-LAM; and Xpert combined with LF-LAM. Primary outcomes were the costs and DALY's averted for each algorithm. Cost-effectiveness was represented using incremental cost-effectiveness ratios (ICER).

RESULTS

Compared with an algorithm of Xpert testing alone, the combination of Xpert with LF-LAM was considered highly cost-effective (ICER $57/DALY-averted) at a willingness to pay threshold of Ugandan GDP per capita. Addition of urine LF-LAM testing to smear-microscopy was a less effective strategy than Xpert replacement of smear-microscopy, but was less costly and also considered highly cost-effective (ICER $33 per DALY-averted) compared with continued usage of smear-microscopy alone. Cost-effectiveness of the Xpert plus LF-LAM algorithm was most influenced by HIV/ART costs and life-expectancy of patients after TB treatment.

CONCLUSION

The addition of urinary LF-LAM to TB diagnostic algorithms for HIV-infected individuals is highly cost-effective compared with usage of either sputum smear-microscopy or Xpert alone.

Utilization management in toxicology

Recent upward trends in the prevalence of abuse of prescription drugs and illicit substances have resulted in increased demands for toxicology testing to support the emergency department and drug treatment in pain management programs. This review will discuss the challenges faced by clinical laboratories to manage the utilization of toxicology tests, particularly those ordered in managing poisoned patients in the emergency department and chronic pain patients on opioid therapy. Optimal utilization of toxicology tests to support the emergency department relies on selecting the appropriate tests for the patient, and the availability of the results in a timely fashion. Two tiers of toxicology testing systems with different requirements for turnaround time will be discussed. In patients with chronic pain urine drug testing, including screening and confirmation testing are used extensively in pain management to monitor patient compliance. A thorough understanding of the performance characteristics of the test methodologies and drug metabolism is a key to making a proper analytical and clinical interpretation of the test results and will contribute to effective utilization of these tests. In addition, the reimbursement system is an important factor in the decision making process for test selection utilization as significant costs can be incurred by both payers and patients. Collaboration, trust, and effective communication among clinicians, patients, and clinical laboratory professionals are essential for effective utilization of toxicology testing.

A clinician's perspective on laboratory utilization management

BACKGROUND

Excessive laboratory utilization is a common problem in the hospital setting. Physicians control up to 80% of healthcare costs and wield great influence.

METHODS

This review article describes reasons for overutilization of labs and recommends interventional strategies to change clinician ordering behavior.

RESULTS

Powerful factors exist that encourage overutilization, including fear of missing a diagnosis, provider inexperience, peer pressure, financial rewards, practice inertia, and fear of legal punishment. Features of automated order entry, such as bundling and "daily until discontinued" options contribute to wasteful ordering behavior.

CONCLUSION

The most successful and long-lasting interventions are multi-faceted and have included a combination of education, feedback and audit, and administrative changes. The support of senior physicians and top administration is critical to the success of any initiative and ideally, interventions should be original from a multi-disciplinary committee of respected individuals.

Healthcare resource use among heart failure patients in a randomized pilot study of a cognitive training intervention

OBJECTIVES

To compare healthcare resource use of patients with heart failure (HF) randomized to the cognitive training intervention and to the health education active control intervention in a randomized controlled pilot study.

BACKGROUND

Cognitive training interventions may be efficacious and improve patients' memory and abilities to perform instrumental activities of daily living and self-care behaviors that may, in turn, lower healthcare resource use, but the influence of these interventions on healthcare resource use is unknown.

METHODS

Thirty-four HF patients were randomized to the computerized plasticity-based cognitive training intervention called Brain Fitness and to the health education active control intervention and completed the study. The primary outcome variable for the study was memory (recall and delayed recall). The secondary purpose of the study that is the focus of this paper was to compare healthcare resource use between the two groups using the third-party payer perspective. Data were collected at baseline and at 8 and 12 weeks after baseline. Healthcare resources were priced at Medicare payment levels for services and average wholesale price for medications.

RESULTS

Average costs of visits, procedures, and medications were similar between groups. Average costs of hospitalizations and tests, and therefore total costs, were half as much in the Brain Fitness group as compared to the active control group, but this difference was not significantly different from zero (p = 0.24).

CONCLUSIONS

Larger randomized controlled trials are needed that include analyses of program costs and costs associated with medical and non-medical services in order to fully evaluate efficacy of this intervention.

Using fee-for-service testing to generate revenue for the 21st century public health laboratory

OBJECTIVES

The decrease in appropriations for state public health laboratories (SPHLs) has become a major concern as tax revenues and, subsequently, state and federal funding, have decreased. These reductions have forced SPHLs to pursue revenue-generating opportunities to support their work. We describe the current state of funding in a sampling of SPHLs and the challenges these laboratories face as they implement or expand fee-for-service testing.

METHODS

We conducted surveys of SPHLs to collect data concerning laboratory funding sources, test menus, fee-for-service testing, and challenges to implementing fee-for-service testing.

RESULTS

Most SPHLS receive funding through three revenue sources: state appropriation, federal funding, and fee-for-service testing (cash funds). Among SPHLs, state appropriations ranged from $0 to more than $6 per capita, federal funding ranged from $0.10 to $5 per capita, and revenue from fee-for-service testing ranged from $0 to $4 per capita. The tests commonly performed on a fee-for-service basis included assays for sexually transmitted diseases, mycobacterial cultures, newborn screening, and water testing. We found that restrictive legislation, staffing shortages, inadequate software for billing fee-for-service testing, and regulations on how SPHLs use their generated revenue are impediments to implementing fee-for-service testing.

CONCLUSIONS

Some SPHLs are considering implementing or expanding fee-for-service testing as a way to recapture funds lost as a result of state and federal budget cuts. This analysis revealed many of the obstacles to implementing fee-for-service testing in SPHLs and the potential impact on SPHLs of continued decreases in funding.

Mini-FLOTAC, an innovative direct diagnostic technique for intestinal parasitic infections: experience from the field

BACKGROUND

Soil-transmitted helminths and intestinal protozoa infection are widespread in developing countries, yet an accurate diagnosis is rarely performed. The aim of this study was to evaluate the recently developed mini-FLOTAC method and to compare with currently more widely used techniques for the diagnosis of intestinal parasitic infections in different settings.

METHODOLOGY/PRINCIPAL FINDINGS

The study was carried out in Dharamsala, Himachal Pradesh, India, and in Bukumbi, Tanzania. A total of 180 pupils from two primary schools had their stool analyzed (n = 80 in Dharamsala and n = 100 in Bukumbi) for intestinal parasitic infections with three diagnostic methods: direct fecal smear, formol-ether concentration method (FECM) and mini-FLOTAC. Overall, 72% of the pupils were positive for any intestinal parasitic infection, 24% carried dual infections and 11% three infections or more. The most frequently encountered intestinal parasites were Entamoeba coli, Entamoeba histolytica/dispar, Giardia intestinalis, hookworm, (and Schistosoma mansoni, in Tanzania). Statistically significant differences were found in the detection of parasitic infections among the three methods: mini-FLOTAC was the most sensitive method for helminth infections (90% mini-FLOTAC, 60% FECM, and 30% direct fecal smear), whereas FECM was most sensitive for intestinal protozoa infections (88% FECM, 70% direct fecal smear, and 68% mini-FLOTAC).

CONCLUSION/SIGNIFICANCE

We present the first experiences with the mini-FLOTAC for the diagnosis of intestinal helminths and protozoa. Our results suggest that it is a valid, sensitive and potentially low-cost alternative technique that could be used in resource-limited settings--particularly for helminth diagnosis.

[The system of quality management in medical laboratory: the problematic issues of implementation of GOST RKS 9001-2008, GOST R ISO 15189-2009 and GOST R ISO 53079-2008]

The article presents the approaches to development and implementation of system of quality management in laboratory as an integral part of the given system in whole medical institution. The costs of works execution concerning quality support are to be weighted with economic profitability and timeliness of medical care provision to ill people considering pre-analytic stage (out-laboratory and in-laboratory) laboratory analysis. Factually it is a matter of development of system of balanced indicators concerning quality management of institution and laboratory functioning. The problematic issues are presented concerning maintenance of particular requirements of GOSTR ISO 15189 about quality of production. The emphasis is made on the necessity of training of administrations of laboratories in the field of quality management and economics of laboratory business.

The benefits or otherwise of managing malaria cases with or without laboratory diagnosis: the experience in a district hospital in Ghana

Background

This study was conducted at the Kintampo Municipal Hospital in Ghana to determine whether there was any benefit (or otherwise) in basing the management of cases of suspected malaria solely on laboratory confirmation (microscopy or by RDT) as compared with presumptive diagnosis.

Method

Children under five years who reported at the Out-Patient Department of the Hospital with axillary temperature ≥37.5°C or with a 48 hr history of fever were enrolled and had malaria microscopy and RDT performed. The attending clinician was blinded from laboratory results unless a request for these tests had been made earlier. Diagnosis of malaria was based on three main methods: presumptive or microscopy and/or RDT. Cost implication for adopting laboratory diagnosis or not was determined to inform malaria control programmes.

Results

In total, 936 children were enrolled in the study. Proportions of malaria diagnosed presumptively, by RDT and microscopy were 73.6% (689/936), 66.0% (618/936) and 43.2% (404/936) respectively. Over 50% (170/318) of the children who were RDT negative and 60% (321/532) who were microscopy negative were treated for malaria when presumptive diagnoses were used. Comparing the methods of diagnoses, the cost of malaria treatment could have been reduced by 24% and 46% in the RDT and microscopy groups respectively; the reduction was greater in the dry season (43% vs. 50%) compared with the wet season (20% vs. 45%) for the RDT and microscopy confirmed cases respectively.

Discussion/Conclusion

Over-diagnosis of malaria was prevalent in Kintampo during the period of the study. Though the use of RDT for diagnosis of malaria might have improved the quality of care for children, it appeared not to have a cost saving effect on the management of children with suspected malaria. Further research may be needed to confirm this.

Neurocysticercosis: HP10 antigen detection is useful for the follow-up of the severe patients

BACKGROUND

The most severe clinical form of neurocysticercosis (NC) occurs when cysticerci are located in the subarachnoid space at the base of the brain (SaB). The diagnosis, monitoring and treatment of NC-SaB, constitutes a severe clinical challenge. Herein we evaluate the potential of the HP10 antigen detection enzyme-linked immunosorbent assay (HP10 Ag-ELISA) in the long term follow-up of NC-SaB cases. Assay performance was compared with that of Magnetic Resonance Imaging (MRI). In addition, the robustness of the HP10 Ag-ELISA was evaluated independently at two different institutions.

METHODOLOGY/PRINCIPAL FINDINGS

A double-blind prospective cohort trial was conducted involving 38 NC-SaB cases and a total of 108 paired serum and cerebrospinal fluid (CSF) samples taken at intervals of 4 to 8 months for up to 43 months. At each medical visit, results of sera and CSF HP10 Ag-ELISA and MRI obtained at last visit were compared and their accuracy was evaluated retrospectively, considering radiological evolution between appointments. In the long-term follow-up study, HP10 Ag-ELISA had a better agreement than MRI with retrospective radiological evaluation. High reproducibility of HP10 Ag-ELISA between laboratories was also demonstrated.

CONCLUSIONS

Results reported in this study establish for the first time the usefulness of the comparatively low cost HP10 Ag-ELISA for long term follow-up of NC-SaB patients.

Seropositivity rates for measles, mumps, and rubella IgG and costs associated with testing and revaccination

Retrospective analysis of IgG test results and patterns for measles, mumps, and rubella revealed generally high seropositivity rates, with that of mumps being the lowest. A simplified cost analysis shows that when there is a suspicion of nonimmunity, serological testing may be cheaper than vaccination.