Treating patients with advanced heart failure in a community-based multidisciplinary team clinic is associated with significant reduction of healthcare utilization and costs

Background/Introduction

Heart failure (HF) care imposes a major economic burden, accounting for 1–3% of healthcare expenditure in developed countries. The greatest proportion of this cost (60%-70%) is accounted for by hospitalizations. A multidisciplinary team (MDT) approach in HF management is a key recommendation in international guidelines, to reduce mortality and HF hospitalization.

Purpose

To investigate whether a community-based MDT in an HF unit (HFU) had an impact on patients' healthcare utilization (HCU), and their associated costs.

Methods

A retrospective cohort study was conducted among members of the country's largest HMO, who visited at least once in a regional community-based HFU, established to provide ambulatory specialist care for patients with advanced HF, emphasizing patients in NYHA functional class III and IV, especially those with recurrent hospitalizations. HCU data were obtained from the HMO's claims data for 12 months before and after first HFU visit.

Results

Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow-up, and 119 (12.4%) died during the 12 months following their first HFU visit. Both groups were comparable with regard to sex, socioeconomic status, Charlson comorbidity index, prevalence of IHD and/or carotid artery disease, AF, obesity, and chronic pulmonary disease. Those who died within 12 months were older, had more hypertension, hyperlipidaemia, diabetes, chronic renal disease and malignancy but were less likely to be smokers or to have supplementary health insurance coverage. There was a significant reduction in the total average HCU costs of the entire study population 12 months after the first HFU visit ($12,675 after vs. $13,188 before, p=0.014). However, while a reduction in these costs was observed among patients who completed 12 months of follow-up ($11,955 after vs. $13,112 before, p<0.001), an increase in these costs was observed among patients who died during follow-up ($17,774 after vs. $13,728 before, p=0.015). These opposite trends stem from a decrease ($3,540 after vs. $4,941 before, p<0.001) versus increase ($10,932 after vs. $6,733 before, p=0.002) in hospitalization costs of these groups, respectively, and an increase ($1,272 after vs. $928 before, p<0.001) versus decrease ($799 after vs. $1,116 before, p<0.001) in medication costs of these subgroups, respectively.

Conclusion(s)

Intensification of therapy by a dedicated MDT significantly reduced costs of HCU, predominantly because of a decrease in hospitalizations. This saving was noted even when including patients who died within a year of commencing treatment in our HFU (a group in whom healthcare costs are known to be excessive). A widespread establishment of dedicated community-based units, should be encouraged.

Funding Acknowledgement

Type of funding sources: None.

Operational models and criteria for incorporating microbial whole genome sequencing in hospital microbiology - A systematic literature review

BACKGROUND

Microbial whole genome sequencing (WGS) has many advantages over standard microbiological methods. However, it is not yet widely implemented in routine hospital diagnostics due to notable challenges.

OBJECTIVES

The aim was to extract managerial, financial and clinical criteria supporting the decision to implement WGS in routine diagnostic microbiology, across different operational models of implementation in the hospital setting.

METHODS

This was a systematic review of literature identified through PubMed and Web of Science. English literature studies discussing the applications of microbial WGS without limitation on publication date were eligible. A narrative approach for categorization and synthesis of the sources identified was adopted.

RESULTS

A total of 98 sources were included. Four main alternative operational models for incorporating WGS in clinical microbiology laboratories were identified: full in-house sequencing and analysis, full outsourcing of sequencing and analysis and two hybrid models combining in-house/outsourcing of the sequencing and analysis components. Six main criteria (and multiple related sub-criteria) for WGS implementation emerged from our review and included cost (e.g. the availability of resources for capital and operational investment); manpower (e.g. the ability to provide training programmes or recruit trained personnel), laboratory infrastructure (e.g. the availability of supplies and consumables or sequencing platforms), bioinformatics requirements (e.g. the availability of valid analysis tools); computational infrastructure (e.g. the availability of storage space or data safety arrangements); and quality control (e.g. the existence of standardized procedures).

CONCLUSIONS

The decision to incorporate WGS in routine diagnostics involves multiple, sometimes competing, criteria and sub-criteria. Mapping these criteria systematically is an essential stage in developing policies for adoption of this technology, e.g. using a multicriteria decision tool. Future research that will prioritize criteria and sub-criteria that were identified in our review in the context of operational models will inform decision-making at clinical and managerial levels with respect to effective implementation of WGS for routine use. Beyond WGS, similar decision-making challenges are expected with respect to future integration of clinical metagenomics.

Elevated healthcare utilisation in young adult males with obstructive sleep apnoea

The aim of the present study was to explore morbidity and healthcare utilisation among young adult males with obstructive sleep apnoea (OSA) compared with middle-aged OSA patients over the 5-yr period preceding diagnosis. A prospective case-control study was performed; 117 young (22-39-yr-old) males with OSA were matched with 117 middle-aged (40-64-yr-old) OSA males for body mass index, apnoea/hypopnoea index, arterial oxygen saturation, arousal and awakening index, and Epworth Sleepiness Scale score. Each OSA patient was matched with controls by age, geographic area and physician. Young adult males with OSA showed no increase in specific comorbidity compared with controls. Middle-aged OSA patients exhibited increased risk of cardiovascular disease. Healthcare utilisation for the 5-yr period was >or=1.9 times higher among young and middle-aged male OSA patients than among controls. Multiple logistic regression analysis revealed that hyperlipidaemia in young adults and a body mass index of >37 kg x m(-2) and cardiovascular disease in middle-aged adults are the only independent determinants of the upper third, most costly, OSA patients. Compared with middle-aged males with obstructive sleep apnoea, in whom increased expenditure was related to cardiovascular disease and body mass index, utilisation was not related to any specific disease in younger cases.