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Dadwani RS, Wan W, Skandari MR, Huang ES. Expected Health Benefits of SGLT-2 Inhibitors and GLP-1 Receptor Agonists in Older Adults. MDM Policy Pract 2023; 8:23814683231187566. [PMID: 37492502 PMCID: PMC10363885 DOI: 10.1177/23814683231187566] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 06/06/2023] [Indexed: 07/27/2023] Open
Abstract
Background. Older and sicker adults with type 2 diabetes (T2D) were underrepresented in randomized trials of glucagon-like peptide 1 receptor-agonist (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2I), and thus, health benefits are uncertain in this population. Objective. To assess the impact of age, health status, and life expectancy in older adults with T2D on health benefits of GLP1RA and SGLT2I. Design. We used the United Kingdom Prospective Diabetes Study (UKPDS) model to simulate lifetime health outcomes. We calibrated the UKPDS model to improve mortality prediction in older adults using a common geriatric prognostic index. Participants. National Health and Nutrition Examination Survey 2013-2018 participants 65 y and older with T2D, eligible for GLP1RA or SGLT2I according to American Diabetes Association guidelines. Interventions. GLP1RA or SGLT2I use versus no additional medication. Main Measures. Lifetime complications and weighted life-years (LYs) and quality-adjusted life-years (QALYs) across overall treatment arms and life expectancies. Key Results. The overall older adult population was predicted to experience significant health benefits from GLP1RA (+0.29 LY [95% confidence interval: 0.27, 0.31], +0.15 QALYs [0.14, 0.16]) and SGLT2I (+0.26 LY [0.24, 0.28], +0.13 QALYs [0.12, 0.14]) as compared with no added medication. However, expected benefits declined in subgroups with shorter life expectancies. Participants with <4 y of life expectancy had minimal gains of <0.05 LY and <0.03 QALYs from added medication. Accounting for injection-related disutility, GLP1RA use reduced QALYs (-0.03 QALYs [-0.04, -0.02]). Conclusions. While GLP1RA and SGLT2I have substantial health benefits for many older adults with type 2 diabetes, benefits are not clinically significant in patients with <4 y of life expectancy. Life expectancy and patient preferences are important considerations when prescribing newer diabetes medications. Highlights On average, older adults benefit significantly from SGLT2I and GLP1RA use. However, the benefits of these drugs are not clinically significant among older patients with life expectancy less than 4 y.There is potential harm in injectable GLP1RA use in the oldest categories of adults with type 2 diabetes.Heterogeneity in life expectancy and patient preferences for injectable versus oral medications are important to consider when prescribing newer diabetes medications.
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Affiliation(s)
- Rahul S. Dadwani
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - M. Reza Skandari
- Imperial College Business School, Imperial College London, London, UK
| | - Elbert S. Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Abstract
BACKGROUND Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care. OBJECTIVE To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. DESIGN Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels. PARTICIPANTS Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017-2018 National Health and Nutrition Examination Survey. MAIN MEASURES The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care. KEY RESULTS PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management). CONCLUSIONS PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.
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Affiliation(s)
- Justin Porter
- Department of Medicine, University of Chicago, Chicago, IL, USA.
| | - Cynthia Boyd
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M Reza Skandari
- Imperial College Business School, Centre for Health Economics & Policy Innovation, Imperial College London, London, UK
| | - Neda Laiteerapong
- Departments of Medicine & Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
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Choi JG, Winn AN, Skandari MR, Franco MI, Staab EM, Alexander J, Wan W, Zhu M, Huang ES, Philipson L, Laiteerapong N. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists : A Cost-Effectiveness Study. Ann Intern Med 2022; 175:1392-1400. [PMID: 36191315 PMCID: PMC10155215 DOI: 10.7326/m21-2941] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs. OBJECTIVE To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists. DESIGN Individual-level Monte Carlo-based Markov model. DATA SOURCES Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey. TARGET POPULATION Drug-naive U.S. patients with type 2 diabetes. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION First-line SGLT2 inhibitors or GLP1 receptor agonists. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin. RESULTS OF SENSITIVITY ANALYSIS By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists. LIMITATION U.S. population and costs not generalizable internationally. CONCLUSION As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would improve type 2 diabetes outcomes, but their costs would need to fall by at least 70% to be cost-effective. PRIMARY FUNDING SOURCE American Diabetes Association.
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Affiliation(s)
- Jin G Choi
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - M Reza Skandari
- Centre for Health Economics & Policy Innovation, Imperial College Business School, Imperial College London, London, United Kingdom (M.R.S.)
| | - Melissa I Franco
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Erin M Staab
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Jason Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Wen Wan
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Mengqi Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Elbert S Huang
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Louis Philipson
- Sections of Adult and Pediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois (L.P.)
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
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Nair V, Auger S, Kochanny S, Howard FM, Ginat D, Pasternak-Wise O, Juloori A, Koshy M, Izumchenko E, Agrawal N, Rosenberg A, Vokes EE, Skandari MR, Pearson AT. Development and Validation of a Decision Analytical Model for Posttreatment Surveillance for Patients With Oropharyngeal Carcinoma. JAMA Netw Open 2022; 5:e227240. [PMID: 35416988 PMCID: PMC9008506 DOI: 10.1001/jamanetworkopen.2022.7240] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based. OBJECTIVES To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status. DESIGN, SETTING, AND PARTICIPANTS In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon's National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020. MAIN OUTCOMES AND MEASURES Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery. RESULTS Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies based on reimbursement guidelines, the model-optimized regimens found disease a mean of 1.8 months (95% CI, 1.3-2.3 months) earlier. CONCLUSIONS AND RELEVANCE Optimized, risk-stratified surveillance regimens consistently outperformed nonoptimized strategies. These gains were obtained without requiring any additional imaging studies. This approach to risk-stratified surveillance optimization is generalizable to a broad range of tumor types and risk factors.
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Affiliation(s)
- Vivek Nair
- University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Samuel Auger
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Sara Kochanny
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Frederick M. Howard
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Daniel Ginat
- Department of Radiology, University of Chicago, Chicago, Illinois
| | | | - Aditya Juloori
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Matthew Koshy
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Evgeny Izumchenko
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Nishant Agrawal
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Ari Rosenberg
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Everett E. Vokes
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - M. Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, Imperial College London, London, United Kingdom
| | - Alexander T. Pearson
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. Longer-term Benefits and Risks of Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes: a Systematic Review and Meta-analysis. J Gen Intern Med 2022; 37:439-448. [PMID: 34850334 PMCID: PMC8811049 DOI: 10.1007/s11606-021-07227-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks' duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Fifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD - 0.55%, 95% CI - 0.62, - 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications. DISCUSSION We found that SGLT2Is led to durable reductions in cardiovascular risk factors compared to both placebo and other anti-hyperglycemic medications. Reductions in macrovascular complications and mortality were only observed in comparisons with placebo, although trials comparing SGLT2Is vs. other anti-hyperglycemic medications were not designed to assess longer-term outcomes.
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Affiliation(s)
- Jason T Alexander
- Department of Medicine, University of Chicago, Chicago, IL, USA.
- , Chicago, USA.
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Melissa Franco
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, UK
| | - Shari Bolen
- Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nisa M Maruthur
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elbert S Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kathryn Gunter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Brittany Bindon
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sanjay Jumani
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. The Longer-Term Benefits and Harms of Glucagon-Like Peptide-1 Receptor Agonists: a Systematic Review and Meta-Analysis. J Gen Intern Med 2022; 37:415-438. [PMID: 34508290 PMCID: PMC8810987 DOI: 10.1007/s11606-021-07105-9] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov (inception-July 2019) for randomized controlled trials ≥ 52 weeks' duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Forty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80-0.90), macrovascular complications (including stroke, RR 0.86, 0.78-0.95), and mortality (RR 0.89, 0.84-0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons. DISCUSSION GLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other anti-hyperglycemic medications. GLP1RAs also reduced MACE, stroke, renal events, and mortality in comparisons with placebo; however, analyses were inconclusive for comparisons with other anti-hyperglycemic medications. Given the high costs of GLP1RAs, the lack of long-term evidence comparing GLP1RAs to other anti-hyperglycemic medications has significant policy and clinical practice implications.
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Affiliation(s)
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Melissa Franco
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, UK
| | - Shari Bolen
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elbert S Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kathryn Gunter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Brittany Bindon
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sanjay Jumani
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Miksanek TJ, Skandari MR, Ham SA, Lee WW, Press VG, Brown MT, Laiteerapong N. The Productivity Requirements of Implementing a Medical Scribe Program. Ann Intern Med 2021; 174:1-7. [PMID: 33017564 DOI: 10.7326/m20-0428] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/22/2022] Open
Abstract
BACKGROUND Economic analyses of medical scribes have been limited to individual, specialty-specific clinics. OBJECTIVE To determine the number of additional patient visits various specialties would need to recover the costs of implementing scribes in their practice at 1 year. DESIGN Modeling study based on 2015 data from the Centers for Medicare & Medicaid Services (CMS) and National Ambulatory Medical Care Survey. Scribe costs were based on literature review and a third-party contractor model. Revenue was calculated from direct visit billing, CPT (Current Procedural Terminology) billing, and data from the National Ambulatory Medical Care Survey. DATA SOURCES 2015 data from CMS and the National Ambulatory Medical Care Survey. TARGET POPULATION Health care providers. TIME HORIZON 1 year. PERSPECTIVE Office-based clinic. OUTCOME MEASURES The number of additional patient visits a physician must have to recover the costs of a scribe program at 1 year. RESULTS OF BASE-CASE ANALYSIS An average of 1.34 additional new patient visits per day (295 per year) were required to recover scribe costs (range, 0.89 [cardiology] to 1.80 [orthopedic surgery] new patient visits per day). For returning patients, an average of 2.15 additional visits per day (472 per year) were required (range, 1.65 [cardiology] to 2.78 [orthopedic surgery] returning visits per day). The addition of 2 new patient (or 3 returning) visits per day was profitable for all specialties. RESULTS OF SENSITIVITY ANALYSIS Results were not sensitive to most inputs, with the exception of hourly scribe cost and inclusion of CPT revenue. LIMITATION Use of Medicare data and failure to account for indirect costs, downstream revenue, or changes in documentation quality. CONCLUSION For all specialties, modest increases in productivity due to scribes may allow physicians to see more patients and offset scribe costs, making scribe programs revenue-neutral. PRIMARY FUNDING SOURCE University of Chicago Medicine's Center for Healthcare Delivery Science and Innovation and the Bucksbaum Institute.
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Affiliation(s)
- Tyler J Miksanek
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois (T.J.M., W.W.L., V.G.P., N.L.)
| | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, Imperial College London, London, United Kingdom (M.R.S.)
| | - Sandra A Ham
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois (S.A.H.)
| | - Wei Wei Lee
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois (T.J.M., W.W.L., V.G.P., N.L.)
| | - Valerie G Press
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois (T.J.M., W.W.L., V.G.P., N.L.)
| | | | - Neda Laiteerapong
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois (T.J.M., W.W.L., V.G.P., N.L.)
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Dadwani RS, Skandari MR, GoodSmith MS, Phillips LS, Rhee MK, Laiteerapong N. Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes. Diabet Med 2020; 37:1935-1943. [PMID: 32449198 PMCID: PMC7572743 DOI: 10.1111/dme.14330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
AIM To evaluate the U.S. population-level impact of two alternatives for initial type 2 diabetes screening [opportunistic random plasma glucose (RPG) > 6.7 mmol/l and a 1-h 50-g glucose challenge test (GCT) > 8.9 mmol/l] compared with American Diabetes Association (ADA)-recommended tests. METHODS Using a sample (n = 1471) from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 that represented 145 million U.S. adults at high risk for developing type 2 diabetes, we simulated a two-test screening process. We compared ADA-recommended screening tests [fasting plasma glucose (FPG), 2-h 75-g oral glucose tolerance test (OGTT), HbA1c ] vs. initial screening with opportunistic RPG or GCT (followed by FPG, OGTT or HbA1c ). After simulation, participants were entered into an individual-level Monte Carlo-based Markov lifetime outcomes model. Primary outcomes were representative number of U.S. adults correctly identified with type 2 diabetes, societal lifetime costs and quality-adjusted life years (QALYs). RESULTS In NHANES 2013-2014, 100 individuals had undiagnosed diabetes [weighted estimate: 8.4 million, standard error (se): 1.1 million]. Among ADA-recommended screening tests, FPG followed by OGTT (FPG-OGTT) was most sensitive, identifying 35 individuals with undiagnosed diabetes (weighted estimate: 3.2 million, se: 0.9 million). Four alternative screening strategies performed superior to FPG-OGTT, with RPG followed by OGTT being the most sensitive overall, identifying 72 individuals with undiagnosed diabetes (weighted estimate: 6.1 million, se: 1.0 million). There was no increase in average lifetime costs and comparable QALYs. CONCLUSIONS Initial screening using opportunistic RPG or a GCT may identify more U.S. adults with type 2 diabetes without increasing societal costs.
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Affiliation(s)
- R S Dadwani
- Pritzker School of Medicine, Chicago, IL, USA
| | - M R Skandari
- Imperial College Business School, Imperial College London, London, UK
| | | | - L S Phillips
- Division of Endocrinology and Metabolism, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - M K Rhee
- Division of Endocrinology and Metabolism, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - N Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
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GoodSmith MS, Skandari MR, Huang ES, Naylor RN. The Impact of Biomarker Screening and Cascade Genetic Testing on the Cost-Effectiveness of MODY Genetic Testing. Diabetes Care 2019; 42:2247-2255. [PMID: 31558549 PMCID: PMC6868460 DOI: 10.2337/dc19-0486] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 09/10/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In the U.S., genetic testing for maturity-onset diabetes of the young (MODY) is frequently delayed because of difficulty with insurance coverage. Understanding the economic implications of clinical genetic testing is imperative to advance precision medicine for diabetes. The objective of this article is to assess the cost-effectiveness of genetic testing, preceded by biomarker screening and followed by cascade genetic testing of first-degree relatives, for subtypes of MODY in U.S. pediatric patients with diabetes. RESEARCH DESIGN AND METHODS We used simulation models of distinct forms of diabetes to forecast the clinical and economic consequences of a systematic genetic testing strategy compared with usual care over a 30-year time horizon. In the genetic testing arm, patients with MODY received treatment changes (sulfonylureas for HNF1A- and HNF4A-MODY associated with a 1.0% reduction in HbA1c; no treatment for GCK-MODY). Study outcomes included costs, life expectancy (LE), and quality-adjusted life years (QALY). RESULTS The strategy of biomarker screening and genetic testing was cost-saving as it increased average quality of life (+0.0052 QALY) and decreased costs (-$191) per simulated patient relative to the control arm. Adding cascade genetic testing increased quality-of-life benefits (+0.0081 QALY) and lowered costs further (-$735). CONCLUSIONS A combined strategy of biomarker screening and genetic testing for MODY in the U.S. pediatric diabetes population is cost-saving compared with usual care, and the addition of cascade genetic testing accentuates the strategy's benefits. Widespread implementation of this strategy could improve the lives of patients with MODY while saving the health system money, illustrating the potential population health benefits of personalized medicine.
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Affiliation(s)
| | - M Reza Skandari
- Imperial College Business School, Imperial College London, London, U.K
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Rochelle N Naylor
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL
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10
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Wan W, Skandari MR, Minc A, Nathan AG, Zarei P, Winn AN, O'Grady M, Huang ES. Cost-effectiveness of Initiating an Insulin Pump in T1D Adults Using Continuous Glucose Monitoring Compared with Multiple Daily Insulin Injections: The DIAMOND Randomized Trial. Med Decis Making 2019; 38:942-953. [PMID: 30403576 DOI: 10.1177/0272989x18803109] [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] [Indexed: 01/22/2023]
Abstract
BACKGROUND The economic impact of both continuous glucose monitoring (CGM) and insulin pumps (continuous subcutaneous insulin infusion [CSII]) in type 1 diabetes (T1D) have been evaluated separately. However, the cost-effectiveness of adding CSII to existing CGM users has not yet been assessed. OBJECTIVE The aim of this study was to evaluate the societal cost-effectiveness of CSII versus continuing multiple daily injections (MDI) in adults with T1D already using CGM. METHODS In the second phase of the DIAMOND trial, 75 adults using CGM were randomized to either CGM+CSII or CGM+MDI (control) and surveyed at baseline and 28 weeks. We performed within-trial and lifetime cost-effectiveness analyses (CEAs) and estimated lifetime costs and quality-adjusted life-years (QALYs) via a modified Sheffield T1D model. RESULTS Within the trial, the CGM+CSII group had a significant reduction in quality of life from baseline (-0.02 ± 0.05 difference in difference [DiD]) compared with controls. Total per-person 28-week costs were $8,272 (CGM+CSII) versus $5,623 (CGM+MDI); the difference in costs was primarily attributable to pump use ($2,644). Pump users reduced insulin intake (-12.8 units DiD) but increased the use of daily number of test strips (+1.2 DiD). Pump users also increased time with glucose in range of 70 to 180 mg/dL but had a higher HbA1c (+0.13 DiD) and more nonsevere hypoglycemic events. In the lifetime CEA, CGM+CSII would increase total costs by $112,045 DiD, decrease QALYs by 0.71, and decrease life expectancy by 0.48 years. CONCLUSIONS Based on this single trial, initiating an insulin pump in adults with T1D already using CGM was associated with higher costs and reduced quality of life. Additional evidence regarding the clinical effects of adopting combinations of new technologies from trials and real-world populations is needed to confirm these findings.
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Affiliation(s)
- Wen Wan
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - M Reza Skandari
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Alexa Minc
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Aviva G Nathan
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Parmida Zarei
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Aaron N Winn
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Michael O'Grady
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL (WW, MRS, AM, AGN, PZ, ESH).,School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI (ANW).,National Opinion Research Center, University of Chicago, Chicago, IL (MO)
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11
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Wan W, Nathan AG, Skandari MR, Zarei P, Reid MW, Raymond JK, Huang ES. Cost-effectiveness of Shared Telemedicine Appointments in Young Adults With T1D: CoYoT1 Trial. Diabetes Care 2019; 42:1589-1592. [PMID: 31189564 PMCID: PMC6647044 DOI: 10.2337/dc19-0363] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/02/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Young adults with type 1 diabetes (T1D) often struggle to achieve glycemic control and maintain routine clinic visits. We aimed to evaluate the societal cost-effectiveness of the Colorado young adults with T1D (CoYoT1) Clinic, an innovative care model of shared medical appointments through home telehealth. RESEARCH DESIGN AND METHODS Patients self-selected into the CoYoT1 (N = 42) or usual care (N = 39) groups. RESULTS Within the trial, we found no significant differences in 9-month quality-adjusted life; however, the control group had a larger decline from baseline in utility than the CoYoT1 group, indicating a quality of life (QoL) benefit of the intervention (difference in difference mean ± SD: 0.04 ± 0.09; P = 0.03). There was no significant difference in total costs. The CoYoT1 group had more study-related visits but fewer nonstudy office visits and hospitalizations. CONCLUSIONS: The CoYoT1 care model may help young adults with T1D maintain a higher QoL with no increase in costs.
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Affiliation(s)
- Wen Wan
- Section of General Internal Medicine, The University of Chicago, Chicago, IL
| | - Aviva G Nathan
- Section of General Internal Medicine, The University of Chicago, Chicago, IL
| | - M Reza Skandari
- Section of General Internal Medicine, The University of Chicago, Chicago, IL
| | - Parmida Zarei
- Section of General Internal Medicine, The University of Chicago, Chicago, IL
| | - Mark W Reid
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Jennifer K Raymond
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Elbert S Huang
- Section of General Internal Medicine, The University of Chicago, Chicago, IL
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12
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Wan W, Skandari MR, Minc A, Nathan AG, Winn A, Zarei P, O'Grady M, Huang ES. Cost-effectiveness of Continuous Glucose Monitoring for Adults With Type 1 Diabetes Compared With Self-Monitoring of Blood Glucose: The DIAMOND Randomized Trial. Diabetes Care 2018; 41:1227-1234. [PMID: 29650803 PMCID: PMC5961392 DOI: 10.2337/dc17-1821] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [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: 08/30/2017] [Accepted: 02/27/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study evaluated the societal cost-effectiveness of continuous glucose monitoring (CGM) in patients with type 1 diabetes (T1D) using multiple insulin injections. RESEARCH DESIGN AND METHODS In the Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes (DIAMOND) trial, 158 patients with T1D and HbA1c ≥7.5% were randomized in a 2:1 ratio to CGM or control. Participants were surveyed at baseline and 6 months. Within-trial and lifetime cost-effectiveness analyses were conducted. A modified Sheffield T1D policy model was used to simulate T1D complications. The main outcome was cost per quality-adjusted life-year (QALY) gained. RESULTS Within the 6-month trial, the CGM group had similar QALYs to the control group (0.462 ± 0.05 vs. 0.455 ± 0.06 years, P = 0.61). The total 6-month costs were $11,032 (CGM) vs. $7,236 (control). The CGM group experienced reductions in HbA1c (0.60 ± 0.74% difference in difference [DiD]), P < 0.01), the daily rate of nonsevere hypoglycemia events (0.07 DiD, P = 0.013), and daily test strip use (0.55 ± 1.5 DiD, P = 0.04) compared with the control group. In the lifetime analysis, CGM was projected to reduce the risk of T1D complications and increase QALYs by 0.54. The incremental cost-effectiveness ratio (ICER) was $98,108 per QALY for the overall population. By extending sensor use from 7 to 10 days in a real-world scenario, the ICER was reduced to $33,459 per QALY. CONCLUSIONS For adults with T1D using multiple insulin injections and still experiencing suboptimal glycemic control, CGM is cost-effective at the willingness-to-pay threshold of $100,000 per QALY, with improved glucose control and reductions in nonsevere hypoglycemia.
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Affiliation(s)
- Wen Wan
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - M Reza Skandari
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Alexa Minc
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Aviva G Nathan
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI
| | - Parmida Zarei
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Michael O'Grady
- National Opinion Research Center, University of Chicago, Chicago, IL
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL
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13
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Laiteerapong N, Cooper JM, Skandari MR, Clarke PM, Winn AN, Naylor RN, Huang ES. Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes: A Cost-Effectiveness Analysis. Ann Intern Med 2018; 168:170-178. [PMID: 29230472 PMCID: PMC5989575 DOI: 10.7326/m17-0537] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 12/30/2022] Open
Abstract
BACKGROUND Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications. OBJECTIVE To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes. DESIGN Patient-level Monte Carlo-based Markov model. DATA SOURCES National Health and Nutrition Examination Survey 2011-2012. TARGET POPULATION The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Individualized versus uniform intensive glycemic control. OUTCOME MEASURES Average lifetime costs, life-years, and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications. RESULTS OF SENSITIVITY ANALYSIS Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%. LIMITATION The model did not account for effects of early versus later intensive glycemic control. CONCLUSION Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Neda Laiteerapong
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | - Jennifer M Cooper
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | - M Reza Skandari
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | | | - Aaron N Winn
- University of North Carolina, Chapel Hill, North Carolina (A.N.W.)
| | - Rochelle N Naylor
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
| | - Elbert S Huang
- University of Chicago, Chicago, Illinois (N.L., J.M.C., M.R.S., R.N.N., E.S.H.)
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14
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Shechter SM, Chandler T, Skandari MR, Zalunardo N. Cost-effectiveness Analysis of Vascular Access Referral Policies in CKD. Am J Kidney Dis 2017; 70:368-376. [PMID: 28599902 DOI: 10.1053/j.ajkd.2017.04.020] [Citation(s) in RCA: 11] [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] [Received: 03/31/2016] [Accepted: 04/25/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND The optimal timing of vascular access referral for patients with chronic kidney disease who may need hemodialysis (HD) is a pressing question in nephrology. Current referral policies have not been rigorously compared with respect to costs and benefits and do not consider patient-specific factors such as age. STUDY DESIGN Monte Carlo simulation model. SETTING & POPULATION Patients with chronic kidney disease, referred to a multidisciplinary kidney clinic in a universal health care system. MODEL, PERSPECTIVE, & TIMEFRAME Cost-effectiveness analysis, payer perspective, lifetime horizon. INTERVENTION The following vascular access referral policies are considered: central venous catheter (CVC) only, arteriovenous fistula (AVF) or graft (AVG) referral upon HD initiation, AVF (or AVG) referral when HD is forecast to begin within 12 (or 3 for AVG) months, AVF (or AVG) referral when estimated glomerular filtration rate is <15 (or <10 for AVG) mL/min/1.73m2. OUTCOMES Incremental cost-effectiveness ratios (ICERs, in 2014 US dollars per quality-adjusted life-year [QALY] gained). RESULTS The ICER of AVF (AVG) referral within 12 (3) months of forecasted HD initiation, compared to using only a CVC, is ∼$105k/QALY ($101k/QALY) at a population level (HD costs included). Pre-HD AVF or AVG referral dominates delaying referral until HD initiation. The ICER of pre-HD referral increases with patient age. Results are most sensitive to erythropoietin costs, ongoing HD costs, and patients' utilities for HD. When ongoing HD costs are excluded from the analysis, pre-HD AVF dominates both pre-HD AVG and CVC-only policies. LIMITATIONS Literature-based estimates for HD, AVF, and AVG utilities are limited. CONCLUSIONS The cost-effectiveness of vascular access referral is largely driven by the annual costs of HD, erythropoietin costs, and access-specific utilities. Further research is needed in the field of dialysis-related quality of life to inform decision making regarding vascular access referral.
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Affiliation(s)
- Steven M Shechter
- Sauder School of Business, University of British Columbia, Vancouver, BC, Canada
| | - Talon Chandler
- Department of Radiology, University of Chicago, Chicago, IL
| | | | - Nadia Zalunardo
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Shechter SM, Skandari MR, Zalunardo N. Timing of Arteriovenous Fistula Creation in Patients With CKD: A Decision Analysis. Am J Kidney Dis 2014; 63:95-103. [DOI: 10.1053/j.ajkd.2013.06.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 06/20/2013] [Indexed: 11/11/2022]
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