Comparing total health care costs and treatment patterns of HIV patients in a managed care setting

[A systematic review on population-based indicators of the quality of care in formal and informal provider networks and their application in health economic evaluations]

BACKGROUND

Provider networks in healthcare can emerge as either formal or informal networks. For sector-encompassing population-based quality measurement in informal networks, which allows for conclusions about the cost-effectiveness of care for home-dwelling persons in need of care, a comprehensive review on suitable quality indicators that can be derived from German social health insurance claims data is still lacking.

OBJECTIVE

Primary review questions: Which population-based indicators of quality of care in formal and informal provider networks are described in the international literature? Which of these indicators are used as outcome parameters in health economic evaluations, and what are the methodological approaches in these evaluations? Rating approaches and methods for establishing thresholds as well as the validity and suitability of quality indicators to predict quality of care as well as the potential for the calculation of quality indicators based on German social health insurance claims data are included in the secondary review questions.

SEARCH METHODS

Databases searched in May 2017 and July 2018 included PubMed, The Cochrane Library und NHS EED, CINAHL, GeroLit and EconLit. In addition, we hand-searched references of the studies identified and screened the project database Health Services Research Germany.

SELECTION CRITERIA

Quantitative design, German or English language. Any kind of formal or informal network for which distinct members regarding single providers are named and population-based quality indicators for adults (18 years or older) are described.

DATA COLLECTION AND ANALYSIS

Two authors (Cohen's Kappa = 0.64) independently screened titles, abstracts and full texts. A third independent reviewer was consulted in cases of uncertainty regarding the inclusion of studies. Critical appraisal was conducted using AMSTAR, the Cochrane Risk-of-Bias Tool, the Newcastle-Ottawa Scale (NOS), the Appraisal Tool for Cross-Sectional Studies (AXIS) and the criteria of the Drummond Checklist.

MAIN RESULTS

137 studies were included, five of which evaluated informal provider networks and applied indicators for medical conditions such as diabetes mellitus or heart failure or events like ambulatory care-sensitive hospitalisations, which were also utilized for formal networks. Five out of 14 health economic evaluations also assessed associations between costs and quality of care. The majority of studies did not include evidence on rating approaches and/or thresholds. Even though the validity and reliability of the used data in single studies is frequently discussed, only one in four of the included studies undertook a discussion of the suitability of the applied indicators. 121 studies explored indicators that can, in whole or in part, potentially be calculated on the basis of German social health insurance claims data and that target medical conditions such as osteoarthritis, asthma, chronic pain, chronic obstructive pulmonary disease, cardiovascular disease, dementia, diabetes mellitus, osteoporosis or mental health disorders as well as ambulatory care-sensitive events, appropriate medication of the elderly and polypharmacy, preventive care and continuity of care.

AUTHORS' CONCLUSIONS

This systematic review identified quality indicators that were predominantly used in formal provider networks and, with sufficient testing and further development, include the possibility of being used for measuring the quality of care in informal networks. The need for further research on suitable approaches to measure the interactions of quality of care and costs and on the validity, reliability and predictive suitability of single indicators as well as the finding that quality indicators especially developed for the German ambulatory sector were rarely used in the included studies constitute promising starting points for both an intensified methodological debate and the critical discussion of issues concerning population-based, sector-encompassing measurement of quality of care in health services research.

Twice-daily versus once-daily antiretroviral therapy and coformulation strategies in HIV-infected adults: benefits, risks, or burden?

The recent development of once-daily antiretroviral agents and fixed-dose combination formulations has been an important development in antiretroviral regimen simplification. Recent studies indicate that once-daily antiretroviral regimens improve adherence, especially in antiretroviral-naïve patients and in difficult-to-treat populations, such as the homeless or marginally housed. However, there are potential risks with the higher peak and lower trough plasma drug concentrations that may result from certain once-daily formulations. Due to the multifactorial and complex nature of adherence behavior, clinicians' efforts to improve patient adherence should not be limited to prescribing once-daily regimens, but should also consider social support, side effect management, and adherence support tools, such as pillbox organizers and other targeted interventions. Additional research will clarify the benefits of once-daily and fixed-dose combination regimens on clinical and virologic outcomes. Comprehensive cost-benefit analysis of regimen simplification could help facilitate evidence-based decisions regarding antiretroviral regimen choices.

The association of adherence to antiretroviral therapy with healthcare utilization and costs for medical care

BACKGROUND

The association between antiretroviral adherence, healthcare utilization and medical costs has not been well studied.

OBJECTIVE

To examine the relationship of adherence to antiretroviral medications to healthcare utilization and healthcare costs.

METHODS

A retrospective cohort study was conducted using data from 325 previously antiretroviral medication-naive HIV-infected individuals initiating first antiretroviral therapy from 1997 through 2003. The setting was an inner-city safety net hospital and HIV clinic in the US. Adherence was assessed using pharmacy refill data. The average wholesale price was used for prescription costs. Healthcare utilization data and medical costs were obtained from the hospital billing database, and differences according to quartile of adherence were compared using analysis of variance (ANOVA). Multivariate logistic regression was used to assess predictors of higher annual medical costs. Sensitivity analyses were used to examine alternative antiretroviral pricing schemes. The perspective was that of the healthcare provider, and costs were in year 2005 values.

RESULTS

In 325 patients followed for a mean (+/- SD) 3.2 (1.9) years, better adherence was associated with lower healthcare utilization but higher total medical costs. Annual non-antiretroviral medical costs were $US 7,612 in the highest adherence quartile versus $US 10,190 in the lowest adherence quartile. However, antiretroviral costs were significantly higher in the highest adherence quartile ($US 17,513 vs $US 8,690), and therefore the total annual medical costs were also significantly higher in the highest versus lowest adherence quartile ($US 25,125 vs $US 18,880). In multivariate analysis, for every 10% increase in adherence, the odds of having annual medical costs in the highest versus lowest quartile increased by 87% (odds ratio 1.87; 95% CI 1.45, 2.40). In sensitivity analyses, very low antiretroviral prices (as seen in resource-limited settings) inverted this relationship - excellent adherence was cost saving.

CONCLUSION

Better adherence to antiretroviral medication was associated with decreased healthcare utilization and associated costs; however, because of the high cost of antiretroviral therapy, total medical costs were increased. Combination antiretroviral therapy is known to be cost effective; lower antiretroviral costs may make it cost saving as well.

The effect of homelessness on hospitalisation among patients with HIV/AIDS

The purpose of this study was to determine the effect of homelessness on the costs and patterns of hospitalisation in patients with HIV/AIDS. A retrospective longitudinal study design, based on medical records data covering 2,768 person-years of observation between 1997 and 2003 on patients with HIV/AIDS, was employed. A contextual measure of neighbourhood socioeconomic status (SES) was also used to uncover differences among low- and high-SES neighbourhood dwellers. The association of homelessness and neighbourhood SES with total annual hospitalisation costs, length of stay, numbers of hospital and emergency department admissions and the probability of an operating room procedure, controlling for other covariates, was assessed using multivariate regression analysis. Our results suggest that the homeless and low-SES neighbourhood residents had a large proportion of total costs attributable to admissions for acute events related to the progression of disease. Hospitalisations for planned operating room procedures comprised a relatively larger proportion of hospitalisation costs for high-SES neighbourhood residents. One implication of our findings is that improvements in the continuity of care and cost savings on inpatient care may be realised through further development of social assistance programs aimed at reaching the homeless and residents of low-SES neighbourhoods.

Antiretroviral Therapy in the??Real World

OBJECTIVE AND METHODS

The aim of our study was to analyse retrospectively the nature and frequency of antiretroviral prescriptions for 990 HIV-infected patients followed at our outpatient centre in Bologna, Italy, from January 2003 to March 2004. The main focus of the study was to identify the most commonly prescribed combinations and their related expenses, in order to identify the most competitive treatment regimens with regard to costs. Prescriptions were given directly to patients at monthly intervals, and drug treatment adherence data was stored in an electronic database. Antiretroviral regimens administered for the longest period to each patient during the 15 months of the study were selected for the study. All patients treated for <9 consecutive months and/or with treatment adherence levels <90% were excluded. Physicians assessed antiretroviral therapy at least quarterly according to efficacy and safety criteria, but not in terms of pharmacoeconomic considerations. Direct pharmacy expenses were obtained for the 24 most commonly used therapeutic regimens, covering 80.1% of patients.

RESULTS

The zidovudine-lamivudine-efavirenz combination proved to be the most prescribed combination (7.3%), followed by zidovudine-lamivudine- nevirapine (7.1%), lamivudine-stavudine (6.2%), zidovudine-lamivudine- lopinavir-ritonavir (5.2%), didanosine-stavudine-lopinavir-ritonavir (4.8%), and lamivudine-stavudine-nevirapine (4.7%). Anti-HIV combinations varied from a minimum yearly cost of euro3895.6 for lamivudine-stavudine to euro9422.8 for the zidovudine-lamivudine-lopinavir-ritonavir combination (+241.9%) [year of costing 2003]. There was a significant difference between the two first-line regimens for antiretroviral-naive subjects, with lopinavir-ritonavir-based combinations costing more than euro9000 per patient/year compared with efavirenz-containing combinations, which were 28% less expensive. Mean daily costs varied substantially, from a minimum of euro10.7 per day for lamivudine-stavudine to a maximum of euro25.8 per day (+241.1%) for zidovudine-lamivudine-lopinavir-ritonavir. Regimens based on non-nucleoside reverse transcriptase inhibitors (NNRTIs) were less costly than most of those including protease inhibitors (PIs). The increased expense of each combination was compared with the cheapest therapeutic selection (lamivudine-stavudine), and costs of all triple combinations were also compared. Regimens based on NNRTIs accounted for 29.3% of our cohort (nevirapine-containing therapies 15.1%, and efavirenz-based ones 14.2%), while PIs were used in the majority of cases (37.3%), with lopinavir-ritonavir as the leading combination (13.6% of patients), followed by nelfinavir (9.9%) and indinavir (9.2%). When drug-related costs were examined, dual nucleoside analogues showed the lowest expense (euro10.7-euro11.6 per day), while triple nucleoside/nucleotide analogue combinations cost nearly twice as much (euro18.5-euro20.4 per day). Among the NNRTIs, there were comparable costs for nevirapine-based combinations (euro18.3-euro18.7 per day), while efavirenz-including regimens were 10% more costly (euro19.2-euro20.l per day). A very broad range of combinations and related costs were found with PIs, but apart from indinavir and saquinavir combinations (euro15.7-euro21.7 per day), all other regimens had a higher daily cost (from euro22.0 per day for ritonavir-based regimens to euro23.4-euro24.3 per day for nelfinavir combinations, and up to euro24.9-euro25.8 per day with lopinavir-ritonavir). When considering nelfinavir- and lopinavir-containing combinations, the difference compared with NNRTI-based regimens varied from 41% when nevirapine- and lopinavir-ritonavir were compared, to 11.6% when efavirenz and nelfinavir were compared.

CONCLUSIONS

Investigations that link prescribing patterns and related costs in the setting of HIV disease therapy are needed to improve patient management and help with the planning of healthcare resource allocation.