The economic consequences of practice style variation in providing medical interventions: A systematic review of the literature

An International Study of Variation in Attitudes to Kidney Biopsy Practice

Key Points

Background

A kidney biopsy is an essential investigation for diagnosis but is invasive and associated with complications. Delaying or missing the opportunity to diagnose kidney disease could result in adverse patient outcomes. The aim of this study was to examine attitudes to kidney biopsy across the world.

Methods

An online questionnaire for nephrologists was designed on the basis of the existing literature with input from patients. Anonymized data were collected on individual and institutional demographics, indications and contraindications for biopsy, and attitudes and barriers to access. A propensity-to-biopsy score was generated from responses, which allowed clinicians to compare their practice with international colleagues. A higher score was associated with an increased likelihood of recommending biopsy. The questionnaire was disseminated through international nephrology societies, including the National Kidney Foundation, and by social media.

Results

Participants responding to the questionnaire included 1181 clinicians from 83 countries, making it the largest international study in this area to date. The propensity-to-biopsy scores were significantly different between the 13 countries with over 20 clinicians participating (P < 0.001) and was highest in Mexico and lowest in the Philippines. Kidney biopsy was most often recommended in patients with higher proteinuria levels and most often avoided in patients with small kidneys. An adjusted linear regression model demonstrated that a significantly higher propensity-to-biopsy score was found in male clinicians, younger clinicians, frequent performers of kidney biopsy, increased job seniority, and larger institution size (P = 0.05).

Conclusions

Kidney biopsy practice is varied internationally and is subject to human and systemic factors. Further research is required to understand the variances behind clinical decision making.

Cost-effectiveness Analysis of Air Emergency Versus Ground Emergency Medical Services Regarding the Patient's Transportation and Treatment in Selected Hospital

Background: The prehospital emergency system is the first initiator of medical care as an alternative to hospitals and health care services that helps patients and injured people in critical situations and accidents. This study aimed to evaluate the cost-effectiveness of air ambulance versus ground ambulance regarding the patient's transportation and treatment. Methods: In this cost-effectiveness analysis study, 300 patients who were transferred to the Shohadaye HaftomTir hospital by air ambulance and 300 patients transferred by ground ambulance during the study period were selected in 2021-2022. This study examined the costs from the society's perspective. After drawing the decision tree model in TreeAge software, the incremental cost-effectiveness ratio was calculated; and to evaluate the strength of the analysis results, one-way and two-way sensitivity analyses were done on all costs and consequence parameters. Results: The effectiveness rate in the ground ambulance group and in the air ambulance group was 0.42591 and 0.5566, respectively, and the total cost of transportation and treatment by ambulance in these patients was $412.88 and for patients transported and treated by air ambulance was $11898.05. Therefore, air ambulance costs more and is more effective than ground ambulance, and the amount of incremental cost and effectiveness of air ambulance compared with ground ambulance was $11485.17 and 0.130773 units, respectively. The incremental cost-effectiveness ratio (ICER) of the 2 strategies was 87825.28, and the cost-effectiveness threshold was $7200. To determine the strength of the study results, one-way and two-way sensitivity analyses were done and the results of the cost-effectiveness analysis was not changed. Conclusion: Our study showed that ground ambulance is more cost-effective than air ambulance and the most important reason is that the total cost of air ambulance is 26 times more than ground ambulance, however, it is more effective than ground ambulance.

A Scoping Review of Different Methods of Assessing the Impact of New Medical Technologies at Early Stages of Development

Background: Investing in the R & D sector of new medical technologies is associated with the risk of being rejected by paying organizations because of the lack of value-for-money. The purpose of this study is to investigate the different methods of evaluating the impacts of emerging medical technologies. Methods: Using scoping review method, we analyzed studies that investigated methods for assessing the impacts of emerging medical technologies on development. To find these studies, the Cochran Library, ISI Web of Knowledge, Embase, Ebsco and Pubmed databases from 2000 to 2018 were searched. The methodological quality of the studies was assessed using the STROBE Checklist. Two reviewers independently selected the qualified studies. Charting and collating the data were used based on the method proposed by Arksey and O'Malley. Results: Overall, 38 studies met the inclusion criteria. Sixteen methods were identified and put in five distinct categories: forecasting, Pro-HTA, Early-HTA, priority setting, and HHS were found to measure the impact of emerging technologies. The quality of these studies was acceptable. Few studies were conducted on emerging pharmaceutical technologies, and they were mostly on emerging medical devices. The Early HTA methods were often used to measure the effects of pharmaceutical technologies and medical devices technologies. The Pro-HTA method used dynamic modeling to examine the impact of medical technologies on a broad range of dimensions, while the HTA and Early-HTA methods used cost-effectiveness techniques throughout the development process. The HHS method used a multivariate decision-making technique. Conclusion: Different methods were used to investigate the impacts of emerging medical technologies. Chronologically Pro-HTA methods are new ways for investigating emerging medical technologies beyond clinical and economic impacts. Assessing the feasibility of implementing Pro-HTA in real environments deserves further research.

Elucidating variations in outcomes among older end-stage renal disease patients on hemodialysis in Fukuoka Prefecture, Japan

Variations in health care outcomes and services potentially indicate resource allocation inefficiency. Therefore, this study was conducted to examine variations in mortality and hospitalization cases among end-stage renal disease (ESRD) patients receiving hemodialysis (HD) care from medical facilities located in 13 secondary medical care areas (SMAs) of Fukuoka prefecture, Japan. The research was designed as a retrospective, cross-sectional study using insurance claims data. The subjects of the study were older patients (over 65 years old) insured by the Fukuoka prefecture’s Latter-Stage Elderly Healthcare Insurance. Using an electronic claims database, we identified patients with chronic kidney disease (CKD) who had received HD care from April 1, 2017 to March 31, 2018. The CKD status was identified using International Classification of Disease, 10th revision code, and HD maintenance status was ascertained using specific insurance procedure codes. A total of 5,243 patients met our inclusion criteria and their records were subsequently reviewed. About 73% (n = 3,809) of patients had admission records during the period studied. Thus, the data regarding hospital length of stay (LOS) and admission costs were analyzed separately. Significant differences in terms of increased risks in hospitalization were evident in a number of SMAs. An increase in mortality risk due to heart failure and malignancy was observed in two separate SMAs. Also, analyzed LOS, total hospitalization cost, and cost per day according to SMAs showed statistically significant variations. The findings highlight the magnitude of the burden of CKD and ESRD in the community. The high prevalence of ESRD, associated mortality, and hospitalized HD patients signal the need for clinicians to assume broader roles in measures against chronic kidney disease through involvement in community awareness programs. To improve patient outcomes, improvement of regional health care provision, the level of medical care, and the development of existing human resources are needed.