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Doan TT, Hutton DW, Wright DR, Prosser LA. Estimating Transition Probabilities for Modeling Major Depression in Adolescents by Sex and Race or Ethnicity Combinations in the USA. Appl Health Econ Health Policy 2024; 22:375-390. [PMID: 38253972 DOI: 10.1007/s40258-024-00872-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVE About one-fifth of US adolescents experienced major depressive symptoms, but few studies have examined longitudinal trends of adolescents developing depression or recovering by demographic factors. We estimated new transition probability inputs, and then used them in a simulation model to project the epidemiologic burden and trajectory of depression of diverse adolescents by sex and race or ethnicity combinations. METHODS Transition probabilities were first derived using parametric survival analysis of data from the National Longitudinal Study of Adolescent to Adult Health and then calibrated to cross-sectional data from the National Survey on Drug Use and Health. We developed a cohort state-transition model to simulate age-specific depression outcomes of US adolescents. A hypothetical adolescent cohort was modeled from 12-22 years with annual transitions. Model outcomes included proportions of youth experiencing depression, recovery, or depression-free cases and were reported for a US adolescent population by sex, race or ethnicity, and sex and race or ethnicity combinations. RESULTS At 22 years of age, approximately 16% of adolescents had depression, 12% were in recovery, and 72% had never developed depression. Depression prevalence peaked around 16-17 years-old. Adolescents of multiracial or other race or ethnicity, White, American Indian or Alaska Native, and Hispanic, Latino, or Spanish descent were more likely to experience depression than other racial or ethnic groups. Depression trajectories generated by the model matched well with historical observational studies by sex and race or ethnicity, except for individuals from American Indian or Alaska Native and multiracial or other race or ethnicity backgrounds. CONCLUSIONS This study validated new transition probabilities for future use in decision models evaluating adolescent depression policies or interventions. Different sets of transition parameters by demographic factors (sex and race or ethnicity combinations) were generated to support future health equity research, including distributional cost-effectiveness analysis. Further data disaggregated with respect to race, ethnicity, religion, income, geography, gender identity, sexual orientation, and disability would be helpful to project accurate estimates for historically minoritized communities.
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Affiliation(s)
- Tran T Doan
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3414 Fifth Avenue, 1st Floor, Pittsburgh, PA, 15213-3205, USA.
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Davene R Wright
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
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Eisman AB, Whitman J, Palinkas LA, Fridline J, Harvey C, Kilbourne AM, Hutton DW. A mixed methods partner-focused cost and budget impact analysis to deploy implementation strategies for school-based prevention. Implement Sci Commun 2023; 4:133. [PMID: 37946235 PMCID: PMC10636820 DOI: 10.1186/s43058-023-00511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Obtaining information on implementation strategy costs and local budget impacts from multiple perspectives is essential to data-driven decision-making about resource allocation for successful evidence-based intervention delivery. This mixed methods study determines the costs and priorities of deploying Enhanced Replicating Effective Programs (REP) to implement the Michigan Model for Health™, a universal school-based prevention intervention, from key shareholder perspectives. METHODS Our study included teachers in 8 high schools across 3 Michigan counties as part of a pilot cluster randomized trial. We used activity-based costing, mapping key Enhanced REP activities across implementation phases. We included multiple perspectives, including state agencies, regional education service agencies, lead organization, and implementers. We also conducted a budget impact analysis (BIA, assessing the potential financial impact of adopting Enhanced REP) and a scenario analysis to estimate replication and account for cost variability. We used an experimental embedded mixed methods approach, conducting semi-structured interviews and collecting field notes during the trial to expand and explain the cost data and the implications of costs across relevant perspectives. RESULTS Based on trial results, we estimate costs for deploying Enhanced REP are $11,903/school, with an estimated range between $8263/school and $15,201/school. We estimate that adding four additional schools, consistent with the pilot, would cost $8659/school. Qualitative results indicated misalignment in school and teacher priorities in some cases. Implementation activities, including training and implementation facilitation with the health coordinator, were sometimes in addition to regular teaching responsibilities. The extent to which this occurred was partly due to leadership priorities (e.g., sticking to the district PD schedule) and organizational priorities (e.g., budget). CONCLUSIONS Previous research findings indicate that, from a societal perspective, universal prevention is an excellent return on investment. However, notable misalignment in cost burden and priorities exists across shareholder groups. Our results indicate significant personal time costs by teachers when engaging in implementation strategy activities that impose an opportunity cost. Additional strategies are needed to improve the alignment of costs and benefits to enhance the success and sustainability of implementation. We focus on those perspectives informed by the analysis and discuss opportunities to expand a multi-level focus and create greater alignment across perspectives. TRIAL REGISTRATION ClinicalTrials.gov NCT04752189. Registered on 12 February 2021.
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Affiliation(s)
- Andria B Eisman
- Division of Kinesiology, Health, and Sport Studies, College of Education, Wayne State University, 2153 Faculty/Administration Building, 656 West Kirby Street, Detroit, MI, 48202, USA.
| | - Jacob Whitman
- Department of Economics, College of Liberal Arts, Wayne State University, 656 West Kirby Street, Detroit, MI, 48202, USA
| | - Lawrence A Palinkas
- School of Social Work, University of Southern California, 669 W 34th Street, Los Angeles, CA, 90089, USA
| | - Judy Fridline
- Genesee Intermediate School District, 2143 Maple Road, Flint, MI, 48507, USA
| | - Christina Harvey
- Oakland Intermediate School District, 2111 Pontiac Lake Road, Waterford Township, MI, 48328, USA
| | - Amy M Kilbourne
- VA Ann Arbor Healthcare System, North Campus Research Complex, 2800 Plymouth Road, Bldg 16, Ann Arbor, MI, 48109, USA
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, M3525 SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
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Doan TT, DeJonckheere M, Wright DR, Hutton DW, Prosser LA. Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study. Compr Psychiatry 2023; 127:152412. [PMID: 37717343 DOI: 10.1016/j.comppsych.2023.152412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting. METHOD Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed. RESULTS Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14). LIMITATIONS Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings. CONCLUSIONS To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.
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Affiliation(s)
- Tran T Doan
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Melissa DeJonckheere
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Davene R Wright
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA; Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
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Schmieder RE, Mahfoud F, Mancia G, Narkiewicz K, Ruilope L, Hutton DW, Cao KN, Hettrick DA, Fahy M, Schlaich MP, Böhm M, Pietzsch JB. Clinical event reductions in high-risk patients after renal denervation projected from the global SYMPLICITY registry. Eur Heart J Qual Care Clin Outcomes 2023; 9:575-582. [PMID: 36057838 PMCID: PMC10495746 DOI: 10.1093/ehjqcco/qcac056] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/15/2022] [Accepted: 08/31/2022] [Indexed: 06/15/2023]
Abstract
AIMS Renal denervation has been shown to lower blood pressure in sham-controlled trials and represents a device-based treatment option for hypertension. We sought to project clinical event reductions after radiofrequency renal denervation using a novel modelling approach. METHODS AND RESULTS The Global SYMPLICITY Registry is a global, prospective all-comer registry to evaluate safety and efficacy after renal denervation. For this analysis, change in office systolic blood pressure from baseline was calculated from reported follow-up in the Global SYMPLICITY Registry. Relative risks for death and other cardiovascular events as well as numbers needed to treat for event avoidance were obtained for the respective blood pressure reductions based on previously reported meta-regression analyses for the full cohort and high-risk subgroups including type 2 diabetes, chronic kidney disease, resistant hypertension, and high basal cardiovascular risk. Average baseline office systolic blood pressure and reduction estimates for the full cohort (N = 2651) were 166±25 and -14.8 ± 0.4 mmHg, respectively. Mean reductions in blood pressure ranged from -11.0--21.8 mmHg for the studied high-risk subgroups. Projected relative risks ranged from 0.57 for stroke in the resistant hypertension cohort to 0.92 for death in the diabetes cohort. Significant absolute reductions in major adverse cardiovascular events over 3 years compared with the projected control (8.6 ± 0.7% observed vs. 11.7 ± 0.9% for projected control; P < 0.01) were primarily due to reduced stroke incidence. The robustness of findings was confirmed in sensitivity and scenario analyses. CONCLUSION Model-based projections suggest radiofrequency renal denervation for patients with uncontrolled hypertension adds considerable clinical benefit across a spectrum of different cohort characteristics.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Bavaria 91054, Germany
| | - Felix Mahfoud
- Internal Medicine and Cardiology, Saarland University Hospital, Homburg/Saar, Saarland 66421, Germany
| | - Giuseppe Mancia
- Department of Medicine, University of Milano-Bicocca, Monza, Lombardia 20126, Italy
| | - Krzysztof Narkiewicz
- Hypertension and Diabetology, Medical University of Gdansk, Gdansk 80-210, Poland
| | - Luis Ruilope
- Cardiorenal Investigation, Institute of Research, Hospital Universitario 12 de Octubre and CIBERCV and School of Doctoral Studies and Research, Universidad Europea de Madrid, Madrid 28041, Spain
| | - David W Hutton
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Khoa N Cao
- Wing Tech Inc., Menlo Park, CA 94025, USA
| | | | - Martin Fahy
- Coronary and Renal Denervation, Medtronic, Santa Rosa, CA 95403, USA
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine—Royal Perth Hospital Unit, The University of Western Australia, Perth, WA 6009, Australia
| | - Michael Böhm
- Internal Medicine and Cardiology, Saarland University Hospital, Homburg/Saar, Saarland 66421, Germany
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Yoon AP, Hutton DW, Chung KC. Cost-effectiveness of surgical treatment of thumb carpometacarpal joint arthritis: a value of information study. Cost Eff Resour Alloc 2023; 21:28. [PMID: 37127634 PMCID: PMC10150507 DOI: 10.1186/s12962-023-00438-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/10/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Thumb carpometacarpal (CMC) joint arthritis is one of the most prevalent arthritic conditions commonly treated with trapeziectomy alone or trapeziectomy with ligament reconstruction and tendon interposition (LRTI). We evaluate the cost-effectiveness and value of perfect and sample information of trapeziectomy alone, LRTI, and non-operative treatment. METHODS A societal perspective decision tree was modeled. To understand the value of future research in comparing quality-of-life after trapeziectomy, LRTI, and non-operative management we characterized uncertainty by fitting distributions to EQ-5D utility data published from the United Kingdom hand surgery registry. We used Monte Carlo simulation for the probabilistic sensitivity analysis and to evaluate the value of perfect and sample information. RESULTS Both trapeziectomy alone and LRTI were cost-effective compared to non-operative management ($2,540 and $3,511/QALY respectively). Trapeziectomy alone (base case total cost $8,251, QALY 14.08) was dominant compared to LRTI (base case total cost $8,798, QALY 13.34). However, probabilistic sensitivity analysis suggested there is a 12.5% chance LRTI may be preferred at a willingness-to-pay of $50,000/QALY. Sensitivity analysis revealed postoperative utilities are the most influential factors in determining cost-effectiveness. The value of perfect information was approximately $1,503/person. A study evaluating the quality-of-life of 1,000 patients in each arm undergoing trapeziectomy alone or LRTI could provide an expected $1,117 of information value. With approximately 40,000 CMC arthroplasties performed each year in the U.S., the annual value is close to $45 million. CONCLUSIONS Trapeziectomy without LRTI appears to be the most cost-effective procedure in treating late-stage CMC arthritis and should be considered as first-line surgical treatment. There is substantial societal value in conducting additional research to better understand the relative quality-of-life improvements gained from these two common hand surgeries.
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Affiliation(s)
- Alfred P Yoon
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, Ann Arbor, MI, Michigan, 48109-0340, USA
| | - David W Hutton
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, Ann Arbor, MI, Michigan, 48109-0340, USA.
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Hutton DW, Glassman AR, Liu D, Sun JK. Cost-effectiveness of Aflibercept Monotherapy vs Bevacizumab First Followed by Aflibercept If Needed for Diabetic Macular Edema. JAMA Ophthalmol 2023; 141:268-274. [PMID: 36729431 PMCID: PMC9896372 DOI: 10.1001/jamaophthalmol.2022.6142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/31/2022] [Indexed: 02/03/2023]
Abstract
Importance The DRCR Retina Network Protocol AC showed no significant difference in visual acuity outcomes over 2 years between treatment with aflibercept monotherapy and bevacizumab first with switching to aflibercept for suboptimal response in treating diabetic macular edema (DME). Understanding the estimated cost and cost-effectiveness of these approaches is important. Objective To evaluate the cost and cost-effectiveness of aflibercept monotherapy vs bevacizumab-first strategies for DME treatment. Design, Setting, and Participants This economic evaluation was a preplanned secondary analysis of a US randomized clinical trial of participants aged 18 years or older with center-involved DME and best-corrected visual acuity of 20/50 to 20/320 enrolled from December 15, 2017, through November 25, 2019. Interventions Aflibercept monotherapy or bevacizumab first, switching to aflibercept in eyes with protocol-defined suboptimal response. Main Outcomes and Measures Between February and July 2022, the incremental cost-effectiveness ratio (ICER) in cost per quality-adjusted life-year (QALY) over 2 years was assessed. Efficacy and resource utilization data from the randomized clinical trial were used with health utility mapping from the literature and Medicare unit costs. Results This study included 228 participants (median age, 62 [range, 34-91 years; 116 [51%] female and 112 [49%] male; 44 [19%] Black or African American, 60 [26%] Hispanic or Latino, and 117 [51%] White) with 1 study eye. The aflibercept monotherapy group included 116 participants, and the bevacizumab-first group included 112, of whom 62.5% were eventually switched to aflibercept. Over 2 years, the cost of aflibercept monotherapy was $26 504 (95% CI, $24 796-$28 212) vs $13 929 (95% CI, $11 984-$15 874) for the bevacizumab-first group, a difference of $12 575 (95% CI, $9987-$15 163). The aflibercept monotherapy group gained 0.015 (95% CI, -0.011 to 0.041) QALYs using the better-seeing eye and had an ICER of $837 077 per QALY gained compared with the bevacizumab-first group. Aflibercept could be cost-effective with an ICER of $100 000 per QALY if the price per dose were $305 or less or the price of bevacizumab was $1307 per dose or more. Conclusions and Relevance Variability in individual needs will influence clinician and patient decisions about how to treat specific eyes with DME. While the bevacizumab-first group costs still averaged approximately $14 000 over 2 years, this approach, as used in this study, may confer substantial cost savings on a societal level without sacrificing visual acuity gains over 2 years compared with aflibercept monotherapy.
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Affiliation(s)
| | | | - Danni Liu
- Jaeb Center for Health Research, Tampa, Florida
| | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard University, Boston, Massachusetts
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Terman SW, Aschmann HE, Hutton DW, Burke JF. Best-worst scaling preferences among patients with well-controlled epilepsy: Pilot results. PLoS One 2023; 18:e0282658. [PMID: 36867630 PMCID: PMC9983827 DOI: 10.1371/journal.pone.0282658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/20/2023] [Indexed: 03/04/2023] Open
Abstract
Epilepsy is a common, serious condition. Fortunately, seizure risk decreases with increasing seizure-free time on antiseizure medications (ASMs). Eventually, patients may consider whether to stop ASMs, which requires weighing treatment benefit versus burden. We developed a questionnaire to quantify patient preferences relevant to ASM decision-making. Respondents rated how concerning they would finding relevant items (e.g., seizure risks, side effects, cost) on a Visual Analogue Scale (VAS, 0-100) and then repeatedly chose the most and least concerning item from subsets (best-worst scaling, BWS). We pretested with neurologists, then recruited adults with epilepsy who were seizure-free at least one year. Primary outcomes were recruitment rate, and qualitative and Likert-based feedback. Secondary outcomes included VAS ratings and best-minus-worst scores. Thirty-one of 60 (52%) contacted patients completed the study. Most patients felt VAS questions were clear (28; 90%), easy to use (27; 87%), and assessed preferences well (25; 83%). Corresponding results for BWS questions were 27 (87%), 29 (97%), and 23 (77%). Physicians suggested adding a 'warmup' question showing a completed example and simplifying terminology. Patients suggested ways to clarify instructions. Cost, inconvenience of taking medication, and laboratory monitoring were the least concerning items. Cognitive side effects and a 50% seizure risk in the next year were the most concerning items. Twelve (39%) of patients made at least one 'inconsistent choice' for example ranking a higher seizure risk as lower concern compared with a lower seizure risk, though 'inconsistent choices' represented only 3% of all question blocks. Our recruitment rate was favorable, most patients agreed the survey was clear, and we describe areas for improvement. 'Inconsistent' responses may lead us to collapse seizure probability items into a single 'seizure' category. Evidence regarding how patients weigh benefits and harms may inform care and guideline development.
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Affiliation(s)
- Samuel W. Terman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Hélène E. Aschmann
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
- Epidemiology Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - David W. Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - James F. Burke
- Department of Neurology, the Ohio State University, Columbus, Ohio, United States of America
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Liu Z, Li M, Hutton DW, Wagner AL, Yao Y, Zhu W, Cao L, Tang S, Pan J, Wang Y, Zhao Q, Ren H, Wang Y, Wang W. Impact of the national hepatitis B immunization program in China: a modeling study. Infect Dis Poverty 2022; 11:106. [PMID: 36221140 PMCID: PMC9552421 DOI: 10.1186/s40249-022-01032-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Elimination of hepatitis B virus (HBV) is a striking challenge for countries with high or moderate disease burden. Therefore, using China as a practical case to share experiences for similar countries may accelerate the achievement of the WHO 2030 target of 90% reduction in HBV-related incidence. We aim to evaluate the impact of national HBV immunization strategies in China; and the feasibility to achieve WHO 2030 targets under different scenarios. Methods We constructed an expanded Susceptible-Exposed-Infectious-Recovered (SEIR) model and decision tree-Markov model to estimate the epidemic of HBV in China, assess the feasibility of 2030 Elimination Goals through the projections and conduct the economic analysis. Least square method was used to calibrate the expanded SEIR model by yearly data of laboratory-confirmed HBV cases from 1990 to 2018. Two models were separately used to evaluate the impact and cost-effectiveness of HBV vaccine by comparing prevalence of chronic HBV infections, quality-adjusted life-years (QALYs), incremental cost effectiveness ratio and benefit–cost ratio (BCR) under various intervention options, providing a basis for exploring new containment strategies. Results Between 1990 and 2020, the number of chronic HBV infections decreased by 33.9%. The current status quo would lead to 55.73 million infections (3.95% prevalence) in 2030, compared to 90.63 million (6.42% prevalence) of the “Without the NIP” scenario (NIP: National Immunization Program), 114.78 million (8.13% prevalence) without any interventions. The prevention of mother to child transmission (PMTCT) strategy showed a net benefit as 12,283.50 dollars per person, with BCR as 12.66, which is higher than that of universal vaccination at 9.49. Compared with no screening and no vaccination, the PMTCT strategy could save 7726.03 dollars for each QALY increase. Conclusions Our findings proved the HBV vaccination has demonstrated a substantial positive impact on controlling the epidemic of HBV in terms of effectiveness and economy after about 30 years of implementation of the national hepatitis B immunization program which also provided containment experience for high or medium burden countries. As for China, the next step should focus on exploring strategies to improve diagnosis and treatment coverage to reduce the burden of HBV-related deaths and ultimately eliminate HBV. Supplementary Information The online version contains supplementary material available at 10.1186/s40249-022-01032-5.
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Affiliation(s)
- Zhixi Liu
- School of Public Health, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Mengying Li
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai, China
| | - David W Hutton
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Abram L Wagner
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ye Yao
- Department of Biostatics, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Wenlong Zhu
- School of Public Health, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Lingsheng Cao
- Chinese Center for Disease Control and Prevention, National Immunization Program, Beijing, China
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jinhua Pan
- School of Public Health, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Yesheng Wang
- School of Public Health, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Qi Zhao
- School of Public Health, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Hong Ren
- Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Ying Wang
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai, China.
| | - Weibing Wang
- School of Public Health, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China.
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Hutton DW, Toy M, Salomon JA, Conners EE, Nelson NP, Harris AM, So S. Cost-Effectiveness of Hepatitis B Testing and Vaccination of Adults Seeking Care for Sexually Transmitted Infections. Sex Transm Dis 2022; 49:517-525. [PMID: 35312661 PMCID: PMC9188991 DOI: 10.1097/olq.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/16/2021] [Accepted: 03/16/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The estimated number of people living with hepatitis B virus (HBV) infection acquired through sexual transmission was 103,000 in 2018, with an estimated incidence of 8300 new cases per year. Although hepatitis B (HepB) vaccination is recommended by the Advisory Committee for Immunization Practices for persons seeking evaluation and treatment for sexually transmitted infections (STIs), prevaccination testing is not yet recommended. Screening may link persons with chronic hepatitis B to care and reduce unnecessary vaccination. METHODS We used a Markov model to calculate the health impact and cost-effectiveness of 1-time HBV testing combined with the first dose of the HepB vaccine for adults seeking care for STI. We ran a lifetime, societal perspective analysis for a hypothetical population of 100,000 aged 18 to 69 years. The disease progression estimates were taken from recent cohort studies and meta-analyses. In the United States, an intervention that costs less than $100,000 per quality-adjusted life-year (QALY) is generally considered cost-effective. The strategies that were compared were as follows: (1) vaccination without HBV screening, (2) vaccination and hepatitis B surface antigen (HBsAg) screening, (3) vaccination and screening with HBsAg and anti-HBs, and (4) vaccination and screening with HBsAg, anti-HBs, and anti-HBc. Data were obtained from Centers for Medicare & Medicaid services reimbursement, the Centers for Disease Control and Prevention vaccine price list, and additional cost-effectiveness literature. RESULTS Compared with current recommendations, the addition of 1-time HBV testing is cost-saving and would prevent an additional 138 cases of cirrhosis, 47 cases of decompensated cirrhosis, 90 cases of hepatocellular carcinoma, 33 liver transplants, and 163 HBV-related deaths, and gain 2185 QALYs, per 100,000 adults screened. Screening with the 3-test panel would save $41.6 to $42.7 million per 100,000 adults tested compared with $41.5 to $42.5 million for the 2-test panel and $40.2 to $40.3 million for HBsAg alone. CONCLUSIONS One-time HBV prevaccination testing in addition to HepB vaccination for unvaccinated adults seeking care for STI would save lives and prevent new infections and unnecessary vaccination, and is cost-saving.
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Affiliation(s)
- David W. Hutton
- From the Department of Health Management and Policy, University of Michigan, Ann Arbor, MI
| | - Mehlika Toy
- Asian Liver Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Joshua A. Salomon
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA
| | - Erin E. Conners
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Noele P. Nelson
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Aaron M. Harris
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Samuel So
- Asian Liver Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
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Avanceña ALV, Miller N, Kim DeLuca E, Iott B, Mauri A, Eisenberg D, Hutton DW. Estimation of Potential Deaths Averted From Hypothetical US Income Support Policies. JAMA Health Forum 2022; 3:e221537. [PMID: 35977246 PMCID: PMC9187947 DOI: 10.1001/jamahealthforum.2022.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/22/2022] [Indexed: 11/14/2022] Open
Abstract
Question How many deaths among working-age US adults can hypothetical income support policies, such as universal basic income, the modified LIFT Act, poverty alleviation, and negative income tax, potentially avert? Findings In this multicohort modeling study that simulated US adults age 18 to 64 years over 5 to 40 years, broad income support policies, like universal basic income, were estimated to avert the most deaths among working-age adults, although targeted approaches, like poverty alleviation, may also avert thousands of deaths among low-income populations. Results were sensitive to several inputs, primarily the income group–specific mortality rates used. Meaning The results of this study suggest that income support policies may prevent thousands of deaths among working-age US adults. Importance Income has a negative, nonlinear association with all-cause mortality. Income support policies may prevent deaths among low-income populations by raising their incomes. Objective To estimate the deaths that could be averted among working-age adults age 18 to 64 years with hypothetical income support policies in the US. Design, Setting, and Population An open, multicohort life-table model was developed that simulated working-age adults age 18 to 64 years in the US over 5 to 40 years. Publicly available household income data and previous estimates of the income-mortality association were used to generate mortality rates by income group. Deterministic sensitivity analyses were conducted to evaluate the effect of parameter uncertainty and various model assumptions on the findings. Interventions In addition to a no-intervention scenario, 4 hypothetical income support policies were modeled: universal basic income, modified LIFT Act, poverty alleviation, and negative income tax. Main Outcome and Measures The main outcome was the number of deaths averted, which was calculated by subtracting the number of deaths experienced in the no-intervention scenario from the number of deaths experienced with the various income support policies. Results Base-case assumptions used average mortality rates by age, sex, and income group, a 20-year time horizon, and a 3-year lag time. Universal basic income worth $12 000 per year per individual was estimated to avert the most deaths among working-age adults (42 000-104 000 per year), followed by a negative income tax that guaranteed an income of 133% of the federal poverty level (19 000-67 000 per year). A modified LIFT Act that provided $6000 to individuals with annual household incomes less than $100 000 was estimated to avert 17 000 to 52 000 deaths per year. A targeted approach that alleviated poverty was estimated to prevent 12 000 to 32 000 deaths among the lowest-income, working-age adult population. Results were most sensitive to several inputs and assumptions, primarily the income-based mortality rates, analytic time horizon, and assumed time lag between when a policy was implemented and when individuals experienced the mortality benefit of having higher incomes. Conclusions and Relevance In this modeling study, 4 hypothetical income support policies were estimated to avert thousands of deaths among working-age US adults every year. Additional research is needed to understand the true association of income gains with mortality. Discussions about the costs and benefits of income support policies should include potential gains in health.
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Affiliation(s)
- Anton L. V. Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Nicholas Miller
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
| | - Ellen Kim DeLuca
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Bradley Iott
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- School of Information, University of Michigan, Ann Arbor
- Now with School of Medicine, University of California, San Francisco
| | - Amanda Mauri
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Political Science, University of Michigan, Ann Arbor
| | - Daniel Eisenberg
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
| | - David W. Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor
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Chen HF, Ali H, Marrero WJ, Parikh ND, Lavieri MS, Hutton DW. The Magnitude of the Health and Economic Impact of Increased Organ Donation on Patients With End-Stage Renal Disease. MDM Policy Pract 2021; 6:23814683211063418. [PMID: 34901442 PMCID: PMC8655828 DOI: 10.1177/23814683211063418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives. There are several approaches such as presumed consent and compensation for deceased donor organs that could reduce the gap between supply and demand for kidneys. Our objective is to evaluate the magnitude of the economic impact of policies to increase deceased donor organ donation in the United States. Methods. We built a Markov model and simulate an open cohort of end-stage renal disease patients awaiting kidney transplantation in the United States over 20 years. Model inputs were derived from the United States Renal Data System and published literature. We evaluate the magnitude of the health and economic impact of policies to increase deceased donor kidney donation in the United States. Results. Increasing deceased kidney donation by 5% would save $4.7 billion, and gain 30,870 quality-adjusted life years over the lifetime of an open cohort of patients on dialysis on the waitlist for kidney transplantation. With an increase in donations of 25%, the cost saved was $21 billion, and 145,136 quality-adjusted life years were gained. Policies increasing deceased kidney donation by 5% could pay donor estates $8000 or incur a onetime cost of up to $4 billion and still be cost-saving. Conclusions. Increasing deceased kidney donation could significantly impact national spending and health for end-stage renal disease patients.
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Affiliation(s)
- Huey-Fen Chen
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Hayatt Ali
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Wesley J Marrero
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Neehar D Parikh
- Department of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
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12
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Zhao PY, Ji S, Newman-Casey PA, Andrews CA, Lonardi A, Bennett OM, Dinh DQ, Talwar N, Hutton DW, Temple S, Stern JH, Rao RC. Assessing patient perception of risk in ocular stem cell therapies. Stem Cell Reports 2021; 16:2415-2421. [PMID: 34597599 PMCID: PMC8514963 DOI: 10.1016/j.stemcr.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/26/2022] Open
Abstract
A wide variety of stem cell-derived therapies are under development for the treatment of retinal degeneration. In order to better understand patient perspectives about these therapies, we assessed risk tolerance using an in-person survey of 178 patients at an academic eye center. Risk of malignancy served as a hypothetical, readily understood, and serious adverse event to be considered in trade for potential visual improvement from a stem cell-derived treatment. The results indicate that patients were willing to trade visual improvement against a risk of malignancy that far exceeds actual risk. Two novel findings were that older patients and those with an intermediate level of visual loss were particularly risk tolerant. The quantitative survey results provide a step toward understanding patient perspectives that will, over the long term, guide the development of ocular stem cell-derived therapies. Patients surveyed were willing to trade visual acuity and risk of cancer Age and visual function score modify utility of risk of cancer and visual acuity Greatest changes in utility of visual acuity occurred between 20/40 and 20/100
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Affiliation(s)
- Peter Y Zhao
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - Sunjong Ji
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - Paula Anne Newman-Casey
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Chris A Andrews
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - Angeline Lonardi
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - Olivia M Bennett
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - Duyhoang Q Dinh
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - Nidhi Talwar
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - David W Hutton
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sally Temple
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA; Neural Stem Cell Institute, Rensselaer, NY, USA
| | - Jeffrey H Stern
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA; Neural Stem Cell Institute, Rensselaer, NY, USA
| | - Rajesh C Rao
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA; Department of Pathology, University of Michigan, Ann Arbor, MI, USA; Center of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA; Center for RNA Biomedicine, Univeristy of Michigan, Ann Arbor, MI, USA; Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA; A. Alfred Taubman Medical Research Institute, University of Michigan, Ann Arbor, MI, USA; Section of Ophthalmology, Surgery Service, VA Ann Arbor Health System, Ann Arbor, MI, USA.
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13
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Hutton DW, Glassman AR, Stein JD, Bressler NM, Sun JK. Costs of Managing Diabetic Macular Edema With Good Visual Acuity With Aflibercept, Laser, or Observation: DRCR Retina Network Protocol V. Am J Ophthalmol 2021; 230:297-302. [PMID: 33713680 DOI: 10.1016/j.ajo.2021.02.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Because eyes with center-involved diabetic macular edema (CI-DME) and good baseline visual acuity (VA) showed no difference in VA loss when managed initially with observation, laser, or aflibercept, understanding the estimated costs of these strategies to the US population is relevant for health care planning. DESIGN Preplanned cost analysis from a randomized controlled trial (DRCR Retina Network Protocol V). METHODS Total costs for managing participants with CI-DME and good baseline VA assigned to aflibercept (n = 226), laser (n = 240), or observation (n = 236) during the 2-year multicenter trial were calculated. Observation or laser groups initiated aflibercept if VA decreased. The aflibercept group received injections up to every 4 weeks. Using epidemiological data and extrapolating costs, 10-year costs of care for all persons with CI-DME and good baseline VA throughout the United States were caluclated. RESULTS Assuming that all patients in the United States with CI-DME and good baseline VA received aflibercept initially, 10-year costs were projected to be $28.80 billion compared with $14.42 billion if initially receiving laser treatment or $15.70 billion if initially observed, with aflibercept added if VA worsened in the laser or observation arms. CONCLUSIONS Similar VA outcomes on average are obtained by initially managing CI-DME and good baseline VA with laser or observation strategies instead of immediately using aflibercept. Although any 1 of these 3 strategies might be warranted depending on an individual's specific circumstances, on a societal level, cost savings might be achieved with these first 2 approaches.
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14
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Avanceña ALV, DeLuca EK, Iott B, Mauri A, Miller N, Eisenberg D, Hutton DW. Income and Income Inequality Are a Matter of Life and Death. What Can Policymakers Do About It? Am J Public Health 2021; 111:1404-1408. [PMID: 34464177 DOI: 10.2105/ajph.2021.306301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anton L V Avanceña
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Ellen Kim DeLuca
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Bradley Iott
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Amanda Mauri
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Nicholas Miller
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - Daniel Eisenberg
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
| | - David W Hutton
- Anton L. V. Avanceña, Ellen Kim DeLuca, Bradley Iott, and Amanda Mauri are PhD candidates in health services organization and policy at the University of Michigan, Ann Arbor. Nicholas Miller is a recent MPH graduate in epidemiology at the University of Michigan, Ann Arbor. Daniel Eisenberg is with the Fielding School of Public Health, University of California, Los Angeles. David W. Hutton is with the School of Public Health, University of Michigan, Ann Arbor
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15
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Yoon AP, Shauver MJ, Hutton DW, Chung KC. Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial. Plast Reconstr Surg 2021; 147:240e-252e. [PMID: 33235040 DOI: 10.1097/prs.0000000000007528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio. RESULTS Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.
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Affiliation(s)
- Alfred P Yoon
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School; and Health Management and Policy, University of Michigan School of Public Health
| | - Melissa J Shauver
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School; and Health Management and Policy, University of Michigan School of Public Health
| | - David W Hutton
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School; and Health Management and Policy, University of Michigan School of Public Health
| | - Kevin C Chung
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School; and Health Management and Policy, University of Michigan School of Public Health
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16
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Marrero WJ, Lavieri MS, Guikema SD, Hutton DW, Parikh ND. A machine learning approach for the prediction of overall deceased donor organ yield. Surgery 2021; 170:1561-1567. [PMID: 34183178 DOI: 10.1016/j.surg.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Optimizing organ yield (number of organs transplanted per donor) is a potentially modifiable way to increase the number of organs available for transplant. Models to predict the expected deceased donor organ yield have been developed based on ordinary least squares regression and logistic regression. However, alternative modeling methodologies incorporating machine learning may have superior performance compared with conventional approaches. METHODS We evaluated the predictive accuracy of 14 machine learning models for predicting overall organ yield in a cross-validation procedure. The models were parameterized using data from the Organ Procurement and Transplantation Network database from 2000 to 2018. The inclusion criteria for the study were adult deceased donors between 18 and 84 years of age that had at least 1 organ procured for transplantation. RESULTS A total of 89,520 donors met the inclusion criteria. Their mean (standard deviation) age was 44 (15) years, and approximately 58% were male. Our cross-validation analysis showed that a tree-based gradient boosting model outperformed the remaining 13 models. Compared with the currently used prediction models, the gradient boosting model improves prediction accuracy by reducing the mean absolute error between 3 and 11 organs per 100 donors. CONCLUSION Our analysis demonstrated that the gradient boosting methodology had the best performance in predicting overall deceased donor organ yield and can potentially serve as an aid to assess organ procurement organization performance.
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Affiliation(s)
- Wesley J Marrero
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, MA
| | - Mariel S Lavieri
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Seth D Guikema
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - David W Hutton
- School of Public Health, University of Michigan Ann Arbor, MI
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
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17
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Hutton DW, Stein JD, Glassman AR, Bressler NM, Jampol LM, Sun JK. Five-Year Cost-effectiveness of Intravitreous Ranibizumab Therapy vs Panretinal Photocoagulation for Treating Proliferative Diabetic Retinopathy: A Secondary Analysis of a Randomized Clinical Trial. JAMA Ophthalmol 2021; 137:1424-1432. [PMID: 31647496 DOI: 10.1001/jamaophthalmol.2019.4284] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The DRCR Retina Network Protocol S randomized clinical trial suggested that the mean visual acuity of eyes with proliferative diabetic retinopathy (PDR) treated with ranibizumab is not worse at 5 years than that of eyes treated with panretinal photocoagulation (PRP). Moreover, the ranibizumab group had fewer new cases of diabetic macular edema (DME) with vision loss or vitrectomy but had 4 times the number of injections and 3 times the number of visits. Although 2-year cost-effectiveness results of Protocol S were previously identified, incorporating 5-year data from Protocol S could alter the longer-term cost-effectiveness of the treatment strategies from the perspective of the health care system. Objective To evaluate 5- and 10-year cost-effectiveness of therapy with ranibizumab, 0.5 mg, compared with PRP for treating PDR. Design, Setting, and Participants A preplanned secondary analysis of the Protocol S randomized clinical trial using efficacy, safety, and resource utilization data through 5 years of follow-up for 213 adults diagnosed with PDR and simulating results through 10 years. Interventions Intravitreous ranibizumab, 0.5 mg, at baseline and as frequently as every 4 weeks based on a structured retreatment protocol vs PRP at baseline for PDR; eyes in both groups could receive ranibizumab for concomitant DME with vision loss. Main Outcomes and Measures Incremental cost-effectiveness ratios (ICERs) of ranibizumab therapy compared with PRP were evaluated for those with and without center-involved DME (CI-DME) and vision loss (Snellen equivalent, 20/32 or worse) at baseline. Results The study included 213 adults with a mean (SD) age of 53 (12) years, of whom 92 (43%) were women and 155 (73%) were white. The ICER of the ranibizumab group compared with PRP for patients without CI-DME at baseline was $582 268 per quality-adjusted life-year (QALY) at 5 years and $742 202/QALY at 10 years. For patients with baseline CI-DME, ICERs were $65 576/QALY at 5 years and $63 930/QALY at 10 years. Conclusions and Relevance This study suggests that during 5 to 10 years of treatment, ranibizumab, 0.5 mg, as given in the studied trial compared with PRP may be within the frequently cited range considered cost-effective in the United States for eyes presenting with PDR and vision-impairing CI-DME, but not for those with PDR but without vision-impairing CI-DME. Substantial reductions in anti-vascular endothelial growth factor cost may make the ranibizumab therapy cost-effective within this range even for patients without baseline CI-DME. Trial Registration ClinicalTrials.gov identifier: NCT01489189.
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Affiliation(s)
- David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor.,Department of Industrial and Operations Engineering, University of Michigan College of Engineering, Ann Arbor.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Joshua D Stein
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor.,Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | | | - Neil M Bressler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Editor, JAMA Ophthalmology
| | - Lee M Jampol
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,CME Editor, JAMA Ophthalmology
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18
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Avanceña AL, Miller N, Uttal SE, Hutton DW, Mellinger JL. Cost-effectiveness of alcohol use treatments in patients with alcohol-related cirrhosis. J Hepatol 2021; 74:1286-1294. [PMID: 33326815 PMCID: PMC8177741 DOI: 10.1016/j.jhep.2020.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Alcohol use treatment such as medication-assisted therapies (MATs) and counseling are available and effective in promoting alcohol abstinence. We sought to explore the cost-effectiveness of different alcohol use treatments among patients with compensated alcohol-related cirrhosis (AC). METHODS We simulated a cohort of patients with compensated AC receiving care from a hepatology clinic over their lifetimes. We estimated costs (in 2017 US$) and benefits in terms of quality-adjusted life years (QALYs) gained from healthcare and societal perspectives. Transition probabilities, costs, and health utility weights were taken from the literature. Treatment effects of FDA-approved MATs (acamprosate and naltrexone) and non-FDA approved MATs (baclofen, gabapentin, and topiramate) and counseling were based on a study of employer-insured patients with AC. We calculated incremental cost-effectiveness ratios (ICERs) and performed one-way and probabilistic sensitivity analyses to understand the impact of parameter uncertainty. RESULTS Compared to a do-nothing scenario, MATs and counseling were found to be cost-saving from a healthcare perspective, which means that they provide more benefits with less costs than no intervention. Compared to other interventions, acamprosate and naltrexone cost the least and provide the most QALYs. If the effectiveness of MATs and counseling decreased, these interventions would still be cost-effective based on the commonly used $100,000 per QALY gained threshold. Several sensitivity and scenario analyses showed that our main findings are robust. CONCLUSIONS Among patients with compensated AC, MATs and counseling are extremely cost-effective, and in some cases cost-saving, interventions to prevent decompensation and improve health. Health policies (e.g. payer reimbursement) should emphasize and appropriately compensate for these interventions. LAY SUMMARY Alcohol use treatments, including physician counseling and medication-assisted therapies (MATs), improve the outcomes of patients with compensated alcohol-related cirrhosis, though use and access have remained suboptimal. In this study, we found that counseling and MATs are extremely cost-effective, and in some cases cost-saving, interventions to help patients with alcohol-related cirrhosis abstain from alcohol and improve their health. Wider use of these interventions should be encouraged.
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Affiliation(s)
- Anton L.V. Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA,Corresponding author: Anton Avanceña, Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, SPH II, Ann Arbor, MI 48109. . Phone: +1-734-0287. Fax: +1-734-764-4338
| | - Nicholas Miller
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sarah E. Uttal
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - David W. Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA,Department of Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Jessica L. Mellinger
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
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Avanceña ALV, Hutton DW, Lee J, Schumacher KR, Si MS, Peng DM. Cost-effectiveness of implantable ventricular assist devices in older children with stable, inotrope-dependent dilated cardiomyopathy. Pediatr Transplant 2021; 25:e13975. [PMID: 33481355 DOI: 10.1111/petr.13975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In a stable, inotrope-dependent pediatric patient with dilated cardiomyopathy, we evaluated the cost-effectiveness of continuous-flow VAD implantation compared to a watchful waiting approach using chronic inotropic therapy. METHODS We used a state-transition model to estimate the costs and outcomes of 14-year-old (INTERMACS profile 3) patients receiving either VAD or watchful waiting. We measured benefits in terms of lifetime QALYs gained. Model inputs were taken from the literature. We calculated the ICER, or the cost per additional QALY gained, of VADs and performed multiple sensitivity analyses to test how our assumptions influenced the results. RESULTS Compared to watchful waiting, VADs produce 0.97 more QALYs for an additional $156 639, leading to an ICER of $162 123 per QALY gained from a healthcare perspective. VADs have 17% chance of being cost-effective given a cost-effectiveness threshold of $100 000 per QALY gained. Sensitivity analyses suggest that VADs can be cost-effective if the costs of implantation decrease or if hospitalization costs or mortality among watchful waiting patients is higher. CONCLUSIONS As a bridge to transplant, VADs provide a health benefit to children who develop stable, inotrope-dependent heart failure, but immediate implantation is not yet a cost-effective strategy compared to watchful waiting based on commonly used cost-effectiveness thresholds. Early VAD support can be cost-effective in sicker patients and if device implantation is cheaper. In complex conditions such as pediatric heart failure, cost-effectiveness should be just one of many factors that inform clinical decision-making.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Josie Lee
- Undergraduate Program, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David M Peng
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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20
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Havumaki J, Eisenberg JNS, Mattison CP, Lopman BA, Ortega-Sanchez IR, Hall AJ, Hutton DW, Eisenberg MC. Immunologic and Epidemiologic Drivers of Norovirus Transmission in Daycare and School Outbreaks. Epidemiology 2021; 32:351-359. [PMID: 33652444 DOI: 10.1097/ede.0000000000001322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Norovirus outbreaks are notoriously explosive, with dramatic symptomology and rapid disease spread. Children are particularly vulnerable to infection and drive norovirus transmission due to their high contact rates with each other and the environment. Despite the explosive nature of norovirus outbreaks, attack rates in schools and daycares remain low with the majority of students not reporting symptoms. METHODS We explore immunologic and epidemiologic mechanisms that may underlie epidemic norovirus transmission dynamics using a disease transmission model. Towards this end, we compared different model scenarios, including innate resistance and acquired immunity (collectively denoted 'immunity'), stochastic extinction, and an individual exclusion intervention. We calibrated our model to daycare and school outbreaks from national surveillance data. RESULTS Including immunity in the model led to attack rates that were consistent with the data. However, immunity alone resulted in the majority of outbreak durations being relatively short. The addition of individual exclusion (to the immunity model) extended outbreak durations by reducing the amount of time that symptomatic people contribute to transmission. Including both immunity and individual exclusion mechanisms resulted in simulations where both attack rates and outbreak durations were consistent with surveillance data. CONCLUSIONS The epidemiology of norovirus outbreaks in daycare and school settings cannot be well described by a simple transmission model in which all individuals start as fully susceptible. More studies on how best to design interventions which leverage population immunity and encourage more rigorous individual exclusion may improve venue-level control measures. See video abstract at http://links.lww.com/EDE/B795.
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Affiliation(s)
- Joshua Havumaki
- From the Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | | | - Claire P Mattison
- National Center for Immunization and Respiratory Diseases, Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN
| | | | - Ismael R Ortega-Sanchez
- National Center for Immunization and Respiratory Diseases, Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Aron J Hall
- National Center for Immunization and Respiratory Diseases, Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Marisa C Eisenberg
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
- Department of Mathematics, University of Michigan, Ann Arbor, MI
- Department of Complex Systems, University of Michigan, Ann Arbor, MI
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21
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DeRoos LJ, Zhou Y, Marrero WJ, Tapper EB, Sonnenday CJ, Lavieri MS, Hutton DW, Parikh ND. Assessment of National Organ Donation Rates and Organ Procurement Organization Metrics. JAMA Surg 2021; 156:173-180. [PMID: 33263743 DOI: 10.1001/jamasurg.2020.5395] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Organ transplant is a life-saving procedure for patients with end-stage organ failure. In the US, organ procurement organizations (OPOs) are responsible for the evaluation and procurement of organs from donors who have died; however, there is controversy regarding what measures should be used to evaluate their performance. Objective To evaluate OPO performance metrics using combined mortality and donation data and quantify the associations of population demographics with donation metrics. Design, Setting, and Participants This national cohort study includes data from the US organ transplantation system from January 2008 through December 2017. All individuals who died within the US, as reported by the National Death index, were included. Exposures Death, organ donation, and donation eligibility. Main Outcomes and Measures Evaluation of the variation in donation metrics and the use of ineligible donors by OPO and demographic subgroup. Results This study included 17 501 742 deaths and 75 769 deceased organ donors (45 040 men [59.4%]; 51 908 White individuals [68.5%]). Of these donors, 15 857 (20.9%) were not eligible, as defined by the OPOs. The median donation metrics by OPO were 0.004 (range, 0.002-0.012) donors per death, 0.89 (range, 0.68-1.30) donors per eligible death, and 0.72 (range, 0.57-0.86) eligible donors per eligible death. The OPOs in the upper quartile of the overall eligible donors per eligible death metric were in the upper quartile of annual rankings on 90 of 140 occasions (64.3%). There was little overlap in top-performing OPOs between metrics; an OPO in the upper quartile for 1 metric was also in the upper quartile for the other metrics on 37 of 570 occasions (6.5% of the time). The median donor eligibility rate, defined as the number of eligible donors per donor, was 0.79 (range, 0.61-0.95) across OPOs. Age (eg, 65 to 84 years, coefficient, -0.55 [SE, 0.03]; P < .001; vs those aged 18 to 34 years), sex (male individuals, -0.09 [SE, 0.02]; P < .001; vs female individuals), race (eg, Black individuals, 0.35 [SE, 0.02]; P < .001; vs White individuals), cause of death (eg, central nervous system tumor, 0.48 [SE, 0.08]; P < .001; vs anoxia), year (eg, 2016-2017: -0.10 [SE, 0.03]; P < .001; vs 2008-2009), and OPO were associated with the use of ineligible donors; OPO was a significant factor associated with performance in all metrics (χ256, 500.5; P < .001; coefficient range across individual OPOs, -0.15 [SE, 0.09] to 0.75 [SE, 0.09]), even after accounting for population differences. Female and non-White individuals were significantly less likely to be used as ineligible donors. Conclusions and Relevance We demonstrate significant variability in OPO performance rankings, depending on which donation metric is used. There were significant differences in OPO performance, even after accounting for differences in potential donor populations. Our data suggest significant variation in use of ineligible donors among OPOs, a source for increased donors. The performance of OPOs should be evaluated using a range of donation metrics.
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Affiliation(s)
- Luke J DeRoos
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Yuhang Zhou
- Electrical Engineering and Computer Science, University of Michigan, Ann Arbor
| | - Wesley J Marrero
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Christopher J Sonnenday
- Department of Surgery, University of Michigan, Ann Arbor.,School of Public Health, University of Michigan, Ann Arbor
| | - Mariel S Lavieri
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - David W Hutton
- Industrial and Operations Engineering, University of Michigan, Ann Arbor.,School of Public Health, University of Michigan, Ann Arbor
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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22
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Hutton DW, McCullough JS, Prosser L, Ye W, Herman WH, Zhang P, Pilishvili T, Pike J. Costs implications of pneumococcal vaccination of adults aged 30-60 with a recent diagnosis of diabetes. Vaccine 2021; 39:1333-1338. [PMID: 33494965 DOI: 10.1016/j.vaccine.2020.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/30/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The 23-valent pneumococcal polysaccharide vaccine is routinely recommended for adults with diabetes, but little is known about adherence to this recommendation and how vaccination of these adults affects costs related to pneumococcal disease. RESEARCH DESIGN AND METHODS We used data from a commercial insurance claims dataset to examine a cohort of non-elderly adults with a new diagnosis of diabetes and adults with no diagnosis of diabetes from 2005 to 2014. We examined rates of pneumococcal polysaccharide vaccination and the relationship between vaccination and pneumococcal disease costs, comparing results for persons with a diagnosis of diabetes and those with no diagnosis of diabetes. RESULTS Overall rates of pneumococcal polysaccharide vaccination among adults 30-60 years old were <1%/year. Rates of pneumococcal polysaccharide vaccination were higher for adults with diabetes. Pneumococcal polysaccharide vaccination rates more than doubled from 2.9% per year in 2005 to 6.0% per year in 2014 for adults vaccinated during the same year as their diabetes diagnosis. Using a two-part differences-in-differences model on a propensity-score matched dataset, pneumococcal polysaccharide vaccination may reduce average annual per-person pneumococcal disease costs by $90.54 [95% CI: $183.59, -$2.49, (p = 0.056)] in persons with diabetes from two years before to two years after vaccination. CONCLUSIONS Non-elderly adults with diabetes have low but rising rates of pneumococcal polysaccharide vaccination. Pneumococcal polysaccharide vaccination has a modest impact reducing overall costs of pneumococcal disease in this population.
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Affiliation(s)
- David W Hutton
- Department of Health Management and Policy, University of Michigan, United States.
| | - Jeffrey S McCullough
- Department of Health Management and Policy, University of Michigan, United States
| | - Lisa Prosser
- Department of Health Management and Policy, University of Michigan, United States; Department of Pediatrics and Communicable Diseases, University of Michigan, United States
| | - Wen Ye
- Department of Biostatistics, University of Michigan, United States
| | - William H Herman
- Departments of Internal Medicine and Epidemiology, University of Michigan, United States
| | - Ping Zhang
- Centers for Disease Control and Prevention, United States
| | | | - Jamison Pike
- Centers for Disease Control and Prevention, United States
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23
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Eisman AB, Hutton DW, Prosser LA, Smith SN, Kilbourne AM. Cost-effectiveness of the Adaptive Implementation of Effective Programs Trial (ADEPT): approaches to adopting implementation strategies. Implement Sci 2020; 15:109. [PMID: 33317593 PMCID: PMC7734829 DOI: 10.1186/s13012-020-01069-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 12/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Theory-based methods to support the uptake of evidence-based practices (EBPs) are critical to improving mental health outcomes. Implementation strategy costs can be substantial, and few have been rigorously evaluated. The purpose of this study is to conduct a cost-effectiveness analysis to identify the most cost-effective approach to deploying implementation strategies to enhance the uptake of Life Goals, a mental health EBP. METHODS We used data from a previously conducted randomized trial to compare the cost-effectiveness of Replicating Effective Programs (REP) combined with external and/or internal facilitation among sites non-responsive to REP. REP is a low-level strategy that includes EBP packaging, training, and technical assistance. External facilitation (EF) involves external expert support, and internal facilitation (IF) augments EF with protected time for internal staff to support EBP implementation. We developed a decision tree to assess 1-year costs and outcomes for four implementation strategies: (1) REP only, (2) REP+EF, (3) REP+EF add IF if needed, (4) REP+EF/IF. The analysis used a 1-year time horizon and assumed a health payer perspective. Our outcome was quality-adjusted life years (QALYs). The economic outcome was the incremental cost-effectiveness ratio (ICER). We conducted deterministic and probabilistic sensitivity analysis (PSA). RESULTS Our results indicate that REP+EF add IF is the most cost-effective option with an ICER of $593/QALY. The REP+EF/IF and REP+EF only conditions are dominated (i.e., more expensive and less effective than comparators). One-way sensitivity analyses indicate that results are sensitive to utilities for REP+EF and REP+EF add IF. The PSA results indicate that REP+EF, add IF is the optimal strategy in 30% of iterations at the threshold of $100,000/QALY. CONCLUSIONS Our results suggest that the most cost-effective implementation support begins with a less intensive, less costly strategy initially and increases as needed to enhance EBP uptake. Using this approach, implementation support resources can be judiciously allocated to those clinics that would most benefit. Our results were not robust to changes in the utility measure. Research is needed that incorporates robust and relevant utilities in implementation studies to determine the most cost-effective strategies. This study advances economic evaluation of implementation by assessing costs and utilities across multiple implementation strategy combinations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02151331 , 05/30/2014.
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Affiliation(s)
- Andria B Eisman
- Community Health, Division of Kinesiology, Health and Sport Studies, College of Education, Wayne State University, 2153 Faculty/Administration Building, 656 West Kirby, Detroit, MI, 48202, USA.
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
- Susan B. Meister Child Health Evaluation & Research Center, Dept of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs, Washington, USA
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24
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Tordrup D, Hutin Y, Stenberg K, Lauer JA, Hutton DW, Toy M, Scott N, Chhatwal J, Ball A. Cost-Effectiveness of Testing and Treatment for Hepatitis B Virus and Hepatitis C Virus Infections: An Analysis by Scenarios, Regions, and Income. Value Health 2020; 23:1552-1560. [PMID: 33248510 PMCID: PMC7806510 DOI: 10.1016/j.jval.2020.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups. METHODS We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination). RESULTS Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results. CONCLUSIONS Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.
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Affiliation(s)
- David Tordrup
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Utrecht University, Utrecht, The Netherlands; World Health Organization Headquarters (Department of HIV and Global Hepatitis Programme and Department of Health Systems Governance and Financing), Geneva, Switzerland.
| | - Yvan Hutin
- World Health Organization Headquarters (Department of HIV and Global Hepatitis Programme and Department of Health Systems Governance and Financing), Geneva, Switzerland.
| | - Karin Stenberg
- World Health Organization Headquarters (Department of HIV and Global Hepatitis Programme and Department of Health Systems Governance and Financing), Geneva, Switzerland
| | - Jeremy A Lauer
- World Health Organization Headquarters (Department of HIV and Global Hepatitis Programme and Department of Health Systems Governance and Financing), Geneva, Switzerland; Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - David W Hutton
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Mehlika Toy
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Nick Scott
- Burnet Institute, Melbourne, Victoria, Australia
| | - Jagpreet Chhatwal
- Massachusetts, General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Ball
- World Health Organization Headquarters (Department of HIV and Global Hepatitis Programme and Department of Health Systems Governance and Financing), Geneva, Switzerland; Division of Universal Health Coverage, Communicable and Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
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Avanceña ALV, Hutton DW. Optimization Models for HIV/AIDS Resource Allocation: A Systematic Review. Value Health 2020; 23:1509-1521. [PMID: 33127022 DOI: 10.1016/j.jval.2020.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This study reviews optimization models for human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) resource allocation. METHODS We searched 2 databases for peer-reviewed articles published from January 1985 through August 2019 that describe optimization models for resource allocation in HIV/AIDS. We included models that consider 2 or more competing HIV/AIDS interventions. We extracted data on selected characteristics and identified similarities and differences across models. We also assessed the quality of mathematical disease transmission models based on the best practices identified by a 2010 task force. RESULTS The final qualitative synthesis included 23 articles that used 14 unique optimization models. The articles shared several characteristics, including the use of dynamic transmission modeling to estimate health benefits and the inclusion of specific high-risk groups in the study population. The models explored similar HIV/AIDS interventions that span primary and secondary prevention and antiretroviral treatment. Most articles were focused on sub-Saharan African countries (57%) and the United States (39%). There was notable variation in the types of optimization objectives across the articles; the most common was minimizing HIV incidence or maximizing infections averted (87%). Articles that utilized mathematical modeling of HIV disease and transmission displayed variable quality. CONCLUSIONS This systematic review of the literature identified examples of optimization models that have been applied in different settings, many of which displayed similar features. There were similarities in objective functions across optimization models, but they did not align with global HIV/AIDS goals or targets. Future work should be applied in countries facing the largest declines in HIV/AIDS funding.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA.
| | - David W Hutton
- Department of Health Management and Policy and Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
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26
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Chung GS, Hutton DW. Epidemiological impact and cost-effectiveness of universal meningitis b vaccination among college students prior to college entry. PLoS One 2020; 15:e0239926. [PMID: 33035260 PMCID: PMC7546456 DOI: 10.1371/journal.pone.0239926] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/15/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES University students are at significantly higher risk of serogroup B meningococcal (MenB) infection, which can result in debilitating sequelae and excessive healthcare usage. This study aimed to elucidate the impact of universal pre-enrollment vaccination on MenB outbreak probability and the cost-effectiveness in outbreak-only scenarios. METHODS We developed an infectious disease transmission model to determine the number of outbreaks averted under universal vaccination and a Markov model to simulate the costs accrued and QALYs lost associated with infection. The analysis was done on a hypothetical population of 40,000 college students over a four-year time frame. We used the outputs of these two models to calculate the incremental cost-effectiveness ratio (ICER) of universal MenB vaccination from a societal perspective. RESULTS We find that the vaccination strategy was estimated to reduce MenB incidence by 63% and outbreak frequency rate by 90%. Under base case assumptions, the ICER of universal vaccination was $748,129 per QALY and in outbreak-only scenarios, it was cost-saving. CONCLUSIONS Universal vaccination is not cost-effective at the current low MenB incidence levels and vaccine price in the U.S., but it is cost-saving if outbreak is imminent.
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Affiliation(s)
- Grace S. Chung
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, United States of America
| | - David W. Hutton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, United States of America
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Abstract
IMPORTANCE Owing to its tendency to recur, Dupuytren contracture often requires multiple treatments, which places additional economic burden on health care. The likelihood of contracture recurrence varies not only with treatment but also with disease characteristics, such as contracture severity and location, but prior cost-effectiveness analyses of Dupuytren contracture treatments have not considered these patient-specific disease characteristics. OBJECTIVE To identify the most cost-effective treatment regimen for patients with recurrent Dupuytren contracture. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation was conducted with state-transition microsimulation modeling using data from published studies and Medicare. A simulated cohort of 10 000 individuals with Dupuytren contracture was created. Patients could transition yearly between the following health states: symptom-free, symptomatic, and death. Available treatments were collagenase clostridium histolyticum injection, percutaneous needle aponeurotomy (PNA), and limited fasciectomy (LF); individuals randomly chose any treatment when symptomatic. Patients were limited to 3 rounds of treatment for a contracture affecting 1 joint, totaling 27 unique combinations. If the contracture recurred after 3 treatments, patients lived with the disease for the remainder of life. EXPOSURES PNA, collagenase clostridium histolyticum injection, or LF. MAIN OUTCOMES AND MEASURES Quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per quality-adjusted life-year was used to assess cost-effectiveness. RESULTS For the base case scenario of a patient aged 60 years with recurrent, low-severity metacarpophalangeal (MCP) joint contracture, repeated PNA treatment was the only cost-effective treatment (2 PNA treatments followed by LF vs 3 PNA treatments, ICER [Monte Carlo SE]: $212 647/QALY [$36 000/QALY]). For recurrent high-severity MCP joint contractures, treatment regimens composed of PNA and LF were cost-effective (ICER [Monte Carlo SE], $93 932/QALY [$16 500/QALY]). LF was cost-effective for high-severity MCP joint contracture (ICER [Monte Carlo SE], $98 624/QALY [$26 233/QALY]). For recurrent proximal interphalangeal (PIP) joint contractures, PNA was the only cost-effective treatment, regardless of severity (eg, 2 PNA treatments followed by LF vs 3 PNA treatments for low-severity PIP joint contracture, ICER [Monte Carlo SE]: $263 726/QALY [$29 000/QALY]). Any combination with collagenase clostridium histolyticum injection compared with 3 PNA treatments had an ICER greater than $100 000 per QALY. Probabilistic sensitivity analysis estimated a 44%, 15%, 41%, and 52% chance of a regimen consisting of only PNA being cost-effective in low-severity MCP, high-severity MCP, low-severity PIP, and high-severity PIP joint contractures, respectively. CONCLUSIONS AND RELEVANCE The results of this study suggest that LF is a cost-effective intervention for recurrent high-severity MCP joint contractures. For recurrent low-severity MCP joint contractures and PIP joint contractures of all severity levels, PNA was the only cost-effective intervention. Collagenase clostridium histolyticum injections were not a cost-effective intervention for recurrent Dupuytren contracture and should not be preferred over PNA or LF.
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Affiliation(s)
- Alfred P. Yoon
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Robert L. Kane
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - David W. Hutton
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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28
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Saran R, Pearson A, Tilea A, Shahinian V, Bragg-Gresham J, Heung M, Hutton DW, Steffick D, Zheng K, Morgenstern H, Gillespie BW, Leichtman A, Young E, O'Hare AM, Fischer M, Hotchkiss J, Siew E, Hynes D, Fried L, Balkovetz D, Sovern K, Liu CF, Crowley S. Burden and Cost of Caring for US Veterans With CKD: Initial Findings From the VA Renal Information System (VA-REINS). Am J Kidney Dis 2020; 77:397-405. [PMID: 32890592 DOI: 10.1053/j.ajkd.2020.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022]
Abstract
Kidney disease is a common, complex, costly, and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national US Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT). Data from the VA's Corporate Data Warehouse were processed and linked with national Medicare data for patients with CKD receiving KRT. Operational definitions for VA user, CKD, acute kidney injury, and kidney failure were developed. Among 7 million VA users in fiscal year 2014, CKD was identified using either a strict or liberal operational definition in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an estimated glomerular filtration rate laboratory phenotype, some through proteinuria assessment, and very few through International Classification of Diseases, Ninth Revision coding. The VA spent ∼$18 billion for the care of patients with CKD without KRT, most of which was for CKD stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, and improving the quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.
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Affiliation(s)
- Rajiv Saran
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI.
| | - Aaron Pearson
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Vahakn Shahinian
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer Bragg-Gresham
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Michael Heung
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Diane Steffick
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Kai Zheng
- Department of Informatics, University of California - Irvine, Irvine, CA
| | - Hal Morgenstern
- Department of Epidemiology and Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI; Department of Urology, Medical School, University of Michigan, Ann Arbor, MI
| | - Brenda W Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Alan Leichtman
- Department of Internal Medicine - Nephrology, University of Michigan Medical School, Ann Arbor, MI
| | - Eric Young
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Ann M O'Hare
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Medicine - Nephrology, VA Puget Sound Health Care System, Seattle, WA
| | - Michael Fischer
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL
| | - John Hotchkiss
- Department of Critical Care Medicine, Pittsburgh VA Medical Center, Pittsburgh, PA
| | - Eddie Siew
- Division of Nephrology and Hypertension, Nashville VA Medical Center, Nashville, TN
| | | | - Linda Fried
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | - Karen Sovern
- Department of Veterans Affairs, Center Office of Analytics and Business Intelligence
| | | | - Susan Crowley
- Section of Nephrology, VA Connecticut Healthcare System, West Haven, CT; Yale University School of Medicine, New Haven, CT
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Han Y, Balkrishnan R, Hirth RA, Hutton DW, He K, Steffick DE, Saran R. Assessment of Prescription Analgesic Use in Older Adults With and Without Chronic Kidney Disease and Outcomes. JAMA Netw Open 2020; 3:e2016839. [PMID: 32997126 PMCID: PMC7527874 DOI: 10.1001/jamanetworkopen.2020.16839] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Pain is a common symptom among patients with kidney disease. However, little is known about use of analgesics among patients aged 65 years or older with chronic kidney disease (CKD) who do not receive dialysis treatment. OBJECTIVE To assess national trends and geographic variations in use of opioids and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults with and without CKD in the US (2006-2015) and examine associations between use of opioids and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used the 5% Medicare claims data (2005-2015) to select 10 retrospective annual cohorts of Medicare Part D beneficiaries aged 65 years and older from 2006 to 2015 and a retrospective longitudinal cohort. Data were analyzed in August 2019. EXPOSURES CKD status and other comorbidities identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. MAIN OUTCOMES AND MEASURES Analgesic use was measured by overall use (proportion of ever used opioids/NSAIDs), long-term use (prescribed >90 days), and cumulative use (total annual days' supply). Patient outcomes included progression to end-stage kidney disease (ESKD) and all-cause mortality. RESULTS A total of 6 260 454 beneficiaries (9.6% identified with CKD by claims) were selected in the annual cohorts and 649 339 beneficiaries (8.3% identified with CKD) were selected in the longitudinal cohort. There was significant growth in opioid use (31.2%-42.4%) and NSAID use (10.7%-16.6%) among patients aged 65 years and older with CKD from 2006 to 2015. Long-term use of opioids increased during 2006 to 2014 (25.8%-36.7%) but decreased through 2015 at 35.6%, while long-term use of NSAIDs remained stable. Opioid use was higher in patients with CKD, particularly CKD stages 4 to 5 (odds ratio [OR], 1.35; 95% CI, 1.33-1.37; P < .001) compared with non-CKD. NSAID use was lower in patients with CKD stages 4 to 5 (OR, 0.55; 95% CI, 0.54-0.56; P < .001). Substantial geographic variations in analgesic use were observed across states (opioid use in CKD: 24.7%-54.3%; NSAID use in CKD: 11.2%-20.8%, 2012-2015). Opioid use was associated with progression to ESKD (hazard ratio [HR], 1.10; 95% CI, 1.04-1.16; P = .001) and death (HR, 1.19; 95% CI, 1.18-1.20; P < .001) independent of CKD status and other covariates. There was an inverse association between NSAID use and death (HR, 0.84; 95% CI, 0.83-0.85; P < .001). CONCLUSIONS AND RELEVANCE Among Medicare patients with CKD, use of prescription analgesics, both opioid and NSAID, increased from 2006 to 2015. Optimizing pain management in a complex condition such as kidney disease should remain a priority for clinicians and researchers alike.
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Affiliation(s)
- Yun Han
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Rajesh Balkrishnan
- University of Michigan School of Public Health, Department of Health Policy and Management, Ann Arbor
| | - Richard A. Hirth
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- University of Michigan School of Public Health, Department of Health Policy and Management, Ann Arbor
| | - David W. Hutton
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- University of Michigan School of Public Health, Department of Health Policy and Management, Ann Arbor
| | - Kevin He
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Diane E. Steffick
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, and the Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
- University of Michigan School of Public Health, Department of Epidemiology, Ann Arbor
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Gopalakrishnan L, Kabbani L, Brown S, Goodman R, Montoya A, Hutton DW. Abstract 29: Cost-effectiveness of Inpatient Case Management for Heart Failure Patients. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Prior studies have demonstrated that approximately 5.7 million Americans suffer from heart failure (HF). The direct costs of HF have been estimated at $39.3 billion, and the annual cost of unplanned readmissions is approximately $17.4 billion. Many interventions have been implemented in order to decrease healthcare costs and burden of this disease. Case management (CM) is an intervention that has been utilized in inpatient and outpatient settings. The purpose of this study was to analyze the cost-effectiveness of using CM in addition to usual care in a tertiary hospital that has a large HF population to decrease the 30-day readmission rate.
Objectives:
We hypothesize that the addition of CM to provide transitional care services to HF patients will decrease 30-day readmission rate, consequently decreasing healthcare utilization costs and improving patient’s quality of life (QoL).
Methods:
We conducted a cost-effectiveness analysis using a decision analytic model that incorporated Markov processes to evaluate the use of CM for HF patients. We compared two different management strategies following index HF hospitalization: ‘usual care’ versus ‘usual care plus CM’. Our analysis was conducted from a societal perspective with estimated key cost parameters based on established Diagnosis-related Groups (DRGs) and the Healthcare Cost and Utilization Project (HCUP). Lastly, patients’ quality adjusted life years (QALYs) were measured by days spent out of the hospital.
Results:
In our analysis, ’usual care plus CM’ resulted in cost savings of $696.58 per patient when compared to ‘usual care’ alone for an ACO based health system with large HF patient volume. In addition, ‘usual care plus CM’ was associated with shorter inpatient stay (decrease in 0.35 inpatient days), and a slight increase in QALYs by 0.003.
Conclusion:
Our study demonstrated that ACO-based health system’s investment in CM in addition to usual care decrease the cost per discharge of complex HF patients.
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Affiliation(s)
| | - Loay Kabbani
- Univ of Michigan Sch of Public Health, Ann Arbor, MI
| | - Sarah Brown
- Univ of Michigan Sch of Public Health, Ann Arbor, MI
| | | | - Ana Montoya
- Univ of Michigan Sch of Public Health, Ann Arbor, MI
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Liu J, Hutton DW, Gu Y, Hu Y, Li Y, Ma L, Zeng X, Fu P. Financial implications of dialysis modalities in the developing world: A Chinese perspective. Perit Dial Int 2020; 40:193-201. [PMID: 32063196 DOI: 10.1177/0896860819893812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND End-stage renal disease has been imposing a heavy economic burden on public health; however, few studies have been performed on the cost-effectiveness of dialysis modalities. We aim to estimate the cost-effectiveness of different dialysis modalities in China. METHODS Cost-effectiveness analyses were performed using Markov models based on published data of hemodialysis (HD) and peritoneal dialysis (PD) modalities in China. Sensitivity analyses were conducted to identify key variables influencing the results. RESULTS Over a 10-year time horizon, the base-case cost-effectiveness analysis indicated that PD-first absolutely dominated the HD-first option by gaining 0.13 more quality-adjusted life years (QALYs) and costing RMB ¥81,081 less. When using reported mortality of HD and PD from the United States, the PD-first option still dominated HD-first with higher QALYs and lower costs. Sensitivity analyses revealed that the results were more sensitive to the direct cost of HD, utility of HD, utility of PD, direct cost of PD, PD mortality, and HD mortality, while less sensitive to the indirect costs and transition probabilities. The HD utility needed to be at least 0.148 higher than PD utility for HD to be cost-effective. PD was about 72% likely to be considered cost-effective compared with HD, regardless of the willingness-to-pay for QALYs. CONCLUSION PD appears to be more cost-effective than HD in China, and the major influential factors on the cost-effectiveness are the direct costs of HD, utility of HD, utility of PD, direct costs of PD, PD mortality, and HD mortality.
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Affiliation(s)
- Jing Liu
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Yonghong Gu
- West China Biomedical Big Data Center, Sichuan University, Chengdu, Sichuan, China
| | - Yao Hu
- West China Biomedical Big Data Center, Sichuan University, Chengdu, Sichuan, China
| | - Yi Li
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Liang Ma
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaoxi Zeng
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,West China Biomedical Big Data Center, Sichuan University, Chengdu, Sichuan, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institution, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,West China Biomedical Big Data Center, Sichuan University, Chengdu, Sichuan, China
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Abstract
OBJECTIVES The objective of this study is to explore the cost-effectiveness of Doctor to the Barrios (DTTB), a physician deployment program in the Philippines. DESIGN Cost-effectiveness analysis using decision tree models with a lifetime time horizon and probabilistic sensitivity analysis. SETTING Societal and healthcare perspectives. POPULATION Hypothetical cohort of children under 5 years in two provinces (Aklan and Nueva Ecija) and in a representative rural municipality. PARTICIPANTS None. INTERVENTIONS DTTB's impact on paediatric pneumonia and diarrhoea outcomes compared with a scenario without DTTB. MAIN OUTCOME MEASURES Costs, effectiveness (in terms of lives saved and quality-adjusted life years (QALYs) gained) and incremental cost-effectiveness ratio (ICER). RESULTS DTTB is cost-effective in the two provinces that were included in the study from societal and healthcare perspectives. Looking at a representative rural municipality, base case analysis and probabilistic sensitivity analyses suggest that DTTB has an ICER of 27 192 per QALY gained from a societal perspective. From a healthcare perspective, the base case ICER of DTTB is Philippine pesos (PHP) 71 839 per QALY gained and PHP 2 064 167 per life saved, and 10 000 Monte Carlo simulations produced similar average estimates. The cost per QALY of DTTB from a healthcare perspective is lower than the WHO recommended willingness-to-pay threshold of 100% of the country's per-capita gross domestic product. CONCLUSIONS DTTB can be a cost-effective intervention, but its value varies by setting and the conditions of the municipality where it is implemented. By focusing on a narrow set of paediatric outcomes, this study has likely underestimated the health benefits of DTTB. Additional research is needed to understand the full extent of DTTB's impact on the health of communities in rural and remote areas. Future cost-effectiveness analysis should empirically estimate various parameters and include other health conditions in addition to pneumonia and diarrhoea in children.
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Affiliation(s)
- Anton L V Avanceña
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, United States
| | - Kim Patrick S Tejano
- Health Policy Development and Planning Bureau, Philippines Department of Health, Manila, Philippines
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, United States
- Department of Industrial and Operations Engineering, University of Michigan College of Engineering, Ann Arbor, MI, United States
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Abstract
IMPORTANCE Traumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown. OBJECTIVE To assess the cost-effectiveness of finger replantation compared with revision amputation. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis. EXPOSURES Revision amputation or replantation of traumatic finger amputations. MAIN OUTCOMES AND MEASURES Main outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness. RESULTS Of the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns. CONCLUSIONS AND RELEVANCE With proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.
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Affiliation(s)
- Alfred P. Yoon
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Tanvi Mahajani
- School of Public Health, University of Michigan, Ann Arbor
| | - David W. Hutton
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Hutton DW, Rose A, Singer DC, Bridges CB, Kim D, Pike J, Prosser LA. Importance of reasons for stocking adult vaccines. Am J Manag Care 2019; 25:e334-e341. [PMID: 31747238 PMCID: PMC9004468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify the most important reasons underlying decisions to stock or not stock adult vaccines. STUDY DESIGN US physicians, nurses, pharmacists, and administrators of internal medicine, family medicine, obstetrics/gynecology, and multispecialty practices who were involved in vaccine stocking decisions (N = 125) completed a best-worst scaling survey online between February and April 2018. METHODS Sixteen potential factors influencing stocking decisions were developed based on key informant interviews and focus groups. Respondents selected factors that were most and least important in vaccine stocking decisions. Relative importance scores for the best-worst scaling factors were calculated. Survey respondents described which vaccines their practice stocks and reasons for not stocking specific vaccines. Subgroup analyses were performed based on the respondent's involvement in vaccine decision making, role in the organization, specialty, and affiliation status, as well as practice characteristics such as practice size, insurance mix, and patient age mix. RESULTS Relative importance scores for stocking vaccines were highest for "cost of purchasing vaccine stock," "expense of maintaining vaccine inventory," and "lack of adequate reimbursement for vaccine acquisition and administration." Most respondents (97%) stocked influenza vaccines, but stocking rates of other vaccines varied from 39% (meningococcal B) to 83% (tetanus-diphtheria-pertussis). Best-worst scaling results were consistent across respondent subgroups, although the range of vaccine types stocked differed by practice type. CONCLUSIONS Economic factors associated with the purchase and maintenance of vaccine inventory and inadequate reimbursement for vaccination services were the most important to decision makers when considering whether to stock or not stock vaccines for adults.
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Affiliation(s)
- David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Room M3525, Ann Arbor, MI 48109-2029.
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Goodman RM, Bridges CB, Kim D, Pike J, Rose A, Prosser LA, Hutton DW. Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act. Vaccine 2019; 37:6803-6813. [PMID: 31585724 DOI: 10.1016/j.vaccine.2019.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Provider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims. METHODS We assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing. RESULTS Pharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination. CONCLUSIONS Adult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.
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Affiliation(s)
- Robert M Goodman
- Blue Care Network/Blue Cross Blue Shield of Michigan, Southfield, MI, United States
| | - Carolyn B Bridges
- Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division, Atlanta, GA, United States; Berry Technology Solutions, Inc., Peachtree City, GA, United States(1)
| | - David Kim
- Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division, Atlanta, GA, United States
| | - Jamison Pike
- Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division, Atlanta, GA, United States
| | - Angela Rose
- University of Michigan, Ann Arbor, MI, United States
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DeRoos LJ, Marrero WJ, Tapper EB, Sonnenday CJ, Lavieri MS, Hutton DW, Parikh ND. Estimated Association Between Organ Availability and Presumed Consent in Solid Organ Transplant. JAMA Netw Open 2019; 2:e1912431. [PMID: 31577360 PMCID: PMC6777259 DOI: 10.1001/jamanetworkopen.2019.12431] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Presumed consent, or an opt-out organ transplant policy, has been adopted by many countries worldwide to increase organ donation. The implication of such a policy for transplants in the United States is uncertain, however. OBJECTIVE To simulate the potential implications of a presumed consent policy in the United States. DESIGN, SETTING, AND PARTICIPANTS In a decision analytical model, a simulation model was developed using cohort data from January 1, 2004, to December 31, 2014, in the Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files. All US patients (n = 524 359) who were on the waiting list for at least 1 solid organ and all deceased organ donors during the study period were included in the analyses. All data and statistical analyses were performed from January 30, 2019, to July 31, 2019. MAIN OUTCOMES AND MEASURES Increase in the organs available for donation and life-years gained associated with a 5%, 15%, or 25% increase in deceased donors, based on the published changes from a presumed consent policy. RESULTS This study considered 524 359 unique candidates (aged ≥18 years; 320 908 [61.2%] male) for a solid organ transplant from January 1, 2004, to December 31, 2014. With a base case scenario of a 5% presumed consent-associated increase in donors, the removals (owing to death or illness) from the waiting list for all organs would have an associated 3.2% to 10.4% mean reduction, depending on the random or ideal allocation of new organs to patients on the waiting list. Sensitivity analyses showed that waiting list removals could be decreased up to 52%; however, this reduction was not enough to completely eliminate waiting list removals during the study period. The biggest estimated increases in annual life-years gained associated with a presumed consent policy were in kidney transplant candidates (95% CIs by deceased donor increase: 5% increase, 3440-3466 years; 15% increase, 10 321-10 399 years; 25% increase, 17 201-17 332 years) and liver transplant candidates (95% CIs by deceased donor increase: 5% increase, 898-905 years; 15% increase, 2693-2714 years; 25% increase, 4448-4523 years). Adoption of a presumed consent policy could result in a 4295-year (95% CI, 4277-4313 years) to 11 387-year (95% CI, 11 339-11 435 years) increase in life-years, accounting for the survival advantages associated with a transplant. CONCLUSIONS AND RELEVANCE In this study, presumed consent was estimated to be associated with modest but important improvement in the number of organ transplants and increases in life-years gained for patients awaiting an organ transplant. Further consideration and even debate about the ethical and public policy implications of a presumed consent policy are warranted.
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Affiliation(s)
- Luke J. DeRoos
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Wesley J. Marrero
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | | | - Mariel S. Lavieri
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - David W. Hutton
- Industrial and Operations Engineering, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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Toy M, Hutton DW, Lauer J, Bulterys M, Hutin Y, So S. The Hep B Calculator: an online tool for cost-effectiveness analyses of treatment. Lancet Gastroenterol Hepatol 2019; 4:668. [DOI: 10.1016/s2468-1253(19)30223-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/15/2019] [Indexed: 12/15/2022]
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Townsend T, Blostein F, Doan T, Madson-Olson S, Galecki P, Hutton DW. Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States. Int J Drug Policy 2019; 75:102536. [PMID: 31439388 DOI: 10.1016/j.drugpo.2019.07.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/03/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The U.S. is facing an unprecedented number of opioid-related overdose deaths, and an array of other countries have experienced increases in opioid-related fatalities. In the U.S., naloxone is increasingly distributed to first responders to improve early administration to overdose victims, but its cost-effectiveness has not been studied. Lay distribution, in contrast, has been found to be cost-effective, but rising naloxone prices and increased mortality due to synthetic opioids may reduce cost-effectiveness. We evaluate the cost-effectiveness of increased naloxone distribution to (a) people likely to witness or experience overdose ("laypeople"); (b) police and firefighters; (c) emergency medical services (EMS) personnel; and (d) combinations of these groups. METHODS We use a decision-analytic model to analyze the cost-effectiveness of eight naloxone distribution strategies. We use a lifetime horizon and conduct both a societal analysis (accounting for productivity and criminal justice system costs) and a health sector analysis. We calculate: the ranking of strategies by net monetary benefit; incremental cost-effectiveness ratios; and number of fatal overdoses. RESULTS High distribution to all three groups maximized net monetary benefit and minimized fatal overdoses; it averted 21% of overdose deaths compared to minimum distribution. High distribution to laypeople and one of the other groups comprised the second and third best strategies. The majority of health gains resulted from increased lay distribution. In the societal analysis, every strategy was cost-saving compared to its next-best alternative; cost savings were greatest in the maximum distribution strategy. In the health sector analysis, all undominated strategies were cost-effective. Results were highly robust to deterministic and probabilistic sensitivity analysis. CONCLUSIONS Increasing naloxone distribution to laypeople and first responder groups would maximize health gains and be cost-effective. If feasible, communities should distribute naloxone to all groups; otherwise, distribution to laypeople and one of the first responder groups should be emphasized.
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Affiliation(s)
- Tarlise Townsend
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States; Department of Sociology, University of Michigan, 500 S. State St. #2005, Ann Arbor, MI 48109, United States.
| | - Freida Blostein
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Tran Doan
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Samantha Madson-Olson
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Paige Galecki
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - David W Hutton
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
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Parikh ND, Marrero WJ, Wang J, Steuer J, Tapper EB, Konerman M, Singal AG, Hutton DW, Byon E, Lavieri MS. Projected increase in obesity and non-alcoholic-steatohepatitis-related liver transplantation waitlist additions in the United States. Hepatology 2019; 70:487-495. [PMID: 28833326 DOI: 10.1002/hep.29473] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 08/03/2017] [Accepted: 08/08/2017] [Indexed: 12/19/2022]
Abstract
Nonalcoholic steatohepatitis (NASH) cirrhosis is the fastest growing indication for liver transplantation (LT) in the United States. We aimed to determine the temporal trend behind the rise in obesity and NASH-related additions to the LT waitlist in the United States and make projections for future NASH burden on the LT waitlist. We used data from the Organ Procurement and Transplantation Network database from 2000 to 2014 to obtain the number of NASH-related LT waitlist additions. The obese population in the United States from 2000 to 2014 was estimated using data from the U.S. Census Bureau and the National Health and Nutrition Examination Survey. Based on obesity trends, we established a time lag between obesity prevalence and NASH-related waitlist additions. We used data from the U.S. Census Bureau on population projections from 2016 to 2030 to forecast obesity estimates and NASH-related LT waitlist additions. From 2000 to 2014, the proportion of obese individuals significantly increased 44.9% and the number of NASH-related annual waitlist additions increased from 391 to 1,605. Increase in obesity prevalence was strongly associated with LT waitlist additions 9 years later in derivation and validation cohorts (R2 = 0.9). Based on these data, annual NASH-related waitlist additions are anticipated to increase by 55.4% (1,354-2,104) between 2016 and 2030. There is significant regional variation in obesity rates and in the anticipated increase in NASH-related waitlist additions (P < 0.01). Conclusion: We project a marked increase in demand for LT for NASH given population obesity trends. Continued public health efforts to curb obesity prevalence are needed to reduce the projected future burden of NASH. (Hepatology 2017).
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Affiliation(s)
- Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Wesley J Marrero
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Jingyuan Wang
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Justin Steuer
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Monica Konerman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - David W Hutton
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI.,School of Public Health, University of Michigan, Ann Arbor, MI
| | - Eunshin Byon
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Mariel S Lavieri
- Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
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40
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Tordrup D, Hutin Y, Stenberg K, Lauer JA, Hutton DW, Toy M, Scott N, Bulterys M, Ball A, Hirnschall G. Additional resource needs for viral hepatitis elimination through universal health coverage: projections in 67 low-income and middle-income countries, 2016-30. Lancet Glob Health 2019; 7:e1180-e1188. [PMID: 31353061 DOI: 10.1016/s2214-109x(19)30272-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/17/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The World Health Assembly calls for elimination of viral hepatitis as a public health threat by 2030 (ie, -90% incidence and -65% mortality). However, WHO's 2017 cost projections to achieve health-related Sustainable Development Goals did not include the resources needed for hepatitis testing and treatment. We aimed to estimate the incremental commodity cost of adding scaled up interventions for testing and treatment of hepatitis to WHO's investment scenarios. METHODS We added modelled costs for implementing WHO recommended hepatitis testing and treatment to the 2017 WHO cost projections. We quantified additional requirements for diagnostic tests, medicines, health workers' time, and programme support across 67 low-income and middle-income countries, from 2016-30. A progress scenario scaled up interventions and a more ambitious scenario was modelled to reach elimination by 2030. We used 2018 best available prices of diagnostics and generic medicines. We estimated total costs and the additional investment needed over the projection of the 2016 baseline cost. FINDINGS The 67 countries considered included 230 million people living with hepatitis B virus (HBV) and 52 million people living with hepatitis C virus (HCV; 90% and 73% of the world's total, respectively). Under the progress scenario, 3250 million people (2400 million for HBV and 850 million for HCV) would be tested and 58·2 million people (24·1 million for HBV and 34·1 million for HCV) would be treated (total additional cost US$ 27·1 billion). Under the ambitious scenario, 11 631 million people (5502 million for HBV and 6129 million for HCV) would be tested and 93·8 million people (32·2 million for HBV and 61·6 million for HCV) would be treated (total additional cost $58·7 billion), averting 4·5 million premature deaths and leading to a gain of 51·5 million healthy life-years by 2030. However, if affordable HCV medicines remained inaccessible in 13 countries where medicine patents are protected, the additional cost of the ambitious scenario would increase to $118 billion. Hepatitis elimination would account for a 1·5% increase to the WHO ambitious health-care strengthening scenario costs, avert an additional 4·6% premature deaths, and add an additional 9·6% healthy life-years from 2016-30. INTERPRETATION Access to affordable medicines in all countries will be key to reach hepatitis elimination. This study suggests that elimination is feasible in the context of universal health coverage. It points to commodities as key determinants for the overall price tag and to options for cost reduction strategies. FUNDING WHO, United States Centers for Disease Control and Prevention, Unitaid.
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Affiliation(s)
- David Tordrup
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, University of Utrecht, Utrecht, Netherlands; Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | - Yvan Hutin
- Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland.
| | - Karin Stenberg
- Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | - Jeremy A Lauer
- Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | - David W Hutton
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Mehlika Toy
- School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Nick Scott
- Burnet Institute, Melbourne, VIC, Australia
| | - Marc Bulterys
- Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | - Andrew Ball
- Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
| | - Gottfried Hirnschall
- Department of HIV and Global Hepatitis Programme, and Department of Health Systems Governance and Financing, WHO, Geneva, Switzerland
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Toy M, Hutton DW, So S. Population Health And Economic Impacts Of Reaching Chronic Hepatitis B Diagnosis And Treatment Targets In The US. Health Aff (Millwood) 2019; 37:1033-1040. [PMID: 29985701 DOI: 10.1377/hlthaff.2018.0035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The National Academies of Sciences, Engineering, and Medicine have concluded that eliminating the public health problem of chronic hepatitis B is feasible. We examined the economic and public health impact of reaching the World Health Organization targets of having 90 percent of chronic hepatitis B cases diagnosed and 80 percent being treated by 2030 in the United States with an annual incremental increase in screening and treatment rates. To reach the targets by 2030 would require screening approximately 14.5 million adults in at-risk populations to diagnose an estimated 870,000 undiagnosed cases and would result in substantial health gains: an increase of 16.5 million quality-adjusted life-years (QALYs), and reductions in liver-related deaths of 37 percent and in cases of compensated cirrhosis of 24 percent, decompensated liver cirrhosis of 51 percent, and liver cancer of 35 percent. Achieving the targets by 2030 would be highly cost-effective at $103 per QALY and would be cost-saving if the antiviral drug price were no more than $114 per month. Achieving them by 2025 would be cost-saving and would reduce liver-related deaths by 47 percent.
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Affiliation(s)
- Mehlika Toy
- Mehlika Toy ( ) is a research scientist at the Stanford University School of Medicine, in California
| | - David W Hutton
- David W. Hutton is an associate professor of health management and policy at the University of Michigan, in Ann Arbor
| | - Samuel So
- Samuel So is a professor of surgery at the Stanford University School of Medicine
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Bettampadi D, Boulton ML, Power LE, Hutton DW. Are community health workers cost-effective for childhood vaccination in India? Vaccine 2019; 37:2942-2951. [PMID: 31010713 DOI: 10.1016/j.vaccine.2019.04.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Accredited Social Health Activists (ASHAs) are female community health workers whose primary role is to promote utilization of primary healthcare services and improve sanitation in rural areas and are financially incentivized for services provided. Prior studies evaluating ASHAs have been largely qualitative, and assess their knowledge, skills, and practice. Globally, there have been very few studies that have quantitatively assessed community health workers. We analyzed the cost effectiveness of ASHAs in facilitating measles vaccination among children under 5 years during 2012-2013. METHODS We utilized Markov modeling simulating a cohort of children in villages with and without ASHAs. We extrapolated the health states to a lifetime of 68 years to estimate the effects of ASHA intervention. Measles vaccination rates were obtained from 2013 District Level Household and Facilities Survey 4. Other parameter estimates were obtained from a review of relevant literature. RESULTS ASHA intervention was highly cost effective at $162 per DALY averted compared to no ASHA and remained cost effective with the ASHA incentive increased from $2 to $15, across the range of probabilities and cost parameters. Analyses were sensitive to probability of death due to childhood pneumonia, susceptibility to measles after one dose measles vaccine, and probability of pneumonia after measles infection. CONCLUSION ASHAs were cost-effective under a wide range of scenarios even when a single health outcome such as measles vaccination was considered. The Government of India and individual state governments of India should consider increasing the incentives provided to ASHAs.
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Affiliation(s)
- Deepti Bettampadi
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA.
| | - Matthew L Boulton
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA; Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Laura E Power
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA; Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
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Hutton DW, Krein SL, Saint S, Graves N, Kolli A, Lynem R, Mody L. Economic Evaluation of a Catheter-Associated Urinary Tract Infection Prevention Program in Nursing Homes. J Am Geriatr Soc 2018; 66:742-747. [PMID: 29489017 DOI: 10.1111/jgs.15316] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- David W Hutton
- Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sanjay Saint
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Nicholas Graves
- School of Public Health and Biomedical Innovation, Queensland University of Technology, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Australia
| | - Ajay Kolli
- Cellular and Molecular Biology, University of Michigan, Ann Arbor, Michigan
| | - Raymond Lynem
- Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Lona Mody
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Division of Geriatric and Palliative Care Medicine, School of Medicine, University of Michigan Ann Arbor, Michigan.,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Rattay T, Dumont IP, Heinzow HS, Hutton DW. Cost-Effectiveness of Access Expansion to Treatment of Hepatitis C Virus Infection Through Primary Care Providers. Gastroenterology 2017; 153:1531-1543.e2. [PMID: 29074450 DOI: 10.1053/j.gastro.2017.10.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 08/28/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND & AIMS Chronic hepatitis C virus (HCV) infection is a major burden on individuals and health care systems. The Extension for Community Healthcare Outcomes (Project ECHO) enables primary care providers to deliver best-practice care for complex conditions to underserved populations. The US Congress passed the ECHO Act in late 2016, requiring the Department of Health and Human Services to investigate the model. We performed a cost-effectiveness analysis to assess diagnosis and treatment of HCV infection in a primary care patient panel with and without the implementation of Project ECHO. METHODS We used Markov models to simulate disease progression, quality of life, and life expectancy among individuals with HCV infection and for the general population. Data from the University of New Mexico's ECHO operation for HCV show an increase in treatment rates. Corresponding increases in survival, quality-adjusted life years (QALYs), costs, and resulting budget impact between ECHO and non-ECHO patients with HCV were then compared. RESULTS Project ECHO increased costs and QALYs. The incremental cost-effectiveness ratio of ECHO was $10,351 per QALY compared with the status quo; >99.9% of iterations fell below the willingness-to-pay threshold of $100,000 per QALY. We were unable to confirm whether the increase in rates of treatment associated with Project ECHO were due to increased or more targeted screening, higher adherence, or access to treatment. Our sensitivity analyses show that the results are largely independent of the cause. Budget impact analysis shows payers would have to invest an additional $339.54 million over a 5-year period to increase treatment by 4446 patients, per 1 million covered lives. CONCLUSION Using a simulated primary care patient panel, we showed that Project ECHO is a cost-effective way to find and treat patients with HCV infection at scale using existing primary care providers. This approach could substantially reduce the burden of chronic HCV infection in the United States, but high budgetary costs suggest that incremental rollout of ECHO may be best.
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Affiliation(s)
- Thilo Rattay
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan; Medical School, University of Münster, Münster, Germany.
| | - Ian P Dumont
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan; Ross School of Business, University of Michigan, Ann Arbor, Michigan
| | - Hauke S Heinzow
- University Hospital, Medical Clinic B - Gastroenterology and Hepatology, University of Münster, Münster, Germany
| | - David W Hutton
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
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Hutton DW, Stein JD, Bressler NM, Jampol LM, Browning D, Glassman AR. Cost-effectiveness of Intravitreous Ranibizumab Compared With Panretinal Photocoagulation for Proliferative Diabetic Retinopathy: Secondary Analysis From a Diabetic Retinopathy Clinical Research Network Randomized Clinical Trial. JAMA Ophthalmol 2017; 135:576-584. [PMID: 28492920 DOI: 10.1001/jamaophthalmol.2017.0837] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance The Diabetic Retinopathy Clinical Research Network Protocol S randomized clinical trial results suggest that ranibizumab is a reasonable treatment alternative to panretinal photocoagulation (PRP) when managing proliferative diabetic retinopathy (PDR), with or without concomitant baseline diabetic macular edema (DME). However, ranibizumab injections are costly. Thus, it would be useful to examine the relative cost-effectiveness of these 2 treatment modalities. Objective To evaluate incremental cost-effectiveness ratios of 0.5-mg ranibizumab therapy vs PRP for PDR. Design, Setting, and Participants Preplanned secondary analysis using efficacy, safety, and resource utilization data through 2 years of follow-up at 55 US sites for 213 adults with PDR. Data were collected from February 2012 to January 2015. Interventions Intravitreous 0.5-mg ranibizumab at baseline and as frequently as every 4 weeks based on a structured retreatment protocol or PRP at baseline for PDR. Eyes in both groups could receive ranibizumab for concomitant DME. Main Outcomes and Measures Incremental cost-effectiveness ratios of ranibizumab compared with PRP evaluated within 2 prespecified subgroups for the study eye: with baseline vision-impairing (Snellen equivalent 20/32 or worse) DME and without baseline vision-impairing DME. Results The study included 305 adults with PDR, the mean age was 52 years, 44% were women, and 52% were white. Of the 46 participants with PDR and vision-impairing DME at baseline, 21 were assigned to the ranibizumab group and 25 to the PRP group (plus ranibizumab for DME). Among the remaining participants without baseline vision-impairing DME, 80 and 87 were in the ranibizumab and PRP groups, respectively. For participants with and without baseline vision-impairing DME, the incremental cost-effectiveness ratios of ranibizumab therapy compared with PRP were $55 568/quality-adjusted life-year and $662 978/quality-adjusted life-year, respectively, over 2 years. Conclusions and Relevance Over 2 years, compared with PRP, 0.5-mg ranibizumab as given in this trial is within the $50 000/quality-adjusted life-year to $150 000/quality-adjusted life-year range frequently cited as cost-effective in the United States for eyes presenting with PDR and vision-impairing DME, but not for those with PDR without vision-impairing DME. Trial Registration Clinicaltrials.gov Identifier: NCT01489189.
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Affiliation(s)
- David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor2Department of Industrial and Operations Engineering, University of Michigan College of Engineering, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Joshua D Stein
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor4Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
| | - Neil M Bressler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland6Editor, JAMA Ophthalmology
| | - Lee M Jampol
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David Browning
- Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina
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Parikh ND, Singal AG, Hutton DW. Cost effectiveness of regorafenib as second-line therapy for patients with advanced hepatocellular carcinoma. Cancer 2017; 123:3725-3731. [DOI: 10.1002/cncr.30863] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 05/05/2017] [Accepted: 05/10/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Neehar D. Parikh
- Department of Internal Medicine; University of Michigan; Ann Arbor Michigan
| | - Amit G. Singal
- Department of Internal Medicine; University of Texas Southwestern; Dallas Texas
| | - David W. Hutton
- University of Michigan School of Public Health; Ann Arbor Michigan
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47
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Freeman JV, Hutton DW, Barnes GD, Zhu RP, Owens DK, Garber AM, Go AS, Hlatky MA, Heidenreich PA, Wang PJ, Al-Ahmad A, Turakhia MP. Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.115.003407. [PMID: 27307517 DOI: 10.1161/circep.115.003407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/31/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data. METHODS AND RESULTS We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20 486 and $23 422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50 000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation. CONCLUSIONS Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice.
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Affiliation(s)
- James V Freeman
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.).
| | - David W Hutton
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Geoffrey D Barnes
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Ruo P Zhu
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Douglas K Owens
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Alan M Garber
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Alan S Go
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Mark A Hlatky
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Paul A Heidenreich
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Paul J Wang
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Amin Al-Ahmad
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
| | - Mintu P Turakhia
- From the Yale University School of Medicine, New Haven, CT (J.V.F.); University of Michigan, Ann Arbor (D.W.H., G.D.B., R.P.Z.); VA Palo Alto Health Care System, CA (D.K.O., P.A.H., M.P.T.); Stanford University School of Medicine, CA (D.K.O., A.S.G., M.A.H., P.A.H., P.J.W., M.P.T.); Harvard University, Cambridge, MA (A.M.G.); Kaiser Permanente Northern California Division of Research, Oakland (A.S.G.); University of California, San Francisco (A.S.G.); and Texas Cardiac Arrhythmia Institute, Austin (A.A.-A.)
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48
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Ross EL, Hutton DW, Stein JD, Bressler NM, Jampol LM, Glassman AR. Cost-effectiveness of Aflibercept, Bevacizumab, and Ranibizumab for Diabetic Macular Edema Treatment: Analysis From the Diabetic Retinopathy Clinical Research Network Comparative Effectiveness Trial. JAMA Ophthalmol 2017; 134:888-96. [PMID: 27280850 DOI: 10.1001/jamaophthalmol.2016.1669] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Anti-vascular endothelial growth factor (VEGF) medicines have revolutionized diabetic macular edema (DME) treatment. A recent randomized clinical trial comparing anti-VEGF agents for patients with decreased vision from DME found that at 1 year aflibercept (2.0 mg) achieved better visual outcomes than repackaged (compounded) bevacizumab (1.25 mg) or ranibizumab (0.3 mg); the worse the starting vision, the greater the treatment benefit with aflibercept. However, aflibercept and ranibizumab, respectively, are approximately 31 and 20 times more expensive than bevacizumab. OBJECTIVE To examine the incremental cost-effectiveness ratios (ICERs) of aflibercept, bevacizumab, and ranibizumab for the treatment of DME. DESIGN, SETTING, AND PARTICIPANTS Post hoc analysis of efficacy, safety, and resource utilization data at 1-year follow-up from the Diabetic Retinopathy Clinical Research Network Comparative Effectiveness Trial. Patients were enrolled from August 22, 2012, through August 28, 2013, and analysis was performed from August 21, 2014, through November 7, 2015. MAIN OUTCOMES AND MEASURES The ICERs for all trial participants and subgroups with baseline vision of approximate Snellen equivalent 20/32 to 20/40 (better vision) and baseline vision of approximate Snellen equivalent 20/50 or worse (worse vision). One-year trial data were used to calculate cost-effectiveness for 1 year for the 3 anti-VEGF agents; mathematical modeling was then used to project 10-year cost-effectiveness results. RESULTS The study included 624 participants (mean [SD] age, 60.6 [10.5] years; 45.7% female; 65.5% white), 209 in the aflibercept group, 207 in the bevacizumab group, and 208 in the ranibizumab group. For all participants, during 1 year, the ICERs of aflibercept and ranibizumab compared with bevacizumab were $1 110 000 per quality-adjusted life-year (QALY) and $1 730 000 per QALY, respectively. During 10 years, they were $349 000 per QALY and $603 000 per QALY, respectively. Compared with ranibizumab, aflibercept's ICER was $648 000 per QALY at 1 year and $203 000 per QALY at 10 years. For the subgroup with worse baseline vision, the 10-year ICERs of aflibercept and ranibizumab compared with bevacizumab were $287 000 per QALY and $817 000 per QALY, respectively. In eyes with decreased vision from DME, treatment costs of aflibercept and ranibizumab would need to decrease by 69% and 80%, respectively, to reach a cost-effectiveness threshold of $100 000 per QALY compared with bevacizumab during a 10-year horizon; for the subgroup with worse baseline vision, the costs would need to decrease by 62% and 84%, respectively. CONCLUSIONS AND RELEVANCE Aflibercept (2.0 mg) and ranibizumab (0.3 mg) are not cost-effective relative to bevacizumab for treatment of DME unless their prices decrease substantially. These results highlight the challenges that physicians, patients, and policymakers face when safety and efficacy results are at odds with cost-effectiveness results.
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Affiliation(s)
- Eric L Ross
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor2Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor3Department of Industrial and Operations Engineering, University of Michigan College of Engineering, Ann Arbor4Institute for Healthcare Policy and Innovat
| | - Joshua D Stein
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor2Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor4Institute for Healthcare Policy and Innovation, Univers
| | - Neil M Bressler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland6Editor, JAMA Ophthalmology
| | - Lee M Jampol
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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49
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Bressler NM, Glassman AR, Hutton DW. Controversies in Using Off-Label Intravitreous Bevacizumab for Patients With Diabetic Macular Edema-Reply. JAMA Ophthalmol 2017; 135:291-292. [PMID: 28152135 DOI: 10.1001/jamaophthalmol.2016.5686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Neil M Bressler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland2Editor, JAMA Ophthalmology
| | | | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor5Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor6College of Engineering, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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50
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Maurer KA, Chen HF, Wagner AL, Hegde ST, Patel T, Boulton ML, Hutton DW. Cost-effectiveness analysis of pneumococcal vaccination for infants in China. Vaccine 2016; 34:6343-6349. [PMID: 27810315 DOI: 10.1016/j.vaccine.2016.10.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/15/2016] [Accepted: 10/19/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although China has a high burden of pneumococcal disease among young children, the government does not administer publicly-funded pneumococcal conjugate vaccines (PCV) through its Expanded Program on Immunization (EPI). We evaluated the cost-effectiveness of publicly-funded PCV-7, PCV-10, and PCV-13 vaccination programs for infants in China. METHODS Using a Markov model, we simulated a cohort of 16 million Chinese infants to estimate the impact of PCV-7, PCV-10, and PCV-13 vaccination programs from a societal perspective. We extrapolated health states to estimate the effects of the programs over the course of a lifetime of 75years. Parameters in the model were derived from a review of the literature. RESULTS We found that PCV-7, PCV-10, and PCV-13 vaccination programs would be cost-effective compared to no vaccination. However, PCV-13 had the lowest incremental cost-effectiveness ratio ($11,464/QALY vs $16,664/QALY for PCV-10 and $18,224/QALY for PCV-7) due to a reduction in overall costs. Our sensitivity analysis revealed that the incremental cost-effectiveness ratios were most sensitive to the utility of acute otitis media, the cost of PCV-13, and the incidence of pneumonia and acute otitis media. CONCLUSIONS The Chinese government should take steps to reduce the burden of pneumococcal diseases among young children through the inclusion of a pneumococcal conjugate vaccine in its EPI. Although all vaccinations would be cost-effective, PCV-13 would save more costs to the healthcare system and would be the preferred strategy.
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Affiliation(s)
- Kristin A Maurer
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Huey-Fen Chen
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Abram L Wagner
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Sonia T Hegde
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Tejasi Patel
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
| | - Matthew L Boulton
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States; Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States; Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, United States.
| | - David W Hutton
- Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States.
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