Cost consequences of unscheduled emergency admissions in cancer patients in the last year of life

OBJECTIVES

Cancer is a leading cause of death. This paper examines the utilisation of unscheduled emergency end-of-life healthcare and estimates expenditure in this domain. We explore care patterns and quantify the likely benefits from service reconfigurations which may influence rates of hospital admission and deaths.

METHODS

Using prevalence-based retrospective data from the Northern Ireland General Registrar's Office linked by cancer diagnosis to Patient Administration episode data for unscheduled emergency care (1st January 2014 to 31st December 2015), we estimate unscheduled-emergency-care costs in the last year of life. We model potential resources released by reductions in length-of-stay for cancer patients. Linear regression examined patient characteristics affecting length of stay.

RESULTS

A total of 3134 cancer patients used 60,746 days of unscheduled emergency care (average 19.5 days). Of these, 48.9% had ≥1 admission during their last 28 days of life. Total estimated cost was £28,684,261, averaging £9200 per person. Lung cancer patients had the highest proportion of admissions (23.2%, mean length of stay = 17.9 days, mean cost=£7224). The highest service use and total cost was in those diagnosed at stage IV (38.4%), who required 22,099 days of care, costing £9,629,014. Palliative care support, identified in 25.5% of patients, contributed £1,322,328. A 3-day reduction in the mean length of stay with a 10% reduction in admissions, could reduce costs by £7.37 million. Regression analyses explained 41% of length-of-stay variability.

CONCLUSIONS

The cost burden from unscheduled care use in the last year of life of cancer patients is significant. Opportunities to prioritise service reconfiguration for high-costing users emphasized lung and colorectal cancers as offering the greatest potential to influence outcomes.

poor glycemic control in type 1 diabetes?

OBJECTIVE

The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy for type 1 diabetes delayed the development of microvascular and neuropathic complications compared to conventional therapy. At the end of DCCT, all participants were trained in intensive therapy, care was transferred to community providers, and the difference in HbA1c between treatment groups narrowed and disappeared. Our objective was to describe the outcomes and the quality-of-life and costs associated with those outcomes in participants who maintained excellent vs. poor glycemic control over 30 years.

RESEARCH DESIGN AND METHODS

We assessed the incidence of retinopathy, nephropathy, neuropathy, cardiovascular disease, acute metabolic complications, death, quality-of-life, and costs in the tertile of DCCT intensive therapy participants who achieved a mean updated HbA1c of <7.2% (55 mmol/mol) and the tertile of DCCT conventional therapy participants (n = 240) who achieved a mean updated HbA1c of >8.8% (73 mmol/mol) over 30 years.

RESULTS

Thirty years of excellent vs. poor glycemic control substantially reduced the incidence of retinopathy requiring laser therapy (5% vs. 45%), end-stage renal disease (0% vs. 5%), clinical neuropathy (15% vs. 50%), myocardial infarction (3% vs. 5%), stroke (0.4% vs. 2%), and death (6% vs. 20%). It also resulted in a gain of ~1.62 quality-adjusted life-years and averted ~$90,900 in costs of complications per participant.

CONCLUSIONS

Thirty years of excellent vs. poor glycemic control for T1DM can substantially reduce the incidence of complications, comorbidities, and death, improve quality-of-life, and reduce costs. These estimates represent the benefits that may be achieved with excellent glycemic control.

Cost implications for the NHS of using the Alere™ i Influenza A & B near patient test with nasal swabs

BACKGROUND

Influenza is an acute viral infection of the respiratory tract. A rapid confirmatory diagnosis of influenza is important, since it is highly transmissible and outbreaks of influenza within the hospital setting increase morbidity and mortality. The objective of this study was to evaluate the cost implications, from the perspective of the UK NHS, of using on-label nasal swabs with the Alere™ i Influenza A & B test in a near patient setting.

METHODS

A cost consequence model was developed. The time horizon of the model was from hospital admission on suspicion of influenza until the end of treatment (following a diagnosis of influenza or discharge from hospital). Data on the prevalence of influenza and the sensitivity and specificity of the Alere™ i Influenza A & B test came from two prospective observational diagnostic accuracy studies. Costs were obtained from published resources. Uncertainties in the model data were investigated using deterministic, one-way sensitivity analyses.

RESULTS

Using the Alere™ i Influenza A & B point of care test with nasal swabs (on label) in NHS medical assessment units and emergency departments could save approximately £242,730 per 1000 adults presenting with influenza-like symptoms. The main cause for this was reduced times to availability of the result compared with the laboratory RT-PCR test. Other key drivers of savings were the cost of isolation, the prevalence of influenza, the specificity of the test, and the availability of isolation resources.

CONCLUSIONS

The Alere™ i Influenza A & B point of care test would have greatest impact in hospitals that have extensive delays in the time to receive a result. Sensitivity analyses identified the model parameters which would have greatest effect on the result and confirmed that assumptions were conservative, i.e. did not change key results.