Does preventive care save money? Health economics and the presidential candidates

Screening, diagnosis, and long-term health outcomes in developing countries-The case of hypertension

Hypertension is a rapidly growing problem in developing countries. At the same time, due to its asymptomatic nature, the afflicted population is largely unaware of being hypertensive. Due to a lack of resources, routine medical exams are very rare in developing countries and many sick individuals remain undiagnosed. Using a large sample of hypertensive individuals from Indonesia, we show the importance of being diagnosed. Diagnosed individuals exhibit lower systolic and diastolic blood pressure, and overall lower probability of remaining hypertensive than undiagnosed individuals. We also show the main channels through which this is achieved: taking medication, routinely monitoring one’s blood pressure, and engaging in moderate physical activities. We also point to channels through which additional benefits could be realized, but that are currently ineffective: dietary changes and maintaining a healthy body weight. Combined, these results point to the importance of directing public policy towards addressing the under-diagnosis problem and educating the public of the benefits of adopting a healthy life-style.

The roles of preventive and curative health care in economic development

Introduction

Both the preventive and curative healthcare provisions accumulate agents’ health stock and stimulate economies’ productivities. However, with limited medical resources, increases in preventive health expenditure crowd out curative expenditure, and vice versa, which in turn impairs the population’s health and deters economic growth. This research aims to provide a empirically rigorous test on the hypothesis that optimally allocating health expenditure between prevention and cures stimulates economic growth within different countries, especially developed countries, and investigates whether health services are luxury goods on the path of economic development.

Methods

Based on OECD country experiences, this present study uses the system generalized method of moments (GMM) estimation method to examine the roles of preventive and curative healthcare services over the path of economic development and proves that preventive and curative health spending have non-linear effects on economic performance.

Results

For growth maximization, the optimal share of preventive health expenditure to GDP is 0.44% with per capita GDP at US$40,465; the real share is 0.25% with per capita GDP at US$35,230. The optimal share of curative health expenditure to GDP is 10.96% with per capita GDP at US$41,816; the real share is 8.26% with per capita GDP at US$35,230. Accordingly, the estimated optimal provision of health services are currently underprovided. This research further estimates the effects of income on demand for care and shows that the income elasticities of preventive and curative health care are greater than unity. Health services are luxury goods.

Conclusions

Economies with higher incomes demand such services more than those with lower incomes. The large positive effects of income on preventive care use exist.

Creating a preference for prevention: the role of universal health care in the demand for preventive care among Mexico's vulnerable populations

The introduction of Seguro Popular (SP)- providing health insurance to over 50 million Mexicans since the early 2000s-represents a large shift in health care delivery to the Mexican population. And yet, its impact on Mexico's marginalized communities has been little studied, and its impact on health is unclear. Using a survey of poor urban Mexicans and Mexican Ministry of Health administrative data, this article investigates SP's effect on those at the most risk for health disparities by looking at the impact of the programme on demand for preventive care services, especially among women, children and the indigenous. Three outcomes important to Mexico's burden of disease are explored: general physical exams, diabetes screening, and cervical cancer screening. Ordinary least square regressions show that the introduction of SP is associated with an increase in demand for all three services, but these results are likely biased due to selection into the programme. I then use the staggered geographic roll out of SP between 2004 and 2007 to identify the causal impact of the programme on demand. I use length of exposure to SP as an instrumental variable to predict SP affiliation in 2009. Two stage least squares estimates of the causal impact of SP on demand for preventive care services finds that SP affiliation increases adult demand for physicals, but does not affect demand for diabetes screening. Additionally, I find that female and child SP affiliates are less likely to demand physicals, while affiliates who identify as indigenous are less likely to demand physicals but more likely to demand cervical cancer screenings.

Prevention of seroma following inguinal lymph node dissection with prophylactic, incisional, negative-pressure wound therapy (SEROMA trial): study protocol for a randomized controlled trial

Background

Radical inguinal lymphadenectomy (ILND) for metastatic melanoma is associated with a high complication rate. Seroma is often the first postoperative complication, followed by prolonged wound healing sometimes requiring reoperation, infection, multiple outpatient visits and re-hospitalization. Prevention of seroma may, therefore, lead to a reduction in many of the other complications.

Methods/design

The primary aim of this randomized study is to investigate whether fewer patients require treatment for seroma by immediate prophylactic application of incisional, Negative-pressure Wound Therapy (iNPWT) following ILND, compared to standard postoperative treatment. The secondary outcomes include surgical-site infection, dehiscence, hematoma, length of hospitalization, quality of life, safety, long-term assessment of lymphedema and non-inferiority oncological outcome. Data will be registered prospectively at check-ups after 7 and 14 days, 1 and 3 months and 2 years after inguinal lymphadenectomy using case report forms and questionnaires and stored in a secure online database.

Discussion

To our knowledge, this trial is the first randomized study evaluating negative-pressure wound therapy as a prophylactic intervention for complications following melanoma-related ILND. The results from this trial will hopefully determine the efficacy and safety of prophylactic iNPWT treatment in prevention of the clinical relevant short- and long-term postoperative complications following ILND and may provide an evidence base for the an improved postoperative regimen.

Trial registration

ClinicalTrials.gov, ID: NCT03433937. Prospectively registered on 15 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2757-6) contains supplementary material, which is available to authorized users.

Immersive Interactive Technologies for Positive Change: A Scoping Review and Design Considerations

Practices such as mindfulness, introspection, and self-reflection are known to have positive short and long-term effects on health and well-being. However, in today's modern, fast-paced, technological world tempted by distractions these practices are often hard to access and relate to a broader audience. Consequently, technologies have emerged that mediate personal experiences, which is reflected in the high number of available applications designed to elicit positive changes. These technologies elicit positive changes by bringing users' attention to the self—from technologies that show representation of quantified personal data, to technologies that provide experiences that guide the user closer in understanding the self. However, while many designs available today are either built to support or are informed by these aforementioned practices, the question remains: how can we most effectively employ different design elements and interaction strategies to support positive change? Moreover, what types of input and output modalities contribute to eliciting positive states? To address these questions, we present here a state of the art scoping review of immersive interactive technologies that serve in a role of a mediator for positive change in users. We performed a literature search using ACM Digital Library, Web of Science, IEEE Xplore, and Design and Applied Arts Index (beginning of literature—January 1, 2018). We retrieved English-language articles for review, and we searched for published and unpublished studies. Risk of bias was assessed with Downs and Black 26-item QAT scale. We included 34 articles as relevant to the literature, and the analysis of the articles resulted in 38 instances of 33 immersive, interactive experiences relating to positive human functioning. Our contribution is three-fold: First we provide a scoping review of immersive interactive technologies for positive change; Second, we propose both a framework for future designs of positive interactive technologies and design consideration informed by the comparative analysis of the designs; Third, we provide design considerations for immersive, interactive technologies to elicit positive states and support positive change.

Relapse to smoking following release from smoke-free correctional facilities in Queensland, Australia

BACKGROUND

Smoke-free prison policies are increasingly common, but few studies have investigated relapse to smoking after release from prison. This study investigated return to tobacco smoking and correlates of smoking at reduced levels after release among adults recently released from smoke-free prisons in Queensland, Australia.

METHODS

A cross-sectional survey of 114 people at parole offices within two months of release from prison was used. The survey measured health, social, and criminological factors related to tobacco smoking. We used logistic regression to identify factors associated with reduced post-release smoking levels compared to pre-incarceration levels.

RESULTS

94% of participants relapsed to smoking within two months of release; 72% relapsed on the day of release. 62% of participants smoked significantly less per day after compared with before incarceration. Living with a partner (Odds Ratio (OR) 2.77, 95%CI 1.02-7.52), expressing support for smoke-free prison policies (OR 2.44, 95%CI 1.12-5.32), intending to remain abstinent post-release (OR 4.29, 95%CI 1.88-9.82), and intending to quit in the future (OR 3.88, 95%CI 1.66-9.07) were associated with reduced smoking post-release. Use of illicit drugs post-release was negatively associated with reduced smoking post-release (OR 0.27, 95%CI 0.09-0.79). In multivariate analyses, pre-release intention to remain smoke-free was associated with reduced smoking post-release (AOR 2.69, 95%CI 1.01-7.14).

DISCUSSION

Relapse to smoking after release from smoke-free prisons is common, but many who relapse smoke less than before incarceration, suggesting that smoke-free prison policies may reduce post-release tobacco smoking. There is a need for tailored, evidence-based tobacco cessation interventions for people recently released from prison.

Cardiovascular Disease Prevention: Training Opportunities, the Challenges, and Future Directions

PURPOSE

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide, necessitating major efforts in prevention. This review summarizes the currently available training opportunities in CVD prevention for fellows-in-training (FITs) and residents. We also highlight the challenges and future directions for CVD prevention as a field and propose a structure for an inclusive CVD prevention training program.

RECENT FINDINGS

At present, there is a lack of centralized training resources for FITs and residents interested in pursuing a career in CVD prevention. Training in CVD prevention is not an accredited subspecialty fellowship by the American Council of Graduate Medical Education (ACGME). Although there are several independent training programs under the broad umbrella of CVD prevention focusing on different aspects of prevention, there is no unified curriculum or training. More collaborative efforts are needed to identify CVD prevention as an ACGME-accredited subspecialty fellowship. Providing more resources can encourage and produce more leaders in this essential field.

Challenges in adult vaccination

Life-long primary prevention interventions beginning and continuing throughout an individual's lifetime are increasingly seen as key to meeting the global healthcare challenges that accompany demographic changes - a concept referred to as "Healthy aging". In this perspective, vaccination is seen as part of a triad, together with healthy diet and exercise. Current adult vaccine coverage is lower than target vaccination rates in most developed countries, and so vaccine preventable diseases continue to present a substantial burden on health and healthcare resources, especially in older individuals. In part, this is due to lack of knowledge and understanding of the benefits of vaccination, inconsistent recommendations by providers and uncertainties about cost benefits. However, lower vaccine effectiveness in older adults plays a part, and new vaccines with novel characteristics to improve effectiveness in older adults are required. A life-course immunization approach to ensure optimal vaccine uptake across adults of all ages can be expected to reduce morbidity and mortality in later life. To achieve this, greater emphasis on public and healthcare provider education is necessary, based on appropriate economic analyses that demonstrate the overall value of vaccination. This article introduces the technical, economic, political and demographic issues that make establishing effective adult vaccination programs such a difficult, but pressing issue, and outlines some of the steps that are now being taken to address them. Key messages Life-long preventive activities that start and continue throughout life are essential, especially as the world's population is "getting older". This "Healthy aging" approach includes not only healthy diet and physical exercise; vaccination is critical in reducing some infectious diseases and their complications. Many adults, especially older adults (who have lower immunity than younger people) develop infections such as influenza and shingles that could potentially be prevented through vaccination. This review provides a perspective on the challenges in delivering a life-course immunization program. While some vaccines are less effective in older people, newer vaccines have been developed which provide stronger and longer protection in older patients than standard existing vaccines. However, the benefits of vaccination can only be realized if the vaccines are recommended and used. For that purpose, greater education of patients and their healthcare providers is necessary. Better knowledge of vaccines and making sure that all adults are up to date with all their recommended vaccines is an essential part of "Healthy aging". This should prevent not only vaccine-preventable diseases but also reduce the risk of complications in later life.

Lifetime cost for type 2 diabetes mellitus in Singapore

BACKGROUND

The mean annual direct medical cost of type 2 diabetes mellitus (T2DM) in Singapore has been found to be SGD 2034 using the prevalence-based approach, but the lifetime direct medical cost of T2DM in Singapore remains largely unknown. The aim of the present study was to determine the lifetime direct medical cost attributable to T2DM and provide estimates of potential savings if T2DM can be prevented or delayed.

METHODS

The incidence-based approach was used for the cost-of-illness analysis. Yearly medical expenses were obtained from a regional health system database in Singapore to estimate the lifetime medical cost of T2DM patients. Then, the lifetime medical cost of non-T2DM subjects was predicted using a regression model. From the database, gender- and age-specific annual survival rates of T2DM and non-T2DM subjects were obtained and survival-adjusted yearly expenses over the estimated remaining life span were added to obtain lifetime medical costs. The difference between T2DM and non-T2DM subjects was attributed to excess direct medical costs of T2DM.

RESULTS

The excess lifetime medical expenses for T2DM patients were SGD 132 506, 108 589, 83 326 and 70 110 when the age of T2DM diagnosis was 40, 50, 60, and 65 years, respectively.

CONCLUSIONS

Even though T2DM patients have a lower life expectancy, T2DM is associated with substantially higher lifetime medical costs. Delaying the onset of T2DM, especially in the young, may lead to lower lifetime medical expenses. If prevention costs can be kept sufficiently low, effective T2DM prevention efforts would likely lead to a reduction in long-term medical costs.

Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes

OBJECTIVE

To assess the economic effect and cost effectiveness of a targeted catheter-associated urinary tract infection (CAUTI) prevention intervention in the nursing home (NH) setting.

DESIGN

Randomized clinical trial.

SETTING

Community-based NHs (N=12).

PARTICIPANTS

NH residents with indwelling urinary catheters (N=418).

INTERVENTION

Standard care versus infection prevention program involving barrier precautions, active surveillance, and NH staff education.

MEASUREMENTS

Costs of the intervention, costs of disease, and health outcomes were used to calculate an incremental cost-effectiveness ratio for the intervention. Data came from intervention results and the literature and outcomes were analyzed over one year.

RESULTS

A 120-bed NH would have program costs of $20,279/year. The cost of disease treatment would be reduced by $54,316 per year, resulting in a $34,037 net cost savings. Most of this savings would come from fewer CAUTI hospitalizations ($39,180), with $15,136 in savings from CAUTI care within the NH. The intervention also yielded a gain of 0.197 quality-adjusted life-years (QALYs). Taking into account uncertainty in all parameters suggests there is an 85% chance that the intervention is cost-saving.

CONCLUSIONS

The CAUTI prevention program is expected to benefit payers by reducing costs and improving health outcomes. Because the savings accrue to payers and not to NHs, payers such as Medicare and private insurers may want to provide incentives for NHs to implement such programs.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01062841.

Pay For Success And Population Health: Early Results From Eleven Projects Reveal Challenges And Promise

Pay for success (PFS) is a type of social impact investing that uses private capital to finance proven prevention programs that help a government reduce public expenditures or achieve greater value. We conducted an analysis of the first eleven PFS projects in the United States to investigate the potential of PFS as a strategy for financing and disseminating interventions aimed at improving population health and health equity. The PFS approach has significant potential for bringing private-sector resources to interventions regarding social determinants of health. Nonetheless, a number of challenges remain, including structuring PFS initiatives so that optimal prevention benefits can be achieved and ensuring that PFS interventions and evaluation designs are based on rigorous research principles. In addition, increased policy attention regarding key PFS payout issues is needed, including the "wrong pockets" problem and legal barriers to using federal Medicaid funds as an investor payout source.

Evidence of effectiveness of preventive dental care in reducing dental treatment use and related expenditures

OBJECTIVES

Preventive dental health services are intended to reduce the likelihood of development of tooth decay and the need for more intensive treatment overtime. The evidence on the effectiveness of preventive dental care in reducing treatment services and expenditures is lagging for adults, particularly those with lower incomes and chronic conditions. We assessed the impact of preventive dental services on dental treatment service use and expenditures overall and by category of service.

METHODS

We calculated the annual numbers of preventive (periodic diagnostic and prophylactic procedures) and treatment (restorative, surgery, prosthodontic, endodontic, and periodontic) services per beneficiary using Medicaid enrollment and claims data for beneficiaries with three categories of conditions (diabetes, heart disease, and respiratory disease) from 10 largest California counties. We used Cragg hurdle exponential regression models controlling for past service use, demographics, length of enrollment, and county.

RESULTS

We found that using preventive services in 2005-2007 was associated with higher likelihood and number of treatment dental services used, but associated with lower treatment expenditures in 2008. The reduction in expenditures was noted only in restorative, prosthodontics, and periodontic services.

CONCLUSIONS

The findings provide much needed evidence of the contribution of preventive dental care in maintaining oral health of low-income adults with chronic conditions and potential for savings to the Medicaid program. Providing lower cost preventive dental care to the individuals with chronic conditions would achieve better oral health and lower treatment expenditures.

Cost-effective options for the prevention and management of gastrointestinal and liver disease in the Asia-Pacific region

The Asia-Pacific region contains more than half of the world's population and is markedly heterogeneous in relation to income levels and the provision of public and private health services. For low-income countries, the major health priorities are child and maternal health. In contrast, priorities for high-income countries include vascular disease, cancer, diabetes, dementia, and mental health disorders as well as chronic inflammatory disorders such as hepatitis B and hepatitis C. Cost-effectiveness analyses are methods for assessing the gains in health relative to the costs of different health interventions. Methods for measuring health outcomes include years of life saved (or lost), quality-adjusted life years, and disability-adjusted life years. The incremental cost-effectiveness ratio measures the cost (usually in US dollars) per life year saved, quality-adjusted life year gained, or disability-adjusted life year averted of one intervention relative to another. In low-income countries, approximately 50% of infant deaths (< 5 years) are caused by gastroenteritis, the major pathogen being rotavirus infection. Rotavirus vaccines appear to be cost-effective but, thus far, have not been widely adopted. In contrast, infant vaccination for hepatitis B is promoted in most countries with a striking reduction in the prevalence of infection in vaccinated individuals. Cost-effectiveness analyses have also been applied to newer and more expensive drugs for hepatitis B and C and to government-sponsored programs for the early detection of hepatocellular, gastric, and colorectal cancer. Most of these studies reveal that newer drugs and surveillance programs for cancer are only marginally cost-effective in the setting of a high-income country.

Valuing Our Communities: Ethical Considerations for Economic Evaluation of Community-Based Prevention

Restricted public budgets and increasing efforts to link the impact of community interventions to public savings have increased the use of economic evaluation. While this type of evaluation can be important for program planning, it also raises important ethical issues about how we value the time of local stakeholders who support community interventions. In particular, researchers navigate issues of scientific accuracy, institutional inequality, and research utility in their pursuit of even basic cost estimates. We provide an example of how we confronted these issues when estimating the costs of a large-scale community-based intervention. Principles for valuing community members' time and conducting economic evaluations of community programs are discussed.

Cost-effectiveness of population based BRCA testing with varying Ashkenazi Jewish ancestry

BACKGROUND

Population-based BRCA1/BRCA2 testing has been found to be cost-effective compared with family history-based testing in Ashkenazi-Jewish women were >30 years old with 4 Ashkenazi-Jewish grandparents. However, individuals may have 1, 2, or 3 Ashkenazi-Jewish grandparents, and cost-effectiveness data are lacking at these lower BRCA prevalence estimates. We present an updated cost-effectiveness analysis of population BRCA1/BRCA2 testing for women with 1, 2, and 3 Ashkenazi-Jewish grandparents.

STUDY DESIGN

Decision analysis model.

METHODS

Lifetime costs and effects of population and family history-based testing were compared with the use of a decision analysis model. 56% BRCA carriers are missed by family history criteria alone. Analyses were conducted for United Kingdom and United States populations. Model parameters were obtained from the Genetic Cancer Prediction through Population Screening trial and published literature. Model parameters and BRCA population prevalence for individuals with 3, 2, or 1 Ashkenazi-Jewish grandparent were adjusted for the relative frequency of BRCA mutations in the Ashkenazi-Jewish and general populations. Incremental cost-effectiveness ratios were calculated for all Ashkenazi-Jewish grandparent scenarios. Costs, along with outcomes, were discounted at 3.5%. The time horizon of the analysis is "life-time," and perspective is "payer." Probabilistic sensitivity analysis evaluated model uncertainty.

RESULTS

Population testing for BRCA mutations is cost-saving in Ashkenazi-Jewish women with 2, 3, or 4 grandparents (22-33 days life-gained) in the United Kingdom and 1, 2, 3, or 4 grandparents (12-26 days life-gained) in the United States populations, respectively. It is also extremely cost-effective in women in the United Kingdom with just 1 Ashkenazi-Jewish grandparent with an incremental cost-effectiveness ratio of £863 per quality-adjusted life-years and 15 days life gained. Results show that population-testing remains cost-effective at the £20,000-30000 per quality-adjusted life-years and $100,000 per quality-adjusted life-years willingness-to-pay thresholds for all 4 Ashkenazi-Jewish grandparent scenarios, with ≥95% simulations found to be cost-effective on probabilistic sensitivity analysis. Population-testing remains cost-effective in the absence of reduction in breast cancer risk from oophorectomy and at lower risk-reducing mastectomy (13%) or risk-reducing salpingo-oophorectomy (20%) rates.

CONCLUSION

Population testing for BRCA mutations with varying levels of Ashkenazi-Jewish ancestry is cost-effective in the United Kingdom and the United States. These results support population testing in Ashkenazi-Jewish women with 1-4 Ashkenazi-Jewish grandparent ancestry.

What Role Does Efficiency Play in Understanding the Relationship Between Cost and Quality in Physician Organizations?

BACKGROUND

The belief that there is inefficiency, or the potential to improve patient health at current levels of spending, is driving the push for greater value in health care. Previous studies demonstrate overuse of a narrow set of services, suggesting provider inefficiency, but existing studies neither quantify inefficiency more broadly nor assess its variation across physician organizations (POs).

DATA AND METHODS

We used data on quality of care and total cost of care from 129 California POs participating in a statewide value-based pay-for-performance program. We estimated a production function with quality as the output and cost as the input, using a stochastic frontier model, to develop a measure of relative efficiency for each PO. To validate the efficiency measure, we examined correlations of PO efficiency estimates with indicators representing overuse of services.

RESULTS

The estimated production function showed that PO quality was positively associated with costs, although there were diminishing marginal returns to spending. A certain minimum level of spending was associated with high quality even among efficient POs. Most strikingly, however, POs had substantial variation in efficiency, producing widely differing levels of quality for the same cost.

CONCLUSIONS

Differences among POs in the efficiency with which they produce quality suggest opportunities for improvements in care delivery that increase quality without increasing spending.

Differences in Incremental Cost-Effectiveness Ratios for Common Versus Rare Conditions: A Case from Oncology

BACKGROUND

Incremental cost-effectiveness ratios (ICERs) are used to assess the value for money of new drugs. Many believe that ICERs for drugs that treat rare diseases are much higher than those of common drugs. Our objective was to compare the proportion of ICERs that are cost effective for rare and common cancers.

METHODS

We used the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry to identify cost-effectiveness studies of pharmaceutical interventions for cancers. Studies that assessed FDA-approved 'orphan drugs' were categorized as assessing rare cancers. The proportion of common and rare cancer drugs that were cost effective at various ICER thresholds were compared along with study characteristics. Logistic regressions were conducted to assess important predictors of cost effectiveness.

RESULTS

We identified 303 studies that reported 701 ICERs. Seventy nine percent (n = 240) of studies evaluated drugs for common cancers. At a threshold of US$50,000/QALY, 58% (n = 321) of ICERs for drugs treating common cancers and 64% (n = 94) of ICERs for drugs treating rare cancers were cost effective (p = 0.23). At US$100,000/QALY, 74% (n = 409) of ICERs for common cancers and 78% (n = 115) of ICERs for rare cancers were cost effective (p = 0.35). Results from the logistic regressions demonstrated that rarity was not a statistically significant predictor of cost effectiveness at both thresholds with publication year, study sponsorship, and cancer type as covariates.

CONCLUSIONS

The proportion of ICERs that were cost effective at both thresholds does not appear to be significantly different between the two groups. Rarity is not statistically significantly associated with cost effectiveness, even when adjusted for important covariates.

Benefit of adjunct universal rectal screening for Chlamydia genital infections in women attending Canadian sexually transmitted infection clinics

Adding universal rectal screening to urogenital screening should positively impact rectal Chlamydia trachomatis (CT) incidence in affected populations. A dynamic Markov model was used to evaluate costs and outcomes of three rectal CT screening strategies among women attending sexually transmitted infection clinics in Alberta, Canada: universal urogenital-only screening (UG-only), additional selected (exposure-based) rectal screening (UG+SR), and additional universal rectal screening (UG+UR). The model included two mutually exclusive health states: infected and susceptible. Additionally, the model included two rounds of transmission: male sex partners of women infected with rectal-only CT and female sex partners of those men. CT complications impacting patients' quality of life (QALY) were considered. Alberta and Canadian data were used to estimate model inputs. We used a health care perspective, a time period of 10 years, and a discount rate of 3% for analyses. Compared to UG-only screening, the incremental cost effectiveness ratios (ICERs) were CA$34,000 and CA$49,000 per QALY gained for UG+SR and UG+UR screening strategies, respectively. Compared to UG+SR, the ICER was CA$62,000 per QALY gained for the UG+UR strategy. Both adjunct selected and universal rectal screening strategies are cost effective compared to UG-only screening, and UG+UR screening is cost effective when compared to UG+SR screening.

Do Regular Cholesterol Screenings Lead to Lower Cholesterol Levels and Better Health Behaviors for All? Spotlight on Middle-Aged and Older Adults in the United States

OBJECTIVE

This study investigates how the causal effects of cholesterol screening differ by likelihood of using this preventive care service in terms of accessibility gaps and effects on health-related outcomes across groups with advantaged and disadvantaged backgrounds.

METHOD

We use propensity score matching to analyze a nationally representative sample using data from 2008, 2010, and 2012 waves of the Health and Retirement Study ( N = 3,907).

RESULTS

We find that respondents who are least likely to get their cholesterol tested benefit most from the use of cholesterol screening when they do use it, while its effects are smallest for those who are most likely to use this service.

DISCUSSION

Understanding the heterogeneous effects of preventive health service has important policy implications, particularly in terms of how to maximize the public health benefits of preventive care.

Task-shifting alcohol interventions for HIV+ persons in Kenya: a cost-benefit analysis

Background

Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and poor adherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problems remains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention’s cost-effectiveness in dollars-per-health-outcome, and the long-term economic impact —or “return on investment” in monetary terms.

Methods

We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440 outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across a six-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administering task-shifted CBT therapy. Benefits included the economic impact of lowered HIV incidence as well as the improvements in household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses to test the robustness of our results.

Results

Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and the benefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratio remained above unity indicating that the intervention was cost-saving (i.e., had positive return on investment). The duration of the treatment effect most effected the results in sensitivity analyses.

Conclusions

CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The intervention can generate not only reductions in morbidity and mortality, but also economic savings for the health system in the medium and long term. The findings have implications for other countries with generalized HIV epidemics, high prevalence of alcohol consumption, and shortages of mental health professionals.

Trial registration

This paper uses data derived from “Cognitive Behavioral Treatment to Reduce Alcohol Use Among HIV-Infected Kenyans (KHBS)” with ClinicalTrials.gov registration NCT00792519 on 11/17/2008; and preliminary data from “A Stage 2 Cognitive-behavioral Trial: Reduce Alcohol First in Kenya Intervention” (NCT01503255, registered on 12/16/2011).

Improving patient flow of people with rheumatoid arthritis has the potential to simultaneously improve health outcomes and reduce direct costs

Background

In our current economic climate of scarce resources there is a lot of debate around the best - and most efficient - way of delivering care, which points patients towards the right physician at the earliest opportunity.

The aim of the study was to assess whether an improvement in the interdisciplinary management of rheumatoid arthritis (RA) has the potential to simultaneously improve health outcomes and reduce costs.

Methods

In a first step, we modelled the ways which lead patients with RA to the correct diagnosis, and the relevant specialist, respectively. On average, a patient experiences 3 GP visits before referral to a specialist. We compared this situation against a reconfiguration of current practice towards a more proactive identification and referral method with initiation of care by a rheumatologist early in the disease. We evaluated the impact of this reconfiguration on the number of RA patients diagnosed and the costs associated with the diagnostic process.

Result

Using data on epidemiology and Austrian practice patterns, we estimate a total of 5294 people with undifferentiated arthritis per year, of which 1765 suffer from RA. Modelling for diagnostic accuracy, we found that 1200 of these patients are initially misdiagnosed in a primary care setting and 95 at a rheumatologist. Our model found that a reconfiguration of current practice towards an approach of more integrated care has the potential to be not only cost-effective, but cost-saving: EUR 100,188 could be saved annually by exclusively adopting the new approach.

Conclusions

Our results show that by better directing the flow of people with RA, simultaneous clinical and economic benefits may be reaped:.

Which BRCA genetic testing programs are ready for implementation in health care? A systematic review of economic evaluations

PURPOSE

There is considerable evidence regarding the efficacy and effectiveness of BRCA genetic testing programs, but whether they represent good use of financial resources is not clear. Therefore, we aimed to identify the main health-care programs for BRCA testing and to evaluate their cost-effectiveness.

METHODS

We performed a systematic review of full economic evaluations of health-care programs involving BRCA testing.

RESULTS

Nine economic evaluations were included, and four main categories of BRCA testing programs were identified: (i) population-based genetic screening of individuals without cancer, either comprehensive or targeted based on ancestry; (ii) family history (FH)-based genetic screening, i.e., testing individuals without cancer but with FH suggestive of BRCA mutation; (iii) familial mutation (FM)-based genetic screening, i.e., testing individuals without cancer but with known familial BRCA mutation; and (iv) cancer-based genetic screening, i.e., testing individuals with BRCA-related cancers.

CONCLUSIONS

Currently BRCA1/2 population-based screening represents good value for the money among Ashkenazi Jews only. FH-based screening is potentially very cost-effective, although further studies that include costs of identifying high-risk women are needed. There is no evidence of cost-effectiveness for BRCA screening of all newly diagnosed cases of breast/ovarian cancers followed by cascade testing of relatives, but programs that include tools for identifying affected women at higher risk for inherited forms are promising. Cost-effectiveness is highly sensitive to the cost of BRCA1/2 testing.Genet Med 18 12, 1171-1180.

Health Examination Is Not a Priority for Less Acculturated Asian Americans

This study examines the associations between acculturation and three health examination behaviors (physical, dental, and eye exams) among 846 Chinese, Korean, and Vietnamese Americans. The study was part of a randomized, community-based trial on liver cancer prevention that targeted Asian Americans in Washington DC metropolitan area. Acculturation was assessed using Suinn-Lew Asian Self-Identity Acculturation (SL-ASIA) scale, acculturation clusters, and length of stay. Health examination behaviors in the last 2 years were self-reported. Potential confounders such as age, gender, ethnicity, income, marital status, self-rated health status, health insurance, and having a regular physician were adjusted. Increased acculturation was associated with greater receipt of preventive services when acculturation was measured by SL-ASIA and acculturation clusters. Compared to those in the "Asian" cluster, those in the "American" cluster and "bicultural" clusters were more likely to have physical exams (American odds ratio (OR) = 1.83, 95 % confidence interval (CI) 0.99, 3.88; bicultural OR = 1.11; 95 % CI 0.72, 1.70), dental exams (American OR = 1.99, 95 % CI 1.09, 3.65; bicultural OR = 1.83, 95 % CI 1.21, 2.78), and eye exams (American OR = 4.48, 95 % CI 2.67, 7.66; bicultural OR = 1.92, 95 % CI 1.31, 2.81). A gradient was observed in these associations with the American cluster having stronger associations than the bicultural cluster. Interaction was found between acculturation and gender for receipt of a physical exam. Future studies are needed to further explicate how access to health care impacts the association between acculturation and health examinations among Asian Americans.

Systematic review of health and behavioural outcomes of smoking cessation interventions in prisons

Objective

We conducted a systematic review to examine the impact of smoking cessation interventions, including smoking bans, on prisoners and prison staff.

Data sources

We systematically searched health and criminal justice databases for relevant studies. Search strings were used to combine terms related to smoking cessation interventions with terms related to incarceration. We used forward and backward snowballing to capture additional studies.

Study selection

Studies were included if: they were published between 1 January 1994 and 23 May 2016; the population was incarcerated adults and/or prison staff; they had a quantitative component; they were published in English; and they reported outcomes of a smoking cessation programme/ban with regard to reported change in smoking behaviour and/or behavioural outcomes.

Data extraction

Studies were reviewed for methodological rigour using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies. Data were independently reviewed for methodological quality by 1 author and a research assistant.

Data synthesis

Cessation programmes, including free nicotine replacement therapy and/or behavioural counselling can significantly increase the likelihood of quitting in prison and increase abstinence postrelease. Indoor bans have little impact on prisoner smoking behaviour. Prisoners who experience a complete smoking ban typically resume smoking shortly after release from prison. Bans may result in adverse behavioural outcomes, but these are generally minimal and short-lived.

Conclusions

While there is limited evidence to inform tobacco control policies in custodial settings, outcomes of this review suggest that cessation programmes/bans can be an effective mechanism to interrupt prisoner smoking behaviour when properly enforced.

The Analysis of Slovenian Political Party Programs Regarding Doctors and Health Workers from 1992 to 2014

Introduction

The study focuses on the programmatic bases of Slovenian political parties since independence. It presents an analysis of party programs and their preferences regarding doctors and other health workers, as well as the contents most commonly related to them. At the same time, the study also highlights the intensity of the presence of doctors on the policy agenda through time.

Methods

In the study, 83 program documents of political parties have been analysed. The study includes programmes of political parties that have occurred in parliamentary elections in Slovenia between 1992 and 2014 and have exceeded the parliamentary threshold. The data were analysed using the content analysis method, which is suitable for analysing policy texts. The analysis was performed using ATLAS.ti, the premier software tool for qualitative data analysis.

Results

The results showed that doctors and other health workers are an important political topic in non-crisis periods. At that time, the parties in the context of doctors mostly dealt with efficiency and the quality of services in the health system. They often criticize doctors and expose the need for their control. In times of economic crisis, doctors and other health workers are less important in normative commitments of parties.

Conclusions

Slovenian political parties and their platforms cannot be distinguished ideologically, but primarily on the principle of access to government. It seems reasonable to conclude that parties do not engage in dialogue with doctors, and perceive the latter aspassive recipients of government decisions—politics.

Investing in a healthy lifestyle strategy: is it worth it?

OBJECTIVES

In Quebec, various actors fund activities aimed at increasing physical activity, improving eating habits and reducing smoking. The objective was to evaluate how effective does the healthy lifestyle habits promotion (HLHP) strategy need to be to make to offset its costs.

METHODS

First, we built the logic model of the HLHP strategy. We then assessed the strategy's total cost as well as the direct health care expenditures associated with lifestyle-related risk factors (smoking, physical inactivity, insufficient intake of fruits and vegetables, obesity and overweight). Finally, we estimated the break-even point beyond which the economic benefits of the HLHP strategy would outweigh its costs.

RESULTS

The HLHP strategy cost for 2010-2011 was estimated at $110 million. Direct healthcare expenditures associated with lifestyle-related risk factors were estimated at $4.161 billion. We estimated that 47 % of these expenditures were attributable to these risk factors.

CONCLUSIONS

We concluded that the HLHP strategy cost corresponded to 5.6 % of the annual healthcare expenditures attributable to these risk factors. This study compared the economic value of HLHP activities against healthcare expenditures associated with targeted risk factors.

The influence of marital status on the use of breast, cervical, and colorectal cancer screening

PURPOSE

To examine the impact of marital status on the use of screening for breast, cervical, and colorectal cancer.

METHODS

We relied on 2012 Behavioral Risk Factor Surveillance System Survey age-appropriate screening cohorts. Appropriate screening for breast, cervical, and colorectal cancer was determined according to United States Preventive Services Task Force recommendations in effect at the time of the 2012 survey. Complex samples logistic regression models were performed to examine the effect of marital status on cancer screening.

RESULTS

Overall, 81.6, 83.9, and 68.9% of married participants underwent breast, cervical, and colorectal cancer, respectively, relative to 74.2, 75.1, and 60.9% for divorced/widowed/separated, individuals, and 74.7, 78.7, and 53.4% for never married individuals. Marital status (married vs. never married) was an independent predictor of screening for all cancers examined: breast cancer, odds ratio (OR): 1.42 (95% confidence interval [CI]: 1.25-1.61); cervical cancer, OR: 1.29 (95% CI: 1.16-1.43); colorectal cancer, OR: 1.63 (95% CI: 1.51-1.77). Gender-specific subgroup analyses for colorectal cancer suggests that marital status may exert a greater effect in men, relative to women (married men: OR 1.75, 95% CI: 1.56-1.96; married women: OR: 1.52, 95% CI: 1.35-1.70).

CONCLUSION

Being married is associated with increased utilization of breast, cervical, and colorectal cancer screening. The influence of marital status was greater in men relative to women eligible for colorectal cancer screening. Our results emphasize the importance of social determinants of health-seeking behaviors.

Communicating nutraceuticals: A multi-stakeholder perspective from a developing nation

Nutraceuticals, a combination of nutrition and pharmaceutical, have grown rapidly as a product globally. Nutraceuticals can be advertised directly to consumers as well as prescribed, and thus involve multiple stakeholders in the marketing communication process. The present study investigates the marketing communication aspects of nutraceuticals using 216 semistructured in-depth interviews including all stakeholders in the process such as company/brand, physicians, pharmacists, and consumers. The findings bring out the role of each participant in the communication process and a comprehensive picture of the same. The insights would facilitate the nutraceutical brands to understand and implement marketing effective communication strategies.

Key Aspects of a Sustainable Health Insurance System in Germany

BACKGROUND

The main goals of health-care systems are to improve the health of the population they serve, respond to people's legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design.

OBJECTIVE

This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges.

METHODS

We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semi-structured interviews with stakeholders in the system, and an online questionnaire.

RESULTS

We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance.

CONCLUSION

We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.

Strengthening Cost-Effectiveness Analysis for Public Health Policy

Although the U.S. spends more on medical care than any country in the world, Americans live shorter lives than the citizens of other high-income countries. Many important opportunities to improve this record lie outside the health sector and involve improving the conditions in which Americans live and work: safe design and maintenance of roads, bridges, train tracks, and airports; control of environmental pollutants; occupational safety; healthy buildings; a safe and healthy food supply; safe manufacture of consumer products; a healthy social environment; and others. Faced with the overwhelming array of possibilities, U.S. decision makers need help identifying those that can contribute the most to health. Cost-effectiveness analysis is designed to serve that purpose, but has mainly been used to assess interventions within the health sector. This paper briefly reviews the objective of cost-effectiveness analysis and its methodologic evolution and discusses the issues that arise when it is used to evaluate interventions that fall outside the health sector under three headings: structuring the analysis, quantifying/measuring benefits and costs, and valuing benefits and costs.

The impact of Medicare eligibility on cancer screening behaviors

INTRODUCTION

Lack of health insurance limits access to preventive services, including cancer screening. We examined the effects of Medicare eligibility on the appropriate use of cancer screening services in the United States.

METHODS

We performed a cross-sectional analysis of the 2012 Behavioral Risk Factor and Surveillance System (analyzed in 2014). Univariable and logistic regression analyses were performed for participants aged 60-64 and 66-70 to examine the effects of Medicare eligibility on prevalence of self-reported screening for colorectal, breast, and prostate cancers. Sub-analyses were performed among low-income (<$25,000 annual/household) individuals.

RESULTS

Medicare-eligible individuals were significantly more likely to undergo all examined preventive services (colorectal cancer OR: 1.90; 95% CI 1.79-2.04; prostate cancer OR: 1.29; 95% CI 1.17-1.43; breast cancer OR: 1.23; 95% CI 1.10-1.37) and the effect was most pronounced among low-income individuals (colorectal cancer OR: 2.04; 95% CI 1.8-2.32; prostate cancer OR: 1.39; 95% CI 1.12-1.72; breast cancer OR: 1.42, 95% CI 1.20-1.67). Access to a healthcare provider was the strongest independent predictor of undergoing appropriate screening, ranging from OR 2.73 (95% CI 2.20-3.39) for colorectal cancer screening in the low-income population to OR 4.79 (95% CI 3.95-5.81) for breast cancer screening in the overall cohort. The difference in screening prevalence was most pronounced when comparing Medicare-eligible participants to uninsured Medicare-ineligible participants (+33.2%).

CONCLUSIONS

Medicare eligibility impacts the prevalence of cancer screening, likely as a result of increased access to primary care. Low-income individuals benefit most from Medicare eligibility. Expanded public insurance coverage to these individuals may improve access to preventive services.

Cost-Utility Analysis of Cancer Prevention, Treatment, and Control: A Systematic Review

CONTEXT

Substantial innovation related to cancer prevention and treatment has occurred in recent decades. However, these innovations have often come at a significant cost. Cost-utility analysis provides a useful framework to assess if the benefits from innovation are worth the additional cost. This systematic review on published cost-utility analyses related to cancer care is from 1988 through 2013. Analyses were conducted in 2013-2015.

EVIDENCE ACQUISITION

This review analyzed data from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), a comprehensive registry with detailed information on 4,339 original cost-utility analyses published in the peer-reviewed medical and economic literature through 2013.

EVIDENCE SYNTHESIS

There were 721 cancer-related cost-utility analyses published from 1998 through 2013, with roughly 12% of studies focused on primary prevention and 17% focused on secondary prevention. The most often studied cancers were breast cancer (29%); colorectal cancer (11%); and prostate cancer (8%). The median reported incremental cost-effectiveness ratios (in 2014 U.S. dollars) were $25,000 for breast cancer, $24,000 for colorectal cancer, and $34,000 for prostate cancer.

CONCLUSIONS

The current evidence indicates that there are many interventions that are cost effective across cancer sites and levels of prevention. However, the results highlight the relatively small number of cancer cost-utility analyses devoted to primary prevention compared with secondary or tertiary prevention.

CHANGING FACE OF MEDICARE'S NATIONAL COVERAGE DETERMINATIONS FOR TECHNOLOGY

OBJECTIVES

The Centers for Medicare and Medicaid Services (CMS) issues National Coverage Determinations (NCDs) for medical interventions expected to have a significant impact on Medicare, the health insurance program for US citizens aged 65 years and older and certain people with disabilities under the age of 65 years. The objective of this study was to evaluate NCDs issued from 1999 to 2013 to identify key trends, and to discuss implications for future CMS policy.

METHODS

We used the Tufts Medical Center Medicare National Coverage Determination Database to examine characteristics of NCDs from 1999 through 2013. We examined various characteristics of NCDs, including: whether the intervention under review is used for prevention or treatment of disease, the type of intervention considered, evidence limitations cited by CMS, and coverage determination outcome. We evaluated longitudinal trends in categorical and continuous variables in the database, using Cochran-Armitage trend tests and linear regression, respectively.

RESULTS

We found that NCDs increasingly focus on preventive care (p = 0.072), pertain to diagnostic imaging (p = 0.033), and evaluate health education/behavioral therapy interventions (p = 0.051). CMS increasingly cites the lack of relevant outcomes (p = 0.019) and the lack of applicability of study results to the Medicare population (p < 0.001) as evidence limitations. CMS less often restricts coverage to certain population subgroups in NCDs (p < 0.001), but increasingly applies coverage with evidence development policies (p < 0.001).

CONCLUSIONS

Identified trends reflect broader changes in Medicare as CMS shifts its focus from treatment to prevention of disease, addresses potentially overutilized technologies, and attempts to issue flexible coverage policies.

The need to improve implementation and use of lifestyle surveillance systems for planning prevention activities: an analysis of the Italian Regions

OBJECTIVES

To describe the level of use of lifestyle surveillance systems in Italy and to identify predictors of their use by the Italian Regions for planning and monitoring purposes.

STUDY DESIGN

Data were extracted from the 19 Regional Prevention Plans (RPPs) and the health promotion and prevention projects included in them developed by the Italian Regions within the National Prevention Plan 2010-2013.

METHODS

The 19 RPPs and the 702 projects were appraised using a tool specifically developed for the purpose. Multiple logistic regression was performed to identify predictors of use of surveillance systems in the 359 projects that could use them.

RESULTS

The analysis of regional epidemiological contexts does not always rely upon surveillance system data and there were too few projects aimed at the maintenance and the development of these systems. Moreover, fewer than half of projects that could have used surveillance systems for planning and evaluation procedures actually did so, despite the potential value of these data. There was a statistically significant association between Regional Health Care Expenditure (RHCE) and the use of surveillance system data for planning and/or evaluation of the projects (OR 7.81, 95% CI 2.86-21.29).

CONCLUSIONS

Use of surveillance systems for regional prevention planning in Italy is not optimal due to late implementation, presence of different data collecting systems and RGDP inequalities. There is a pressing need for full implementation of surveillance systems to allow better definition of the priorities and objectives of public health interventions.

Economic Evaluation of Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force

BACKGROUND

Diabetes is a highly prevalent and costly disease. Studies indicate that combined diet and physical activity promotion programs can prevent type 2 diabetes among persons at increased risk.

PURPOSE

To systematically evaluate the evidence on cost, cost-effectiveness, and cost-benefit estimates of diet and physical activity promotion programs.

DATA SOURCES

Cochrane Library, EMBASE, MEDLINE, PsycINFO, Sociological Abstracts, Web of Science, EconLit, and CINAHL through 7 April 2015.

STUDY SELECTION

English-language studies from high-income countries that provided data on cost, cost-effectiveness, or cost-benefit ratios of diet and physical activity promotion programs with at least 2 sessions over at least 3 months delivered to persons at increased risk for type 2 diabetes.

DATA EXTRACTION

Dual abstraction and assessment of relevant study details.

DATA SYNTHESIS

Twenty-eight studies were included. Costs were expressed in 2013 U.S. dollars. The median program cost per participant was $653. Costs were lower for group-based programs (median, $417) and programs implemented in community or primary care settings (median, $424) than for the U.S. DPP (Diabetes Prevention Program) trial and the DPP Outcomes Study ($5881). Twenty-two studies assessed the incremental cost-effectiveness ratios (ICERs) of the programs. From a health system perspective, 16 studies reported a median ICER of $13 761 per quality-adjusted life-year (QALY) saved. Group-based programs were more cost-effective (median, $1819 per QALY) than those that used individual sessions (median, $15 846 per QALY). No cost-benefit studies were identified.

LIMITATION

Information on recruitment costs and cost-effectiveness of translational programs implemented in community and primary care settings was limited.

CONCLUSION

Diet and physical activity promotion programs to prevent type 2 diabetes are cost-effective among persons at increased risk. Costs are lower when programs are delivered to groups in community or primary care settings.

PRIMARY FUNDING SOURCE

None.

The cost-effectiveness of diabetes prevention: results from the Diabetes Prevention Program and the Diabetes Prevention Program Outcomes Study

Background

The Diabetes Prevention Program (DPP) was a randomized, controlled clinical trial. It demonstrated that among high-risk individuals with impaired glucose tolerance, diabetes incidence was reduced by 58 % with lifestyle intervention and 31 % with metformin compared to placebo. During the Diabetes Prevention Program Outcomes Study (DPPOS), all DPP participants were unmasked to their treatment assignments, the original lifestyle intervention group was offered additional lifestyle support, the metformin group continued metformin, and all three groups were offered a group-implemented lifestyle intervention. Over the 10 years of combined DPP/DPPOS follow-up, diabetes incidence was reduced by 34 % in the lifestyle group and 18 % in the metformin group compared to placebo. The purpose of this article is to review and synthesize analyses published by the DPP/DPPOS Research Group that have described the cost-effectiveness of diabetes prevention.

Methods

We describe the resource utilization and costs of the DPP and DPPOS interventions, the costs of non-intervention-related medical care, the impact of the interventions on diabetes progression and quality-of-life, and the cost-effectiveness of the interventions from health system and societal perspectives. Cost-effectiveness analyses were performed with a 3-year time horizon using DPP data, a lifetime time horizon that simulated 3-year DPP data, and a 10-year time horizon using combined DPP/DPPOS data.

Results

Although more expensive than the placebo intervention, the greater costs of the lifestyle and metformin interventions were offset by reductions in the costs of nonintervention-related medical care. Every year after randomization, quality-of-life was better for participants in the lifestyle intervention compared to those in the metformin or placebo intervention. In both the simulated lifetime analysis and the 10-year within trial economic analysis, lifestyle and metformin were extremely cost-effective (that is, improved outcomes at a low incremental cost) or even cost-saving (that is, improved outcomes and reduced total costs) compared to the placebo intervention.

Conclusions

The implementation of diabetes prevention programs in high-risk individuals will result in important health benefits and represents a good value for money.

Trial registration

NCT00004992 (DPP) and NCT00038727 (DPPOS).

Electronic supplementary material

The online version of this article (doi:10.1186/s40842-015-0009-1) contains supplementary material, which is available to authorized users.

Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources

BACKGROUND

Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery.

METHODS

Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012.

RESULTS

In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure.

CONCLUSION

Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving forward.

National Institutes of Health funding for behavioral interventions to prevent chronic diseases

Chronic non-communicable diseases (NCDs) cause the majority of premature deaths, disability, and healthcare expenditures in the U.S. Six largely modifiable risk behaviors and factors (tobacco use, poor nutrition, physical inactivity, alcohol abuse, drug abuse, and poor mental health) account for more than 50% of premature mortality and considerably more morbidity and disability. The IOM proposed that population burden of disease and preventability should be major determinants of the amount of research funding provided by the U.S. NIH. Data on NIH prevention funding between fiscal years 2010 and 2012 for human behavioral interventions that target the modifiable risk factors of NCDs were analyzed during 2013-2014. The NIH prevention portfolio comprises approximately 37% human behavioral studies and 63% basic biomedical, genetic, and animal studies. Approximately 65% of studies were secondary prevention versus 23% for primary prevention, and 71% of studies intervened at the individual and family levels. Diet and exercise were the most-studied risk factors (41%), and few studies conducted economic analyses (12%). NIH spends an estimated $2.2-$2.6 billion annually (7%-9% of the total of $30 billion) on human behavioral interventions to prevent NCDs. Although NIH prevention funding broadly aligns with the current burden of disease, overall funding remains low compared to funding for treatment, which suggests funding misalignment with the preventability of chronic diseases.

Cardiovascular disease and diabetes mortality, and their relation to socio-economical, environmental, and health behavioural factors in worldwide view

BACKGROUND

Today, non-communicable diseases, mainly cardiovascular diseases and diabetes, represent a leading threat to human health and development. This study observed mortality trends in all income group countries in relation to a wide variety of related factors like economical and environmental factors, health behaviour and health risk factors.

STUDY DESIGN

Ecological study.

METHOD

Data were analysed for 72 countries using the ecological study method. Data were collected from various sources including WHO, World Bank and previous studies. Cardiovascular disease and diabetes mortality rates for males and females were used as the dependent variables. GDP, GINI, literacy rate, urbanization, health expenditure, the number of physicians and the number of beds, BMI, western diet, blood glucose, blood pressure, serum cholesterol, physical inactivity, alcohol, and smoking were used as the independent variables initially. The final model was decided on the basis of availability of complete data and result of co-linearity test. Correlation test and linear regression were employed to identify the affecting factors for the dependent variables.

RESULT

Analysis showed that cardiovascular disease and diabetes mortality was more concentrated in middle- and low-income countries and was negatively associated with GDP, GINI, and western diet. Countries with high average blood pressure had higher mortality rates showing a positive relationship.

CONCLUSION

Non-communicable disease mortality rate is strongly associated with many economical, social, environmental, and behavioural factors. More comprehensive preventive and diagnostic strategies are needed to decrease mortality especially in low- and middle-income countries.

The excess health care costs of KardioPro, an integrated care program for coronary heart disease prevention

Coronary heart disease (CHD) is a major cause of death and important driver of health care costs. Recent German health care reforms have promoted integrated care contracts allowing statutory health insurance providers more room to organize health care provision. One provider offers KardioPro, an integrated primary care-based CHD prevention program. As insurance providers should be aware of the financial consequences when developing optional programs, this study aims to analyze the costs associated with KardioPro participation. 13,264 KardioPro participants were compared with a propensity score-matched control group. Post-enrollment health care costs were calculated based on routine data over a follow-up period of up to 4 years. For those people who incurred costs, KardioPro participation was significantly associated with increased physician costs (by 33%), reduced hospital costs (by 19%), and reduced pharmaceutical costs (by 16%). Overall costs were increased by 4%, but this was not significant. Total excess costs per observation year were €131 per person (95% confidence interval: [€-36.5; €296]). Overall, KardioPro likely affected treatment as the program increased costs of physician services and reduced costs of hospital services. Further effects of substituting potential inpatient care with increased outpatient care might become fully apparent only over a longer time horizon.

Strategic nutrition: a vision for the twenty-first century

It is now widely accepted that poor nutrition plays a major role in the epidemic of various diseases, including obesity, type 2 diabetes and CVD. There has also been much research regarding the role of related factors such as advertising and food prices. Many intervention studies have been carried out where attempts have been made to persuade people to modify their behaviour, such as by making dietary changes, in order to enhance health (health promotion). There has also been much debate on the potential of government policy as a tool for achieving these goals. Various proposals have been made, such as a tax on sugary drinks, the redirection of food subsidies and how the salt content of food can be reduced. However, the great majority of previous papers have considered only single aspects of the topics discussed here. The present paper reviews strategies for improving public health, both health promotion interventions and the use of government policy approaches. Topics discussed include providing advice for the general population and the design of food guides and food labels. This leads to the conclusion that we need an overall strategy that integrates this diverse body of information and formulates a comprehensive action plan. I propose the term ‘strategic nutrition’. The implementation of this plan opens up a path to a major advance in public health.

Medicare's use of cost-effectiveness analysis for prevention (but not for treatment)

CONTEXT

Medicare currently pays for 23 preventive services in its benefits package, the majority of which were added since 2005. In the past decade, the program has transformed from one essentially administering treatment claims, to one increasingly focused on health promotion and maintenance. What is largely unappreciated is the role cost-effectiveness analysis has played in the coverage of preventive services.

METHODS

We review the role of cost-effectiveness analysis in Medicare coverage of preventive services and contrast it to the lack of such consideration in the coverage of treatments.

FINDINGS

While not considered for coverage of treatment, cost-effectiveness analysis played a role in the coverage of nine preventive services, and was evaluated in a number of instances when the service was not added. Pneumococcal vaccine, the first preventive service added to the benefit (1981), followed a Congressionally requested cost-effectiveness analysis, which showed it to be cost-saving. More recently, the Centers for Medicare and Medicaid Services (CMS) reviewed cost-effectiveness evidence when covering preventive services such as HIV screening (2010) and screening and behavioral counseling for alcohol misuse (2011) (studies reported cost-effectiveness ratios of $55,440 per QALY, and $1755 per QALY, respectively).

CONCLUSIONS

Cost-effectiveness analysis has played a longstanding role in informing the addition of preventive services to Medicare. It offers Medicare officials information they can use to help ensure health gains are achieved at reasonable cost. However, limiting cost-effectiveness evidence to prevention and not treatment is inconsistent and potentially inefficient.