The cost-effectiveness of implementing a new guideline for cardiovascular risk management in primary care in the Netherlands

Direct costs of adhering to selected Duchenne muscular dystrophy care considerations: estimates from a Midwestern state

INTRODUCTION/AIMS

The multidisciplinary Duchenne muscular dystrophy (DMD) Care Considerations were developed to standardize care and improve outcomes. We provide cumulative cost estimates for selected key preventive (i.e., excluding new molecular therapies and acute care) elements of the care considerations in eight domains (neuromuscular, rehabilitation, respiratory, cardiac, orthopedic, gastrointestinal, endocrine, psychosocial management) independent of completeness of uptake or provision of non-preventive care.

METHODS

We used de-identified insurance claims data from a large Midwestern commercial health insurer during 2018. We used Current Procedural Terminology and National Drug codes to extract unit costs for clinical encounters representing key preventive elements of the DMD Care Considerations. We projected per-patient cumulative costs from ages 5 to 25 years for these elements by multiplying a schedule of recommended frequencies of preventive services by unit costs in 2018 US dollars.

RESULTS

Assuming a diagnosis at age 5 years, independent ambulation until age 11, and survival until age 25, we estimated 670 billable clinical events. The 20-year per-patient cumulative cost was $174,701 with prednisone ($2.3 million with deflazacort) and an expected total of $12,643 ($29,194) for out-of-pocket expenses associated with those events and medications.

DISCUSSION

Standardized monitoring of disease progression and treatments may reduce overall costs of illness. Costs associated with these services would be needed to quantify potential savings. Our approach demonstrates a method to estimate costs associated with implementation of preventive care schedules.

Estimating Costs of Implementing Stroke Systems of Care and Data-Driven Improvements in the Paul Coverdell National Acute Stroke Program

Purpose and Objectives

We evaluated the costs of implementing coordinated systems of stroke care by state health departments from 2012 through 2015 to help policy makers and planners gain a sense of the potential return on investments in establishing a stroke care quality improvement (QI) program.

Intervention Approach

State health departments funded by the Paul Coverdell National Acute Stroke Program (PCNASP) implemented activities to support the start and proficient use of hospital stroke registries statewide and coordinate data-driven QI efforts. These efforts were aimed at improving the treatment and transition of stroke patients from prehospital emergency medical services (EMS) to in-hospital care and postacute care facilities. Health departments provided technical assistance and data to support hospitals, EMS agencies, and posthospital care agencies to carry out small, rapid, incremental QI efforts to produce more effective and efficient stroke care practices.

Evaluation Methods

Six of the 11 PCNASP-funded state health departments in the United States volunteered to collect and report programmatic costs associated with implementing the components of stroke systems of care. Six health departments reported costs paid directly by Centers for Disease Control and Prevention–provided funds, 5 also reported their own in-kind contributions, and 4 compiled data from a sample of their partners’ estimated costs of resources, such as staff time, involved in program implementation. Costs were analyzed separately for PCNASP-funded expenditures and in-kind contributions by the health department by resource category and program activity. In-kind contributions by partners were also analyzed separately.

Results

PCNASP-funded expenditures ranged from $790,123 to $1,298,160 across the 6 health departments for the 3-year funding period. In-kind contributions ranged from $5,805 to $1,394,097. Partner contributions (n = 22) ranged from $3,912 to $362,868.

Implications for Public Health

Our evaluation reports costs for multiple state health departments and their partners for implementing components of stroke systems of care in the United States. Although there are limitations, our findings represent key estimates that can guide future program planning and efforts to achieve sustainability.

Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention

PURPOSE

Our aim was to update estimates of the health and economic impact of clinical services recommended for the primary prevention of cardiovascular disease (CVD) for the comparative rankings of the National Commission on Prevention Priorities, and to explore differences in outcomes by sex and race/ethnicity.

METHODS

We used a single, integrated, microsimulation model to generate comparable results for 3 services recommended by the US Preventive Services Task Force: aspirin counseling for the primary prevention of CVD and colorectal cancer, screening and treatment for lipid disorders (usually high cholesterol), and screening and treatment for hypertension. Analyses compare lifetime outcomes from the societal perspective for a US-representative birth cohort of 100,000 persons with and without access to each clinical preventive service. Primary outcomes are health impact, measured by the net difference in lifetime quality-adjusted life years (QALYs), and cost-effectiveness, measured in incremental cost per QALY or cost savings per person in 2012 dollars. Results are also presented for population subgroups defined by sex and race/ethnicity.

RESULTS

Health impact is highest for hypertension screening and treatment (15,600 QALYs), but is closely followed by cholesterol screening and treatment (14,300 QALYs). Aspirin counseling has a lower health impact (2,200 QALYs) but is found to be cost saving ($31 saved per person). Cost-effectiveness for cholesterol and hypertension screening and treatment is $33,800 per QALY and $48,500 per QALY, respectively. Findings favor hypertension over cholesterol screening and treatment for women, and opportunities to reduce disease burden across all services are greatest for the non-Hispanic black population.

CONCLUSIONS

All 3 CVD preventive services continue to rank highly among other recommended preventive services for US adults, but individual priorities can be tailored in practice by taking a patient's demographic characteristics and clinical objectives into account.

Modeling the costs and long-term health benefits of screening the general population for risks of cardiovascular disease: a review of methods used in the literature

BACKGROUND

Strategies for screening and intervening to reduce the risk of cardiovascular disease (CVD) in primary care settings need to be assessed in terms of both their costs and long-term health effects. We undertook a literature review to investigate the methodologies used.

METHODS

In a framework of developing a new health-economic model for evaluating different screening strategies for primary prevention of CVD in Europe (EPIC-CVD project), we identified seven key modeling issues and reviewed papers published between 2000 and 2013 to assess how they were addressed.

RESULTS

We found 13 relevant health-economic modeling studies of screening to prevent CVD in primary care. The models varied in their degree of complexity, with between two and 33 health states. Programmes that screen the whole population by a fixed cut-off (e.g., predicted 10-year CVD risk >20 %) identify predominantly elderly people, who may not be those most likely to benefit from long-term treatment. Uncertainty and model validation were generally poorly addressed. Few studies considered the disutility of taking drugs in otherwise healthy individuals or the budget impact of the programme.

CONCLUSIONS

Model validation, incorporation of parameter uncertainty, and sensitivity analyses for assumptions made are all important components of model building and reporting, and deserve more attention. Complex models may not necessarily give more accurate predictions. Availability of a large enough source dataset to reliably estimate all relevant input parameters is crucial for achieving credible results. Decision criteria should consider budget impact and the medicalization of the population as well as cost-effectiveness thresholds.

Cost-effectiveness of cardiovascular risk management by practice nurses in primary care

BACKGROUND

Cardiovascular disease (CVD) is largely preventable and prevention expenditures are relatively low. The randomised controlled SPRING-trial (SPRING-RCT) shows that cardiovascular risk management by practice nurses in general practice with and without self-monitoring both decreases cardiovascular risk, with no additional effect of self-monitoring. For considering future approaches of cardiovascular risk reduction, cost effectiveness analyses of regular care and additional self-monitoring are performed from a societal perspective on data from the SPRING-RCT.

METHODS

Direct medical and productivity costs are analysed alongside the SPRING-RCT, studying 179 participants (men aged 50-75 years, women aged 55-75 years), with an elevated cardiovascular risk, in 20 general practices in the Netherlands. Standard cardiovascular treatment according to Dutch guidelines is compared with additional counselling based on self-monitoring at home (pedometer, weighing scale and/ or blood pressure device) both by trained practice nurses. Cost-effectiveness is evaluated for both treatment groups and patient categories (age, sex, education).

RESULTS

Costs are €98 and €187 per percentage decrease in 10-year cardiovascular mortality estimation, for the control and intervention group respectively. In both groups lost productivity causes the majority of the costs. The incremental cost-effectiveness ratio is approximately €1100 (95% CI: -5157 to 6150). Self-monitoring may be cost effective for females and higher educated participants, however confidence intervals are wide.

CONCLUSIONS

In this study population, regular treatment is more cost effective than counselling based on self-monitoring, with the majority of costs caused by lost productivity.

TRIAL REGISTRATION

Trialregister.nl identifier: http://NTR2188.

Cost effectiveness of full coverage of the medical management of smoking cessation in France

OBJECTIVE

To estimate the incremental cost effectiveness of full coverage of the medical management of smoking cessation from the perspective of statutory health insurance (SHI) in France.

DESIGN AND POPULATION

Cost-effectiveness analysis based on a Markov state-transition decision analytic model was used to compare full SHI coverage of smoking cessation and actual coverage based on an annual €50 lump sum per insured person among current French smokers aged 15-75 years. We used a scenario approach to take into account the many different behaviours of smokers and the likely variability of SHI policy choices in terms of participation rate and number and frequency of attempts covered.

INTERVENTIONS

Drug treatments for smoking cessation combined with six medical consultations including individual counselling.

MAIN OUTCOMES MEASURES

The cost effectiveness of full coverage was expressed by the incremental cost-effectiveness ratio (ICER) in 2009 euros per life-year gained (LYG) at the lifetime horizon.

RESULTS

The cost effectiveness per LYG for smokers ranged from €1786 to €2012, with an average value of €1911. The minimum value was very close to the maximum value with a difference of only €226. The cost-effectiveness ratio was only minimally sensitive to the participation rate, the number of attempts covered and the cessation rate.

CONCLUSIONS

Compared to other health measures in primary and secondary prevention of cardiovascular disease already covered by SHI, full coverage of smoking cessation is the most cost-effective approach.

The DYNAMO-HIA Model: An Efficient Implementation of a Risk Factor/Chronic Disease Markov Model for Use in Health Impact Assessment (HIA)

In Health Impact Assessment (HIA), or priority-setting for health policy, effects of risk factors (exposures) on health need to be modeled, such as with a Markov model, in which exposure influences mortality and disease incidence rates. Because many risk factors are related to a variety of chronic diseases, these Markov models potentially contain a large number of states (risk factor and disease combinations), providing a challenge both technically (keeping down execution time and memory use) and practically (estimating the model parameters and retaining transparency). To meet this challenge, we propose an approach that combines micro-simulation of the exposure information with macro-simulation of the diseases and survival. This approach allows users to simulate exposure in detail while avoiding the need for large simulated populations because of the relative rareness of chronic disease events. Further efficiency is gained by splitting the disease state space into smaller spaces, each of which contains a cluster of diseases that is independent of the other clusters. The challenge of feasible input data requirements is met by including parameter calculation routines, which use marginal population data to estimate the transitions between states. As an illustration, we present the recently developed model DYNAMO-HIA (DYNAMIC MODEL for Health Impact Assessment) that implements this approach.

Revised guidelines for cardiovascular risk management - time to stop medication? A practice-based intervention study

BACKGROUND

According to the new Dutch guideline for cardiovascular risk management, patients with a low risk of cardiovascular mortality may have insufficient benefit to warrant medication. Therefore, numerous patients per general practice may be treated unnecessarily.

AIM

To explore the feasibility and consequences of a re-evaluation programme for patients without target organ damage who were treated for hypertension and/or hypercholesterolaemia.

DESIGN AND SETTING

Practice-based intervention study in six general practices.

METHOD

Patients treated for hypertension and/or hypercholesterolaemia without target organ damage (n = 833) were invited to re-evaluate their cardiovascular risk and were advised whether or not to stop medication. Patients who discontinued medication were followed for 6 months. To determine indicators for successful stopping, logistic regression analyses were performed, and differences between practices were analysed.

RESULTS

About two-thirds of the patients were re-evaluated and 61% of them had a low calculated risk, especially younger patients, females, and non-smokers. Of these, 42% were advised to stop medication, especially younger patients and non-smokers. Of those who discontinued medication, 40% had restarted within 6 months. After 6 months, 80 of the 833 patients (9.6%) had not restarted medication. There were no important side effects related to stopping medication.

CONCLUSION

Over 50% of patients without target organ damage treated for hypertension and/or hypercholesterolaemia may have insufficient benefit to warrant medication. Younger patients, females, and non-smokers in particular are more likely to have an insufficient indication for medication. GPs' and nurse practitioners' views seem to play a role in advising to stop or to restart medication.

Targeted versus universal prevention. a resource allocation model to prioritize cardiovascular prevention

BACKGROUND

Diabetes mellitus brings an increased risk for cardiovascular complications and patients profit from prevention. This prevention also suits the general population. The question arises what is a better strategy: target the general population or diabetes patients.

METHODS

A mathematical programming model was developed to calculate optimal allocations for the Dutch population of the following interventions: smoking cessation support, diet and exercise to reduce overweight, statins, and medication to reduce blood pressure. Outcomes were total lifetime health care costs and QALYs. Budget sizes were varied and the division of resources between the general population and diabetes patients was assessed.

RESULTS

Full implementation of all interventions resulted in a gain of 560,000 QALY at a cost of €640 per capita, about €12,900 per QALY on average. The large majority of these QALY gains could be obtained at incremental costs below €20,000 per QALY. Low or high budgets (below €9 or above €100 per capita) were predominantly spent in the general population. Moderate budgets were mostly spent in diabetes patients.

CONCLUSIONS

Major health gains can be realized efficiently by offering prevention to both the general and the diabetic population. However, a priori setting a specific distribution of resources is suboptimal. Resource allocation models allow accounting for capacity constraints and program size in addition to efficiency.

Cardiovascular disease risk factors and dietary habits of farmers from Crete 45 years after the first description of the Mediterranean diet

BACKGROUND

Farmers from Crete as first studied within the framework of the Seven Countries Study, were historically known for holding the title of the 'gold standard' of health status globally and had a very low prevalence of both cardiovascular disease (CVD) and cancer. Taking the above into account we evaluated the changes in CVD risk factors among farmers in Crete, Greece and compared our findings with data from the 1960s.

DESIGN

Cross-sectional.

METHODS

Five hundred and two farmers (18-79 years old) from the Valley of Messara in Crete were randomly selected and examined in 2005. Complete clinical, biochemical, dietetic, anthropometrical and lifestyle CVD risk factors were assessed, matched and compared with published data from the 1960s.

RESULTS

In comparison with 45 years ago, present day male farmers from Crete were found to have a 30% higher BMI (29.8 vs. 22.9 kg/m, P<0.001) and a 16% higher total cholesterol level (239.6 vs. 206.9 mg/dl, P<0.001) and also a not so favourable daily dietary intake (increase in meat and saturated fat and decrease in fruit, P<0.001, respectively), while a significant reduction in systolic blood pressure and energy intake was noticed. In regards to changes in subcutaneous adipose tissue fatty acid composition, a decrease in monounsaturated (P<0.001) and an increase in saturated fatty acids (P<0.001) was also found elucidating the temporal change in dietary habits.

CONCLUSION

The population's lack of adherence to the Mediterranean diet, have led to the fact that currently farmers from Crete are likely to be at a higher risk for developing CVD in comparison with earlier generations.