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Landon BE, Anderson TS, Curto VE, Cram P, Fu C, Weinreb G, Zaslavsky AM, Ayanian JZ. Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction. JAMA 2022; 328:2126-2135. [PMID: 36472594 PMCID: PMC9856265 DOI: 10.1001/jama.2022.20982] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown. OBJECTIVE To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019). EXPOSURES Enrollment in Medicare Advantage vs traditional Medicare. MAIN OUTCOMES AND MEASURES The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions). RESULTS The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]). CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.
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Affiliation(s)
- Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Timothy S. Anderson
- Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Vilsa E. Curto
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Peter Cram
- Department of Medicine, University of Texas Medical Branch, Galveston
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor
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Abstract
BACKGROUND More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING This study was conducted at a Veterans Affairs medical center. SETTING Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.
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Affiliation(s)
- Laura A Graham
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Todd H Wagner
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Tanmaya D Sambare
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
| | - Mary T Hawn
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, California
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Ross EL, Zuromski KL, Reis BY, Nock MK, Kessler RC, Smoller JW. Accuracy Requirements for Cost-effective Suicide Risk Prediction Among Primary Care Patients in the US. JAMA Psychiatry 2021; 78:642-650. [PMID: 33729432 PMCID: PMC7970389 DOI: 10.1001/jamapsychiatry.2021.0089] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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] [Received: 10/13/2020] [Accepted: 01/17/2021] [Indexed: 12/30/2022]
Abstract
Importance Several statistical models for predicting suicide risk have been developed, but how accurate such models must be to warrant implementation in clinical practice is not known. Objective To identify threshold values of sensitivity, specificity, and positive predictive value that a suicide risk prediction method must attain to cost-effectively target a suicide risk reduction intervention to high-risk individuals. Design, Setting, and Participants This economic evaluation incorporated published data on suicide epidemiology, the health care and societal costs of suicide, and the costs and efficacy of suicide risk reduction interventions into a novel decision analytic model. The model projected suicide-related health economic outcomes over a lifetime horizon among a population of US adults with a primary care physician. Data analysis was performed from September 19, 2019, to July 5, 2020. Interventions Two possible interventions were delivered to individuals at high predicted risk: active contact and follow-up (ACF; relative risk of suicide attempt, 0.83; annual health care cost, $96) and cognitive behavioral therapy (CBT; relative risk of suicide attempt, 0.47; annual health care cost, $1088). Main Outcomes and Measures Fatal and nonfatal suicide attempts, quality-adjusted life-years (QALYs), health care sector costs and societal costs (in 2016 US dollars), and incremental cost-effectiveness ratios (ICERs) (with ICERs ≤$150 000 per QALY designated cost-effective). Results With a specificity of 95% and a sensitivity of 25%, primary care-based suicide risk prediction could reduce suicide death rates by 0.5 per 100 000 person-years (if used to target ACF) or 1.6 per 100 000 person-years (if used to target CBT) from a baseline of 15.3 per 100 000 person-years. To be cost-effective from a health care sector perspective at a specificity of 95%, a risk prediction method would need to have a sensitivity of 17.0% or greater (95% CI, 7.4%-37.3%) if used to target ACF and 35.7% or greater (95% CI, 23.1%-60.3%) if used to target CBT. To achieve cost-effectiveness, ACF required positive predictive values of 0.8% for predicting suicide attempt and 0.07% for predicting suicide death; CBT required values of 1.7% for suicide attempt and 0.2% for suicide death. Conclusions and Relevance These findings suggest that with sufficient accuracy, statistical suicide risk prediction models can provide good health economic value in the US. Several existing suicide risk prediction models exceed the accuracy thresholds identified in this analysis and thus may warrant pilot implementation in US health care systems.
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Affiliation(s)
- Eric L. Ross
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Kelly L. Zuromski
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Ben Y. Reis
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jordan W. Smoller
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Psychiatric and Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston
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Burgdorf JG, Fabius CD, Riffin C, Wolff JL. Receipt of Posthospitalization Care Training Among Medicare Beneficiaries' Family Caregivers. JAMA Netw Open 2021; 4:e211806. [PMID: 33724393 PMCID: PMC7967076 DOI: 10.1001/jamanetworkopen.2021.1806] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Received: 11/16/2020] [Accepted: 01/23/2021] [Indexed: 01/25/2023] Open
Abstract
Importance Medicare conditions of participation require hospitals to provide training to family and unpaid caregivers when their support is necessary to enact the postdischarge care plan. However, caregivers often report feeling unprepared for this role. Objective To describe the characteristics of caregivers who assist with posthospitalization care transitions and assess the prevalence of and factors associated with receipt of adequate transitional care training. Design, Setting, and Participants This cross-sectional study analyzed data from the 2017 National Health and Aging Trends Study and its linked National Study of Caregiving, surveys of Medicare beneficiaries and their family and unpaid caregivers. The present study included family caregivers for community-living Medicare beneficiaries 65 years or older with disabilities. Data analysis was performed from June to September 2020. Main Outcomes and Measures Characteristics of family caregivers by whether they assisted during a posthospitalization care transition in the year preceding the survey interview. Unweighted frequencies and weighted percentages, as well as the results of weighted Pearson and Wald tests for differences between groups, are reported. Receipt of the training needed to manage the older adult's posthospitalization care transition (hereafter referred to as adequate transitional care training) as a function of individual caregiver characteristics was modeled using multivariable, weighted logistic regression. Results Of 1905 family caregivers, 618 (58.9%) were 60 years or older, 1288 (63.8%) were female, and 796 (41.7%) assisted with a posthospitalization care transition. Those who assisted with a posthospitalization care transition were more likely to report experiencing financial (154 [18.3%] vs 123 [10.1%]; P < .001), emotional (344 [41.3%] vs 342 [31.1%]; P < .001), and physical (200 [22.2%] vs 170 [14.6%]; P = .001) difficulty associated with caregiving. Among caregivers who assisted during a posthospitalization care transition, 490 (59.1%) reported receiving adequate transitional care training. Caregivers were less likely to report receiving adequate training if they assisted an older adult who was female (316 [62.3%] vs 227 [73.2%]; P = .02), Black (163 [14.0%] vs 121 [19.8%]; P = .02), or enrolled in Medicaid (127 [21.2%] vs 90 [31.9%]; P = .01). After adjusting for older adult characteristics, caregivers were half as likely to report receiving adequate training if they were Black (adjusted odds ratio [aOR], 0.52; 95% CI, 0.31-0.89) or experienced financial difficulty (aOR, 0.50; 95% CI, 0.31-0.81). Caregivers were more than twice as likely to report receiving adequate training if they were female (aOR, 2.44; 95% CI, 1.65-3.61) or spoke with the older adult's clinician about his or her care in the past year sometimes or often vs never (aOR, 1.93; 95% CI, 1.19-3.12). Conclusions and Relevance In this cross-sectional study, caregivers were less likely to receive adequate transitional care training if they were Black; experienced financial difficulty; or cared for a Black, female, or Medicaid-enrolled older adult. These findings suggest that changes to the discharge process, such as using standardized caregiver assessments, may be necessary to ensure equitable support of family caregivers.
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Affiliation(s)
- Julia G. Burgdorf
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Chanee D. Fabius
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Catherine Riffin
- Department of Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Jennifer L. Wolff
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Henderson SC, Owino H, Thomas KC, Cyr JM, Ansari S, Glickman SW, Dusetzina SB. Post-discharge Health Services Use for Patients with Serious Mental Illness Treated at an Emergency Department Versus a Dedicated Community Mental Health Center. Adm Policy Ment Health 2021; 47:443-450. [PMID: 31813067 DOI: 10.1007/s10488-019-01000-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/25/2022]
Abstract
Emergency Medical Service (EMS) alternative destination programs may lead to improved care quality among those experiencing mental health crises but the association with cost and emergency department (ED) recidivism remains unexamined. We compare rates of post-discharge health services use and Medicaid spending among patients transported to an ED or community mental health center (CMHC) finding higher ED recidivism for patient treated in the ED, compared to those treated in a CMHC (68% vs 34%, p < 0.001). There were no differences in Medicaid spending or health services use post-discharge suggesting EMS-operated alternative destination programs may be cost-neutral for Medicaid programs.
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Affiliation(s)
- Sarah C Henderson
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Hillary Owino
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kathleen C Thomas
- Division of Pharmaceutical Outcomes and Policy, Division of Research, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, UNC Health Sciences at MAHEC, Chapel Hill, NC, USA
| | - Julianne M Cyr
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA.
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1203, Nashville, TN, 37203, USA.
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Levan ML, Waldram MM, DiBrito SR, Thomas AG, Al Ammary F, Ottman S, Bannon J, Brennan DC, Massie AB, Scalea J, Barth RN, Segev DL, Garonzik-Wang JM. Financial incentives versus standard of care to improve patient compliance with live kidney donor follow-up: protocol for a multi-center, parallel-group randomized controlled trial. BMC Nephrol 2020; 21:465. [PMID: 33167882 PMCID: PMC7654057 DOI: 10.1186/s12882-020-02117-9] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/21/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Live kidney donors (LKDs) account for nearly a third of kidney transplants in the United States. While donor nephrectomy poses minimal post-surgical risk, LKDs face an elevated adjusted risk of developing chronic diseases such as hypertension, diabetes, and end-stage renal disease. Routine screening presents an opportunity for the early detection and management of chronic conditions. Transplant hospital reporting requirements mandate the submission of laboratory and clinical data at 6-months, 1-year, and 2-years after kidney donation, but less than 50% of hospitals are able to comply. Strategies to increase patient engagement in follow-up efforts while minimizing administrative burden are needed. We seek to evaluate the effectiveness of using small financial incentives to promote patient compliance with LKD follow-up. METHODS/DESIGN We are conducting a two-arm randomized controlled trial (RCT) of patients who undergo live donor nephrectomy at The Johns Hopkins Hospital Comprehensive Transplant Center (MDJH) and the University of Maryland Medical Center Transplant Center (MDUM). Eligible donors will be recruited in-person at their first post-surgical clinic visit or over the phone. We will use block randomization to assign LKDs to the intervention ($25 gift card at each follow-up visit) or control arm (current standard of care). Follow-up compliance will be tracked over time. The primary outcome will be complete (all components addressed) and timely (60 days before or after expected visit date), submission of LKD follow-up data at required 6-month, 1-year, and 2-year time points. The secondary outcome will be transplant hospital-level compliance with federal reporting requirements at each visit. Rates will be compared between the two arms following the intention-to-treat principle. DISCUSSION Small financial incentivization might increase patient compliance in the context of LKD follow-up, without placing undue administrative burden on transplant providers. The findings of this RCT will inform potential center- and national-level initiatives to provide all LKDs with small financial incentives to promote engagement with post-donation monitoring efforts. TRIAL REGISTRATION ClinicalTrials.gov number: NCT03090646 Date of registration: March 2, 2017 Sponsors: Johns Hopkins University, University of Maryland Medical Center Funding: The Living Legacy Foundation of Maryland.
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Affiliation(s)
- Macey L. Levan
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD USA
| | - Madeleine M. Waldram
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Sandra R. DiBrito
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Alvin G. Thomas
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC USA
| | - Fawaz Al Ammary
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Shane Ottman
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Jaclyn Bannon
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Daniel C. Brennan
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Allan B. Massie
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA
| | - Joseph Scalea
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD USA
| | - Rolf N. Barth
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD USA
| | - Dorry L. Segev
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA
| | - Jacqueline M. Garonzik-Wang
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
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Bak GS, Shaffer BL, Madriago E, Allen A, Kelly B, Caughey AB, Pereira L. Impact of maternal obesity on fetal cardiac screening: which follow-up strategy is cost-effective? Ultrasound Obstet Gynecol 2020; 56:705-716. [PMID: 31614030 DOI: 10.1002/uog.21895] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To perform a cost-effectiveness analysis of different follow-up strategies for non-obese and obese women who had incomplete fetal cardiac screening for major congenital heart disease (CHD). METHODS Three decision-analytic models, one each for non-obese, obese and Class-III-obese women, were developed to compare five follow-up strategies for initial suboptimal fetal cardiac screening. The five strategies were: (1) no follow-up ultrasound (US) examination but direct referral to fetal echocardiography (FE); (2) one follow-up US, then FE if fetal cardiac views were still suboptimal; (3) up to two follow-up US, then FE if fetal cardiac views were still suboptimal; (4) one follow-up US and no FE; and (5) up to two follow-up US and no FE. The models were designed to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. A cost-effectiveness willingness-to-pay threshold was set at US$100 000 per quality-adjusted life year (QALY). Base-case and sensitivity analysis and Monte-Carlo simulation were performed. RESULTS In our base-case models for all body mass index (BMI) groups, no follow-up US, but direct referral to FE led to the best outcomes, detecting 7%, 25% and 82% more fetuses with CHD in non-obese, obese and Class-III-obese women, respectively, compared with the baseline strategy of one follow-up US and no FE. However, no follow-up US, but direct referral to FE was above the US$100 000/QALY threshold and therefore not cost-effective. The cost-effective strategy for all BMI groups was one follow-up US and no FE. Both up to two follow-up US with no FE and up to two follow-up US with FE were dominated (being more costly and less effective), while one follow-up US with FE was over the cost-effectiveness threshold. One follow-up US and no FE was the optimal strategy in 97%, 93% and 86% of trials in Monte-Carlo simulation for non-obese, obese and Class-III-obese models, respectively. CONCLUSION For both non-obese and obese women with incomplete fetal cardiac screening, the optimal CHD follow-up screening strategy is no further US and immediate referral to FE; however, this strategy is not cost-effective. Considering costs, one follow-up US and no FE is the preferred strategy. For both obese and non-obese women, Monte-Carlo simulations showed clearly that one follow-up US and no FE was the optimal strategy. Both non-obese and obese women with initial incomplete cardiac screening examination should therefore be offered one follow-up US. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G S Bak
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - B L Shaffer
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - E Madriago
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A Allen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - B Kelly
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A B Caughey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - L Pereira
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
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Wollersheim BM, van Asselt KM, van der Poel HG, van Weert HCPM, Hauptmann M, Retèl VP, Aaronson NK, van de Poll-Franse LV, Boekhout AH. Design of the PROstate cancer follow-up care in Secondary and Primary hEalth Care study (PROSPEC): a randomized controlled trial to evaluate the effectiveness of primary care-based follow-up of localized prostate cancer survivors. BMC Cancer 2020; 20:635. [PMID: 32641023 PMCID: PMC7346492 DOI: 10.1186/s12885-020-07112-9] [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: 05/20/2020] [Accepted: 06/25/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In its 2006 report, From cancer patient to cancer survivor: lost in transition, the U.S. Institute of Medicine raised the need for a more coordinated and comprehensive care model for cancer survivors. Given the ever increasing number of cancer survivors, in general, and prostate cancer survivors, in particular, there is a need for a more sustainable model of follow-up care. Currently, patients who have completed primary treatment for localized prostate cancer are often included in a specialist-based follow-up care program. General practitioners already play a key role in providing continuous and comprehensive health care. Studies in breast and colorectal cancer suggest that general practitioners could also consider to provide survivorship care in prostate cancer. However, empirical data are needed to determine whether follow-up care of localized prostate cancer survivors by the general practitioner is a feasible alternative. METHODS This multicenter, randomized, non-inferiority study will compare specialist-based (usual care) versus general practitioner-based (intervention) follow-up care of prostate cancer survivors who have completed primary treatment (prostatectomy or radiotherapy) for localized prostate cancer. Patients are being recruited from hospitals in the Netherlands, and randomly (1:1) allocated to specialist-based (N = 195) or general practitioner-based (N = 195) follow-up care. This trial will evaluate the effectiveness of primary care-based follow-up, in comparison to usual care, in terms of adherence to the prostate cancer surveillance guideline for the timing and frequency of prostate-specific antigen assessments, the time from a biochemical recurrence to retreatment decision-making, the management of treatment-related side effects, health-related quality of life, prostate cancer-related anxiety, continuity of care, and cost-effectiveness. The outcome measures will be assessed at randomization (≤6 months after treatment), and 12, 18, and 24 months after treatment. DISCUSSION This multicenter, prospective, randomized study will provide empirical evidence regarding the (cost-) effectiveness of specialist-based follow-up care compared to general practitioner-based follow-up care for localized prostate cancer survivors. TRIAL REGISTRATION Netherlands Trial Registry, Trial NL7068 (NTR7266). Prospectively registered on 11 June 2018.
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Affiliation(s)
- Barbara M Wollersheim
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, Amsterdam, CX, The Netherlands
| | - Kristel M van Asselt
- Department of General Practice, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Michael Hauptmann
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, Amsterdam, CX, The Netherlands
- Institute of Biostatistics and Registry Research, Brandenburg Medical School, Neuruppin, Germany
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, Amsterdam, CX, The Netherlands
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, Amsterdam, CX, The Netherlands
| | - Lonneke V van de Poll-Franse
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, Amsterdam, CX, The Netherlands
- Department of Research, Netherlands Comprehensive Cancer organization (IKNL), Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, CoRPS - Center of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, The Netherlands
| | - Annelies H Boekhout
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, Amsterdam, CX, The Netherlands.
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Al-Shammari I, Roa L, Yorlets RR, Akerman C, Dekker A, Kelley T, Koech R, Mutuku J, Nyarango R, Nzorubara D, Spieker N, Vaidya M, Meara JG, Ljungman D. Implementation of an international standardized set of outcome indicators in pregnancy and childbirth in Kenya: Utilizing mobile technology to collect patient-reported outcomes. PLoS One 2019; 14:e0222978. [PMID: 31618249 PMCID: PMC6795527 DOI: 10.1371/journal.pone.0222978] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/11/2019] [Indexed: 11/29/2022] Open
Abstract
Background Limited data exist on health outcomes during pregnancy and childbirth in low- and middle-income countries. This is a pilot of an innovative data collection tool using mobile technology to collect patient-reported outcome measures (PROMs) selected from the International Consortium of Health Outcomes Measurement (ICHOM) Pregnancy and Childbirth Standard Set in Nairobi, Kenya. Methods Pregnant women in the third trimester were recruited at three primary care facilities in Nairobi and followed prospectively throughout delivery and until six weeks postpartum. PROMs were collected via mobile surveys at three antenatal and two postnatal time points. Outcomes included incontinence, dyspareunia, mental health, breastfeeding and satisfaction with care. Hospitals reported morbidity and mortality. Descriptive statistics on maternal and child outcomes, survey completion and follow-up rates were calculated. Results In six months, 204 women were recruited: 50% of women returned for a second ante-natal care visit, 50% delivered at referral hospitals and 51% completed the postnatal visit. The completion rates for the five PROM surveys were highest at the first antenatal care visit (92%) and lowest in the postnatal care visit (38%). Data on depression, dyspareunia, fecal and urinary incontinence were successfully collected during the antenatal and postnatal period. At six weeks postpartum, 86% of women breastfeed exclusively. Most women that completed the survey were very satisfied with antenatal care (66%), delivery care (51%), and post-natal care (60%). Conclusion We have demonstrated that it is feasible to use mobile technology to follow women throughout pregnancy, track their attendance to pre-natal and post-natal care visits and obtain data on PROM. This study demonstrates the potential of mobile technology to collect PROM in a low-resource setting. The data provide insight into the quality of maternal care services provided and will be used to identify and address gaps in access and provision of high quality care to pregnant women.
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Affiliation(s)
- Ishtar Al-Shammari
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, United States of America
| | - Lina Roa
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Canada
- * E-mail:
| | - Rachel R. Yorlets
- Department of Plastic & Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Christina Akerman
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, United States of America
| | | | - Thomas Kelley
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, United States of America
| | | | - Judy Mutuku
- Gertrude’s Children’s Hospital, Nairobi, Kenya
| | | | | | | | | | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Plastic & Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - David Ljungman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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10
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Hung A, Li Y, Keefe FJ, Ang DC, Slover J, Perera RA, Dumenci L, Reed SD, Riddle DL. Ninety-day and one-year healthcare utilization and costs after knee arthroplasty. Osteoarthritis Cartilage 2019; 27:1462-1469. [PMID: 31176805 PMCID: PMC6750955 DOI: 10.1016/j.joca.2019.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 03/25/2019] [Revised: 05/06/2019] [Accepted: 05/29/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study examined ninety-day and one-year postoperative healthcare utilization and costs following total knee arthroplasty (TKA) from the health sector and patient perspectives. DESIGN This study relied on: 1) patient-reported medical resource utilization data from diaries in the Knee Arthroplasty Pain Coping Skills Training (KASTPain) trial; and 2) Medicare fee schedules. Medicare payments, patient cost-sharing, and patient time costs were estimated. Generalized linear mixed models were used to identify baseline predictors of costs. RESULTS In the first ninety days following TKA, patients had an average of 29.7 outpatient visits and 6% were hospitalized. Mean total costs during this period summed to $3,720, the majority attributed to outpatient visit costs (84%). Over the year following TKA, patients had an average of 48.9 outpatient visits, including 33.2 for physical therapy. About a quarter (24%) of patients were hospitalized. Medical costs were incurred at a decreasing rate, from $2,428 in the first six weeks to $648 in the last six weeks. Mean total medical costs across all patients over the year were $8,930, including $5,328 in outpatient costs. Total costs were positively associated with baseline Charlson comorbidity score (P < 0.01). Outpatient costs were positively associated with baseline Charlson comorbidity score (P = 0.03) and a bodily pain burden summary score (P < 0.01). Mean patient cost-sharing summed to $1,342 and time costs summed to $1,346. CONCLUSIONS Costs in the ninety days and year after TKA can be substantial for both healthcare payers and patients. These costs should be considered as payers continue to explore alternative payment models.
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Affiliation(s)
- A Hung
- Duke Clinical Research Institute, Durham, NC, USA
| | - Y Li
- Duke Clinical Research Institute, Durham, NC, USA
| | - F J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - D C Ang
- Department of Medicine, Section of Rheumatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Slover
- Department of Orthopaedic Surgery, New York University Medical Center, New York, NY, USA
| | - R A Perera
- Department of Biostatistics, VA Commonwealth University, Richmond VA, USA
| | - L Dumenci
- Department of Epidemiology and Biostatistics, Temple University, Philadelphia, PA, USA
| | - S D Reed
- Duke Clinical Research Institute, Durham, NC, USA.
| | - D L Riddle
- Departments of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA
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11
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Baynes C, Yegon E, Kimaro G, Lusiola G, Kahwa J. The Unit and Scale-Up Cost of Postabortion Care in Tanzania. Glob Health Sci Pract 2019; 7:S327-S341. [PMID: 31455628 PMCID: PMC6711630 DOI: 10.9745/ghsp-d-19-00035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 04/11/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions. METHODS Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods. RESULTS We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96. CONCLUSION We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.
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Affiliation(s)
| | | | - Godfather Kimaro
- The National Institutes of Medical Research Tanzania, Dar es Salaam, Tanzania
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12
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Bestwick JP, Wald NJ. Cost and efficacy comparison of prenatal recall and reflex DNA screening for trisomy 21, 18 and 13. PLoS One 2019; 14:e0220053. [PMID: 31344071 PMCID: PMC6658079 DOI: 10.1371/journal.pone.0220053] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/08/2019] [Indexed: 01/20/2023] Open
Abstract
Objective To compare costs and efficacy of reflex and recall prenatal DNA screening for trisomy 21, 18 and 13 (affected pregnancies). In both methods women have Combined test markers measured. With recall screening, women with a high Combined test risk are recalled for counselling and offered a DNA blood test or invasive diagnostic testing. With reflex screening, a DNA analysis is automatically performed on plasma collected when blood was collected for measurement of the Combined test markers. Methods Published data were used to estimate, for each method, using various unit costs and risk cut-offs, the cost per woman screened, cost per affected pregnancy diagnosed, and for a given number of women screened, numbers of affected pregnancies diagnosed, unaffected pregnancies with positive results, and women with unaffected pregnancies having invasive diagnostic testing. Results Cost per woman screened is lower with reflex v recall screening: £37 v £38, and £11,043 v £11,178 per affected pregnancy diagnosed (DNA £250, Combined test markers risk cut-off 1 in 150). Reflex screening results in similar numbers of affected pregnancies diagnosed, with 100-fold fewer false-positives and 20-fold fewer women with unaffected pregnancies having invasive diagnostic testing. Conclusions Reflex DNA screening is less expensive, more cost-effective, and safer than recall screening.
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Affiliation(s)
- Jonathan Paul Bestwick
- Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London Charterhouse Square, London, United Kingdom
- * E-mail:
| | - Nicholas John Wald
- Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London Charterhouse Square, London, United Kingdom
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13
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Morelli L, Guadagni S, Borrelli V, Pisano R, Di Franco G, Palmeri M, Furbetta N, Gambaccini D, Marchi S, Boraschi P, Bastiani L, Campatelli A, Mosca F, Di Candio G. Role of abdominal ultrasound for the surveillance follow-up of pancreatic cystic neoplasms: a cost-effective safe alternative to the routine use of magnetic resonance imaging. World J Gastroenterol 2019; 25:2217-2228. [PMID: 31143072 PMCID: PMC6526159 DOI: 10.3748/wjg.v25.i18.2217] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with pancreatic cystic neoplasms (PCN), without surgical indication at the time of diagnosis according to current guidelines, require lifetime image-based surveillance follow-up. In these patients, the current European evidenced-based guidelines advise magnetic resonance imaging (MRI) scanning every 6 mo in the first year, then annually for the next five years, without reference to any role for trans-abdominal ultrasound (US). In this study, we report on our clinical experience of a follow-up strategy of image-based surveillance with US, and restricted use of MRI every two years and for urgent evaluation whenever suspicious changes are detected by US.
AIM To report the results and cost-efficacy of a US-based surveillance follow-up for known PCNs, with restricted use of MRI.
METHODS We retrospectively evaluated the records of all the patients treated in our institution with non-surgical PCN who received follow-up abdominal US and restricted MRI from the time of diagnosis, between January 2012 and January 2017. After US diagnosis and MRI confirmation, all patients underwent US surveillance every 6 mo for the first year, and then annually. A MRI scan was routinely performed every 2 years, or at any stage for all suspicious US findings. In this communication, we reported the clinical results of this alternative follow-up, and the results of a comparative cost-analysis between our surveillance protocol (abdominal US and restricted MRI) and the same patient cohort that has been followed-up in strict accordance with the European guidelines recommended for an exclusive MRI-based surveillance protocol.
RESULTS In the 5-year period, 200 patients entered the prescribed US-restricted MRI surveillance follow-up. Mean follow-up period was 25.1 ± 18.2 mo. Surgery was required in two patients (1%) because of the appearance of suspicious features at imaging (with complete concordance between the US scan and the on-demand MRI). During the follow-up, US revealed changes in PCN appearance in 28 patients (14%). These comprised main pancreatic duct dilatation (n = 1), increased size of the main cyst (n = 14) and increased number of PNC (n = 13). In all of these patients, MRI confirmed US findings, without adding more information. The bi-annual MRI identified evolution of the lesions not identified by US in only 11 patients with intraductal papillary mucinous neoplasms (5.5%), largely consisting of an increased number of very small PCN (P = 0.14). The overall mean cost of surveillance, based on a theoretical use of the European evidenced-based exclusive MRI surveillance in the same group of patients, would have been 1158.9 ± 798.6 € per patient, in contrast with a significantly lower cost of 366.4 ± 348.7 € (P < 0.0001) incurred by the US-restricted MRI surveillance used at our institution.
CONCLUSION In patients with non-surgical PCN at the time of diagnosis, US surveillance could be a safe complementary approach to MRI, delaying and reducing the numbers of second level examinations and therefore reducing the costs.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa 56124, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
| | - Valerio Borrelli
- Diagnostic and Interventional Ultrasound in Transplants Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
| | - Roberta Pisano
- Diagnostic and Interventional Ultrasound in Transplants Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
| | | | - Santino Marchi
- Gastroenterology Unit, University of Pisa, Pisa 56124, Italy
| | - Piero Boraschi
- 2nd Radiology Unit, Department of Diagnostic Imaging, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
| | - Luca Bastiani
- Institute of Clinical Physiology, National Council of Research, Pisa 56124, Italy
| | - Alessandro Campatelli
- Diagnostic and Interventional Ultrasound in Transplants Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
| | - Franco Mosca
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa 56124, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
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14
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Mayer DK, Alfano CM. Personalized Risk-Stratified Cancer Follow-Up Care: Its Potential for Healthier Survivors, Happier Clinicians, and Lower Costs. J Natl Cancer Inst 2019; 111:442-448. [PMID: 30726949 PMCID: PMC6804411 DOI: 10.1093/jnci/djy232] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [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: 09/24/2018] [Revised: 12/03/2018] [Accepted: 12/20/2019] [Indexed: 12/16/2022] Open
Abstract
The growth in the number of cancer survivors in the face of projected health-care workforce shortages will challenge the US health-care system in delivering follow-up care. New methods of delivering follow-up care are needed that address the ongoing needs of survivors without overwhelming already overflowing oncology clinics or shuttling all follow-up patients to primary care providers. One potential solution, proposed for over a decade, lies in adopting a personalized approach to care in which survivors are triaged or risk-stratified to distinct care pathways based on the complexity of their needs and the types of providers their care requires. Although other approaches may emerge, we advocate for development, testing, and implementation of a risk-stratified approach as a means to address this problem. This commentary reviews what is needed to shift to a risk-stratified approach in delivering survivorship care in the United States.
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Affiliation(s)
- Deborah K Mayer
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health
- School of Nursing, UNC Lineberger Comprehensive Cancer Center, University of North Carolina
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15
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Looker KJ, Buitendam E, Woodhall SC, Hollis E, Ong KJ, Saunders JM, Dunbar K, Turner KME. Economic evaluation of the cost of different methods of retesting chlamydia positive individuals in England. BMJ Open 2019; 9:e024828. [PMID: 30904855 PMCID: PMC6475158 DOI: 10.1136/bmjopen-2018-024828] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES The National Chlamydia Screening Programme (NCSP) in England opportunistically screens eligible individuals for chlamydia infection. Retesting is recommended three3 months after treatment following a positive test result, but no guidance is given on how local areas should recall individuals for retesting. Here , we compare cost estimates for different recall methods to inform the optimal delivery of retesting programmes. DESIGN Economic evaluation. SETTING England. METHODS We estimated the cost of chlamydia retesting for each of the six most commonly used recall methods in 2014 based on existing cost estimates of a chlamydia screen. Proportions accepting retesting, opting for retesting by post, returning postal testing kits and retesting positive were informed by 2014 NCSP audit data. Health professionals 'sense-checked' the costs. PRIMARY AND SECONDARY OUTCOMES Cost and adjusted cost per chlamydia retest; cost and adjusted cost per chlamydia retest positive. RESULTS We estimated the cost of the chlamydia retest pathway, including treatment/follow-up call, to be between £45 and £70 per completed test. At the lower end, this compared favourably to the cost of a clinic-based screen. Cost per retest positive was £389-£607. After adjusting for incomplete uptake, and non-return of postal kits, the cost rose to £109-£289 per completed test (cost per retest positive: £946-£2,506). The most economical method in terms of adjusted cost per retest was no active recall as gains in retest rates with active recall did not outweigh the higher cost. Nurse-led client contact by phone was particularly uneconomical, as was sending out postal testing kits automatically. CONCLUSIONS Retesting without active recall is more economical than more intensive methods such as recalling by phone and automatically sending out postal kits. If sending a short message service (SMS) could be automated, this could be the most economical way of delivering retesting. However, patient choice and local accessibility of services should be taken into consideration in planning.
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Affiliation(s)
- Katharine J Looker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, Bristol, UK
| | - Erna Buitendam
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Sarah C Woodhall
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Emma Hollis
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Koh-Jun Ong
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - John M Saunders
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Kevin Dunbar
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Katherine M E Turner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, Bristol, UK
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16
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Waddle MR, Niazi S, Aljabri D, White L, Kaleem T, Naessens J, Spaulding A, Habboush J, Rummans T, Miller R. Cost of Acute and Follow-Up Care in Patients With Pre-Existing Psychiatric Diagnoses Undergoing Radiation Therapy. Int J Radiat Oncol Biol Phys 2019; 104:748-755. [PMID: 30904707 DOI: 10.1016/j.ijrobp.2019.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/04/2019] [Accepted: 03/12/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE The impact of psychiatric comorbidities on the cost of cancer care in radiation oncology practices is not well studied. We assessed the acute and 24-month follow-up costs for patients with and without pre-existing psychiatric comorbidities undergoing radiation therapy. METHODS AND MATERIALS Patients with cancer undergoing radiation therapy at our institution from 2009 to 2014 were denoted as having pre-existing psychiatric conditions (Psych group) if they had associated billing codes for any of the 422 International Classification of Diseases, 9th revision psychiatric conditions during the 12 months before their cancer diagnosis. The Elixhauser comorbidity index was calculated, excluding psychiatric categories. Medicare reimbursement was assigned to professional services, and Medicare departmental cost-to-charge ratios were applied to service line hospital charges and adjusted for inflation to create 2017 standardized costs. Acute (0-6 month) and follow-up (6-24 month) costs were subcategorized into clinic, emergency department, hospital inpatient, and outpatient costs. RESULTS Among 1275 patients, 126 (9.9%) had at least 1 pre-existing psychiatric diagnosis. On univariate analysis, both acute and long-term costs were higher in the Psych group. The largest significant differences in costs were follow-up hospital inpatient costs ($5861 higher; 95% confidence interval [CI], $687-$11,035; P = .002), follow-up hospital outpatient costs ($2086 higher; 95% CI, -$142 to $4,314; P = .040), and follow-up emergency department costs ($396 higher; 95% CI, $149-$643; P < .001). Age, race, sex, and treatment modalities were comparable, but the Psych group patients had more median comorbidities (2 vs 1) and had more respiratory cancer diagnoses than the nonpsychiatric group (31% vs 17%). On multivariate analysis adjusted for age, sex, cancer diagnosis, and comorbidities, global follow-up costs remained 150% higher in the Psych group (P < .001). Acute costs were similar after adjustment (P = .63). CONCLUSIONS Psychiatric comorbidities independently predict elevated healthcare costs in patients treated for cancer. Radiation oncology payment models should consider adjustments to account for psychiatric comorbidities because addressing these may mitigate cost differential.
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Affiliation(s)
- Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Shehzad Niazi
- Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, Florida
| | - Duaa Aljabri
- Department of Health Information Management and Technology, College of Public Health, Imam Abdulrhman Bin Faisal University, Dammam, Saudi Arabia
| | - Launia White
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida
| | - Tasneem Kaleem
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - James Naessens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida; Division of Health Care Policy & Research, Mayo Clinic, Jacksonville, Florida
| | - Aaron Spaulding
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida
| | - Jacob Habboush
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Teresa Rummans
- Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, Florida
| | - Robert Miller
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
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Abstract
This study characterizes participation of skilled nursing facilities in Medicare’s Model 3 Bundled Payments for Care Improvement (BPCI) initiative and the factors associated with that participation.
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Affiliation(s)
| | | | - Lena M. Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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18
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Hossain MS, Harvey LA, Liu H, Islam MS, Rahman MA, Muldoon S, Biering-Sorensen F, Cameron ID, Chhabra HS, Lindley RI, Jan S. Protocol for process evaluation of CIVIC randomised controlled trial: Community-based InterVentions to prevent serIous Complications following spinal cord injury in Bangladesh. BMJ Open 2018; 8:e024226. [PMID: 30012798 PMCID: PMC6082451 DOI: 10.1136/bmjopen-2018-024226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/14/2018] [Accepted: 06/25/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION People with spinal cord injuries in low-income and middle-income countries are highly vulnerable to life-threatening complications in the period immediately after discharge from hospital. We are conducting a randomised controlled trial in Bangladesh to determine whether all-cause mortality at 2 years can be reduced if health professionals regularly ring and visit participants in their homes following discharge. We will conduct a process evaluation alongside the trial to explain the trial results and determine the feasibility of scaling this intervention up in low-income and middle-income countries if it is found to be effective. METHODS AND ANALYSIS Our process evaluation is based on the Realist and Reach, Effectiveness, Adoption, Implementation and Maintenance frameworks. We will use a mixed methods approach that uses both qualitative and quantitative data. For example, we will audit a sample of telephone interactions between intervention participants and the healthcare professionals, and we will conduct semistructured interviews with people reflective of various interest groups. Quantitative data will also be collected to determine the number and length of interactions between the healthcare professionals and participants, the types of issues identified during each interaction and the nature of the support and advice provided by the healthcare professionals. All quantitative and qualitative data will be analysed iteratively before the final analysis of the trial results. These data will then be triangulated with the final results of the primary outcome. ETHICS AND DISSEMINATION Ethics approval was obtained from the institutional ethics committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval and the relevant regulatory bodies. The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER ACTRN12615000630516.
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Affiliation(s)
- Mohammad Sohrab Hossain
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Hueiming Liu
- George Institute for Global Health, Sydney, New South Wales, Australia
| | | | | | | | | | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | | | - Richard I Lindley
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Stephen Jan
- George Institute for Global Health, Sydney, New South Wales, Australia
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Denchev P, Pearson JL, Allen MH, Claassen CA, Currier GW, Zatzick DF, Schoenbaum M. Modeling the Cost-Effectiveness of Interventions to Reduce Suicide Risk Among Hospital Emergency Department Patients. Psychiatr Serv 2018; 69:23-31. [PMID: 28945181 PMCID: PMC5750130 DOI: 10.1176/appi.ps.201600351] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study estimated the expected cost-effectiveness and population impact of outpatient interventions to reduce suicide risk among patients presenting to general hospital emergency departments (EDs), compared with usual care. Several such interventions have been found efficacious, but none is yet widespread, and the cost-effectiveness of population-based implementation is unknown. METHODS Modeled cost-effectiveness analysis compared three ED-initiated suicide prevention interventions previously found to be efficacious-follow-up via postcards or caring letters, follow-up via telephone outreach, and suicide-focused cognitive-behavioral therapy (CBT)-with usual care. Primary outcomes were treatment costs, suicides, and life-years saved, evaluated over the year after the index ED visit. RESULTS Compared with usual care, adding postcards improved outcomes and reduced costs. Adding telephone outreach and suicide-focused CBT, respectively, improved outcomes at a mean incremental cost of $4,300 and $18,800 per life-year saved, respectively. Monte Carlo simulation (1,000 repetitions) revealed the chance of incremental cost-effectiveness to be a certainty for all three interventions, assuming societal willingness to pay ≥$50,000 per life-year. These main findings were robust to various sensitivity analyses, including conservative assumptions about effect size and incremental costs. Population impact was limited by low sensitivity of detecting ED patients' suicide risk, and health care delivery inefficiencies. CONCLUSIONS The highly favorable cost-effectiveness found for each outpatient intervention provides a strong basis for widespread implementation of any or all of the interventions. The estimated population benefits of doing so would be enhanced by increasing the sensitivity of suicide risk detection among individuals presenting to general hospital EDs.
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Affiliation(s)
- Peter Denchev
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
| | - Jane L Pearson
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
| | - Michael H Allen
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
| | - Cynthia A Claassen
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
| | - Glenn W Currier
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
| | - Douglas F Zatzick
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
| | - Michael Schoenbaum
- At the time of this research, Dr. Denchev was with the Office of Science Policy, Planning and Communication, National Institute of Mental Health (NIMH), Bethesda, Maryland. Dr. Pearson and Dr. Schoenbaum are with the Division of Services and Intervention Research, NIMH, Bethesda. Dr. Allen is with the Department of Psychiatry, University of Colorado Denver School of Medicine, Aurora, and with Rocky Mountain Crisis Partners, Denver. Dr. Claassen is with the Department of Psychiatry, University of North Texas Health Science Center, Fort Worth. Dr. Currier is with the Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa. Dr. Zatzick is with the Department of Psychiatry and Behavioral Sciences, University of Washington and Harborview Medical Center, Seattle
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Kaye DR, Syrjamaki J, Ellimoottil C, Schervish EW, Solomon MH, Linsell S, Montie JE, Miller DC, Dupree JM. Use of Routine Home Health Care and Deviations From an Uncomplicated Recovery Pathway After Radical Prostatectomy. Urology 2017; 112:74-79. [PMID: 29155190 DOI: 10.1016/j.urology.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 09/19/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. METHODS We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of "routine" home care use after prostatectomy by urology practice. We defined "routine" home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. RESULTS We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% (P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P <.01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses (P <.01). Home health had an average payment of $1000 per episode. CONCLUSION Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.
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Affiliation(s)
- Deborah R Kaye
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI.
| | - John Syrjamaki
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - Edward W Schervish
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Michigan Institute of Urology, Detroit, MI
| | - M Hugh Solomon
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI
| | - Susan Linsell
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - James E Montie
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - David C Miller
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
| | - James M Dupree
- Michigan Urological Surgery Improvement Collaborative, Ann Arbor, MI; Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Michigan Value Collaborative, Ann Arbor, MI
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Fawsitt CG, Meaney S, Greene RA, Corcoran P. Surgical Site Infection after Caesarean Section? There Is an App for That: Results from a Feasibility Study On Costs and Benefits. Ir Med J 2017; 110:635. [PMID: 29372950] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Surgical site infections (SSIs) are one of the most common and, yet, preventable healthcare associated infections. In Ireland, the rate of Caesarean section (CS) is increasing, while postpartum hospital stay is decreasing, adversely affecting SSI among women. There is much need to develop post-discharge surveillance which can effectively monitor, detect, and arrange treatment for affected women. The use of modern technology to survey SSI following discharge from hospital remains unexplored. We report the results of a feasibility study which investigates whether an integrated mobile application (hereafter, app) is more cost-beneficial than a stand-alone app or telephone helpline at surveying SSI following CS. We find women prefer the integrated app (47.5%; n=116/244) over the stand-alone app (8.2%; n=20/244) and telephone helpline (18.0%; 44/244), although there is no significant difference in women's valuation of these services using willingness to pay techniques. The stand-alone app is the only cost-beneficial service due to low labour costs. Future research should employ alternative measures when evaluating the benefits of the health technology. The use of a mobile app as a mechanism for postpartum care could represent a considerable advancement towards technological health care.
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Affiliation(s)
- C G Fawsitt
- Bristol Medical School, University of Bristol, United Kingdom
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - S Meaney
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - R A Greene
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - P Corcoran
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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Barfar E, Sharifi V, Amini H, Mottaghipour Y, Yunesian M, Tehranidoost M, Sobhebidari P, Rashidian A. Cost-effectiveness Analysis of an Aftercare Service vs Treatment-As-Usual for Patients with Severe Mental Disorders. J Ment Health Policy Econ 2017; 20:101-110. [PMID: 28869209] [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] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/17/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND There have been claims that community mental health principles leads to the maintenance of better health and functioning in patients and can be more economical for patients with severe and chronic mental disorders. Economic evaluation studies have been used to assess the cost-effectiveness of national health programs, or to propose efficient strategies for health care delivery. AIMS OF THE STUDY The current study is intended to test the cost-effectiveness of an Aftercare Service when compared with Treatment-As-Usual for patients with severe mental disorders in Iran. METHODS This study was a parallel group randomized controlled trial. A total of 160 post-discharge eligible patients were randomized into two equal patient groups, Aftercare Service (that includes either Home Visiting Care, or Telephone Follow-up for outpatient treatment) vs Treatment-As-Usual, using stratified balanced block randomization method. All patients were followed for 12 months after discharge. The perspective of the present study was the societal perspective. The outcome measures were the rate of readmission at the hospitals after discharge, psychotic symptoms, manic symptoms, depressive symptoms, illness severity, global functioning, quality of life, and patients' satisfaction with the services. The costs included the intervention costs and the patient and family costs in the evaluation period. RESULTS There was no significant difference in effectiveness measures between the two groups. The Aftercare Service arm was about 66,000 US$ cheaper than Treatment-As-Usual arm. The average total cost per patient in the Treatment-As-Usual group was about 4651 USD, while it was reduced to 3823 US$ in the Aftercare Service group; equivalent to a cost reduction of about 800 USD per patient per year. DISCUSSION AND LIMITATIONS Given that there was no significant difference in effectiveness measures between the two groups (slightly in favor of the intervention), the Aftercare Service was cost-effective. The most important limitation of the study was the relatively small sample size due to limited budget for the implementation of the study. A larger sample size and longer follow-ups are warranted. IMPLICATIONS FOR HEALTH CARE PROVISION, USE AND POLICIES Considering the limited resources and equity concerns for health systems, the importance of making decisions about healthcare interventions based on cost-effectiveness evidence is increasing. Our results suggest that the aftercare service can be recommended as an efficient service delivery mode, especially when psychiatric bed requirements are insufficient for a population. IMPLICATIONS FOR FURTHER RESEARCH Further research should continue the work done with a larger sample size and longer follow-ups to further establish the cost-effectiveness analysis of an aftercare service program compared with routine conventional care.
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Affiliation(s)
| | | | | | | | | | | | | | - Arash Rashidian
- Department of Health Management and Economics, 4th Floor, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran,
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Moradi-Lakeh M, Yaghoubi M, Hajebi A, Malakouti SK, Vasfi MG. Cost-effectiveness of aftercare services for people with severe mental disorders: an analysis parallel to a randomised controlled clinical trial in Iran. Health Soc Care Community 2017; 25:1151-1159. [PMID: 28147433 DOI: 10.1111/hsc.12416] [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] [Subscribe] [Scholar Register] [Accepted: 11/27/2016] [Indexed: 06/06/2023]
Abstract
Aftercare services are not part of the usual care for people with severe mental disorders in Iran. This study was performed to assess the cost-effectiveness of aftercare services, including telephone follow-up or home visit, in addition to caregivers' education and training of social skills, for all subjects during the 20 months after hospital discharge. An economic evaluation was performed along with a registered randomised controlled trial (IRCT201009052557N2) on two groups of 60 persons recruited between 2010 and 2012. Intervention's effectiveness was measured by psychopathology and quality of life indicators. Cost-effectiveness and cost-utility were analysed from the societal and Ministry of Health (MoH) perspectives. All indicators of psychopathology, quality of life and satisfaction with services in the intervention group were significantly different from the control group. Mean intervention costs was US$674 (95% confidence interval [CI]: 572-776) per subject in the intervention group. Average total direct costs were US$1445 (95% CI: 1086-1804) and US$1640 (95% CI: 1087-2093) per subject in the intervention and control groups respectively. From the societal perspective, intervention had more effects with lower costs. The ratios for incremental cost-effectiveness was US$8399.1 (95% CI: 8178.2-8620.0) per quality-adjusted life year (QALY) gained from the MoH perspective for 20 months of follow-up. This study showed that aftercare services can create opportunities to use hospital beds more efficiently for unmet needs of people with psychiatric disorders. Indirect and intangible costs were not considered in this study, if taken into account, they are likely to further increase the efficiency of intervention.
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Affiliation(s)
- Maziar Moradi-Lakeh
- Institute for Health Metrics and Evaluation, Department of Global Health, University of Washington, Seattle, Washington, USA
- Preventive Medicine and Public Health Research Center, Department of Community Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Yaghoubi
- Preventive Medicine and Public Health Research Center, Department of Community Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Hajebi
- Research Center for Addiction & Risky Behavior (ReCARB), Psychiatric Department, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Kazem Malakouti
- Mental Health Research Center, Tehran Institute of Psychiatry, Faculty of Behavior Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Ghadiri Vasfi
- Mental Health Research Center, Tehran Institute of Psychiatry, Faculty of Behavior Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
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Iacobucci G. Moving care out of hospital is unlikely to save money, new analysis finds. BMJ 2017; 356:j1046. [PMID: 28249839 DOI: 10.1136/bmj.j1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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McFerran E, O'Mahony JF, Fallis R, McVicar D, Zauber AG, Kee F. Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy. Epidemiol Rev 2017; 39:148-160. [PMID: 28402402 PMCID: PMC5858033 DOI: 10.1093/epirev/mxx002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 03/21/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 12/18/2022] Open
Abstract
Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.
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Affiliation(s)
- Ethna McFerran
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - James F O'Mahony
- Centre for Health Policy and Management, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Richard Fallis
- Medical Library, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Duncan McVicar
- Queen's Management School, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
- the United Kingdom Clinical Research Collaboration
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Ilboudo PGC, Greco G, Sundby J, Torsvik G. Estimating the costs for the treatment of abortion complications in two public referral hospitals: a cross-sectional study in Ouagadougou, Burkina Faso. BMC Health Serv Res 2016; 16:559. [PMID: 27717356 PMCID: PMC5055714 DOI: 10.1186/s12913-016-1822-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment costs of induced abortion complications can consume a substantial amount of hospital resources. This use of hospitals scarce resources to treat induced abortion complications may affect hospitals' capacities to deliver other health care services. In spite of the importance of studying the burden of the treatment of induced abortion complications, few studies have been conducted to document the costs of treating abortion complications in Burkina Faso. Our objective was to estimate the costs of six abortion complications including incomplete abortion, hemorrhage, shock, infection/sepsis, cervix or vagina laceration, and uterus perforation treated in two public referral hospital facilities in Ouagadougou and the cost saving of providing safe abortion care services. METHODS The distribution of abortion-related complications was assessed through a review of postabortion care-registers combined with interviews with key informants in maternity wards and in hospital facilities. Two structured questionnaires were used for data collection following the perspective of the hospital. The first questionnaire collected information on the units and the unit costs of drugs and medical supplies used in the treatment of each complication. The second questionnaire gathered information on salaries and overhead expenses. All data were entered in a spreadsheet designed for studying abortion, and analyses were performed on Excel 2007. RESULTS Across six types of abortion complications, the mean cost per patient was USD45.86. The total cost to these two public referral hospital facilities for treating the complications of abortion was USD22,472.53 in 2010 equivalent to USD24,466.21 in 2015. Provision of safe abortion care services to women who suffered from complications of unsafe induced abortion and who received care in these public hospitals would only have cost USD2,694, giving potential savings of more than USD19,778.53 in that year. CONCLUSIONS The treatment of the complications of abortion consumes a significant proportion (up to USD22,472.53) of the two public hospitals resources in Burkina Faso. Safe abortion care services may represent a cost beneficial alternative, as it may have saved USD19,778.53 in 2010.
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Affiliation(s)
- Patrick G. C. Ilboudo
- Département de Santé Publique, Unité de Recherche Politiques et Systèmes de Santé, Centre MURAZ, 2054 Avenue Mamadou Konaté, 01 BP 390, Bobo-Dioulasso, Burkina Faso
- Department of Community Medicine, University of Oslo, Oslo, Norway
| | - Giulia Greco
- London School of Hygiene and Tropical Medicine, Department of Global Health and Development, Health Economics and Systems Analysis Group, London, UK
| | - Johanne Sundby
- Department of Community Medicine, University of Oslo, Oslo, Norway
| | - Gaute Torsvik
- University of Bergen and Chr Michelsen Institute, Bergen, Norway
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28
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Moving patients to care homes would save hospitals money. Nurs Older People 2016; 28:6. [PMID: 27029968 DOI: 10.7748/nop.28.3.6.s2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Kerr M, Rayman G, Jeffcoate WJ. Cost of diabetic foot disease to the National Health Service in England. Diabet Med 2014; 31:1498-504. [PMID: 24984759 DOI: 10.1111/dme.12545] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/12/2014] [Accepted: 06/27/2014] [Indexed: 12/15/2022]
Abstract
AIM To estimate the annual cost of diabetic foot care in a universal healthcare system. METHODS National datasets and economic modelling were used to estimate the cost of diabetic foot disease to the National Health Service in England in 2010-2011. The cost of hospital admissions specific to foot disease or amputation was estimated from Hospital Episode Statistics and national tariffs. Multivariate regression analysis was used to estimate the impact of foot disease on length of stay in admissions that were not specific to foot disease or amputation. Costs in other areas were estimated from published studies and data from individual hospitals. RESULTS The cost of diabetic foot care in 2010-2011 is estimated at £580 m, almost 0.6% of National Health Service expenditure in England. We estimate that more than half this sum (£307 m) was spent on care for ulceration in primary and community settings. Of hospital admissions with recorded diabetes, 8.8% included ulcer care or amputation. Regression analysis suggests that foot disease was associated with a 2.51-fold (95% CI 2.43-2.59) increase in length of stay.The cost of inpatient ulcer care is estimated at £219 m, and that of amputation care at £55 m. CONCLUSIONS The cost of diabetic foot disease is substantial. Ignorance of the cost of current care may hinder commissioning of effective services for prevention and management in both community and secondary care.
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Affiliation(s)
- M Kerr
- Insight Health Economics, London
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Fromer L, Pollack C. Integrated medical processes: redesigning transitions of care. Hosp Pract (1995) 2014; 42:92-98. [PMID: 25502133 DOI: 10.3810/hp.2014.10.1146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Leonard Fromer
- Assistant Clinical Professor, Department of Family Medicine, UCLA School of Medicine, Los Angeles, CA; Executive Medical Director, IMP and Group Practice Forum, New York, NY.
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Gardner R, Li Q, Baier RR, Butterfield K, Coleman EA, Gravenstein S. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Intern Med 2014; 29:878-84. [PMID: 24590737 PMCID: PMC4026506 DOI: 10.1007/s11606-014-2814-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [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: 11/06/2013] [Revised: 01/06/2014] [Accepted: 02/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization. OBJECTIVE To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI). DESIGN A quasi-experimental cohort study using consecutive convenience sampling. PATIENTS Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals. INTERVENTION The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls. MAIN MEASURES We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences. KEY RESULTS Compared to matched internal controls (N = 321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P = 0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed. CONCLUSIONS This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.
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Affiliation(s)
- Rebekah Gardner
- />Healthcentric Advisors, Providence, RI USA
- />Alpert Medical School of Brown University, Providence, RI USA
| | - Qijuan Li
- />School of Public Health, Brown University, Providence, RI USA
| | - Rosa R. Baier
- />Healthcentric Advisors, Providence, RI USA
- />School of Public Health, Brown University, Providence, RI USA
| | | | | | - Stefan Gravenstein
- />Healthcentric Advisors, Providence, RI USA
- />Alpert Medical School of Brown University, Providence, RI USA
- />School of Public Health, Brown University, Providence, RI USA
- />Case Western Reserve University, Cleveland, OH USA
- />University Hospitals--Case Medical Center, Mailstop HAN 6095, 11100 Euclid Avenue, Cleveland, OH 44106 USA
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Russell H, Swint JM, Lal L, Meza J, Walterhouse D, Hawkins DS, Okcu MF. Cost minimization analysis of two treatment regimens for low-risk rhabdomyosarcoma in children: a report from the Children's Oncology Group. Pediatr Blood Cancer 2014; 61:970-6. [PMID: 24453105 PMCID: PMC4370185 DOI: 10.1002/pbc.24950] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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: 07/15/2013] [Accepted: 12/16/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND Recent Children's Oncology Group trials for low-risk rhabdomyosarcoma attempted to reduce therapy while maintaining excellent outcomes. D9602 delivered 45 weeks of outpatient vincristine and dactinomycin (VA) for patients in Subgroup A. ARST0331 reduced the duration of therapy to 22 weeks but added four doses of cyclophosphamide to VA for patients in Subset 1. Failure-free survival was similar. We undertook a cost minimization comparison to help guide future decision-making. PROCEDURE Addressing the costs of treatment from the healthcare perspective we modeled a simple decision-analytic model from aggregate clinical trial data. Medical care inputs and probabilities were estimated from trial reports and focused chart review. Costs of radiation, surgery and off-therapy surveillance were excluded. Unit costs were obtained from literature and national reimbursement and inpatient utilization databases and converted to 2012 US dollars. Model uncertainty was assessed with first-order sensitivity analysis. RESULTS Direct medical costs were $46,393 for D9602 and $43,261 for ARST0331 respectively, making ARST0331 the less costly strategy. Dactinomycin contributed the most to D9602 total costs but varied with age (42-69%). Chemotherapy administration costs accounted for the largest proportion of ARST0331 total costs (39-57%). ARST0331 incurred fewer costs than D9602 under most alternative distributive models and alternative clinical practice assumptions. CONCLUSIONS Cost analysis suggests that ARST0331 may incur fewer costs than D9602 from the healthcare system's perspective. Attention to the services driving the costs provides directions for future efficiency improvements. Future studies should prospectively consider the patient and family's perspective.
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Affiliation(s)
- Heidi Russell
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
- University of Texas School of Public Health, Division of Management, Policy and Community Health, Houston, Texas
- Correspondence to: Heidi Russell, Texas Children’s Cancer and Hematology Centers, 6701 Fannin, CCC 1510.00, Houston, TX 77030.
| | - J. Michael Swint
- University of Texas School of Public Health, Division of Management, Policy and Community Health, Houston, Texas
- University of Texas School of Medicine, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas
| | - Lincy Lal
- University of Texas School of Public Health, Division of Management, Policy and Community Health, Houston, Texas
| | - Jane Meza
- University of Nebraska Medical Center College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - David Walterhouse
- Ann & Robert H Lurie Children’s Hospital of Chicago, Division of Hematology/Oncology/Stem Cell Transplant, Chicago, Illinois
| | - Douglas S. Hawkins
- Seattle Children’s Hospital, Fred Hutchinson Cancer Research Center, University of Washington, Department of Pediatrics, Seattle, Washington
| | - M. Fatih Okcu
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
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Affiliation(s)
- Robert Mechanic
- From the Heller School for Social Policy and Management, Brandeis University, Waltham, MA
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Sathar Z, Rashida G, Shah Z, Singh S, Woog V. Postabortion care in Pakistan. Issues Brief (Alan Guttmacher Inst) 2013:1-8. [PMID: 24006560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The current law in Pakistan permits abortion only under narrow circumstances. As a result, women resort to clandestine and unsafe abortion procedures, which often lead to complications. This report summarizes findings from a study that examined the conditions under which women obtain abortion in Pakistan; the incidence, coverage and quality of facility-based postabortion care (PAC); and the extent to which recommended standards for PAC have been implemented in health facilities.
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Hajebi A, Sharifi V, Ghadiri Vasfi M, Moradi-Lakeh M, Tehranidoost M, Yunesian M, Amini H, Rashidian A, Malakouti SK, Mottaghipour Y. A multicenter randomized controlled trial of aftercare services for severe mental illness: study protocol. BMC Psychiatry 2013; 13:178. [PMID: 23816199 PMCID: PMC3722090 DOI: 10.1186/1471-244x-13-178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 06/25/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Severe mental illness is responsible for a significant proportion of burden of diseases in Iranian population. People with severe mental illnesses are more likely to have high rates of non-attendance at follow-up visits, and lack of an active follow-up system, particularly in the country's urban areas that has resulted in the revolving door phenomenon of rehospitalizations. Therefore, there is an increasing need for implementation of effective and cost-effective aftercare services. METHOD/DESIGN This is a randomized control trial with the primary hypothesis that aftercare services delivered to patients with severe mental illnesses in outpatient department and patient's home by a community care team would be more effective when compared to treatment as usual (TAU) in reducing length of hospital stay and any psychiatric hospitalization. Patients were recruited from three psychiatric hospitals in Iran. After obtaining informed written consent, they were randomly allocated into aftercare intervention and control (TAU) groups. Aftercare services included treatment follow-up (through either home care or telephone follow-up prompts for outpatient attendance), family psychoeducation, and patient social skills training that were provided by community mental health teams. Patients were followed for 12 months after discharge. The primary outcome measures were length of hospital stay and any hospitalization in the 12 month follow-up. Secondary outcome measures included patients' clinical global impression, global functioning, quality of life, and patient's satisfaction. The trial also allowed an assessment of direct cost-effectiveness of the aftercare services. DISCUSSION This paper presents a protocol for an RCT of aftercare services delivered to patients with severe mental illnesses within patients' home or outpatient department. The findings of this study can influence policy and program planning for people with severe mental illnesses in Iran. TRIAL REGISTRATION IRCT201009052557N2.
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Affiliation(s)
- Ahmad Hajebi
- Mental Health Research Centre, Tehran Psychiatric Institute, Iran University of Medical Sciences, Tehran 15745-344, Iran
| | - Vandad Sharifi
- Department of Psychiatry and Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran 13337-95914, Iran
| | - Mohammad Ghadiri Vasfi
- Mental Health Research Centre, Tehran Psychiatric Institute, Iran University of Medical Sciences, Tehran 15745-344, Iran
| | - Maziar Moradi-Lakeh
- Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Tehranidoost
- Department of Psychiatry and Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran 13337-95914, Iran
| | - Masud Yunesian
- Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Homayoun Amini
- Department of Psychiatry and Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran 13337-95914, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Kazem Malakouti
- Mental Health Research Centre, Tehran Psychiatric Institute, Iran University of Medical Sciences, Tehran 15745-344, Iran
| | - Yasaman Mottaghipour
- Psychiatry Department, Imam Hosein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Huff C. New way to staff a hospital. Hosp Health Netw 2013; 87:38-41. [PMID: 23885484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Herrera-Espiñeira C, Escobar A, Navarro-Espigares JL, Castillo JDDL, García-Pérez L, Godoy-Montijano A. [Total knee and hip prosthesis: variables associated with costs]. CIR CIR 2013; 81:207-213. [PMID: 23769249] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The elevated prevalence of osteoarthritis in Western countries, the high costs of hip and knee arthroplasty, and the wide variations in the clinical practice have generated considerable interest in comparing the associated costs before and after surgery. OBJECTIVE To determine the influence of a number of variables on the costs of total knee and hip arthroplasty surgery during the hospital stay and during the one-year post-discharge. METHODS A prospective multi-center study was performed in 15 hospitals from three Spanish regions. Relationships between the independent variables and the costs of hospital stay and postdischarge follow-up were analyzed by using multilevel models in which the "hospital" variable was used to group cases. Independent variables were: age, sex, body mass index, preoperative quality of life (SF-12, EQ-5 and Womac questionnaires), surgery (hip/knee), Charlson Index, general and local complications, number of beds and economic-institutional dependency of the hospital, the autonomous region to which it belongs, and the presence of a caregiver. RESULTS The cost of hospital stay, excluding the cost of the prosthesis, was 4,734 Euros, and the post-discharge cost was 554 Euros. With regard to hospital stay costs, the variance among hospitals explained 44-46% of the total variance among the patients. With regard to the post-discharge costs, the variability among hospitals explained 7-9% of the variance among the patients. CONCLUSIONS There is considerable potential for reducing the hospital stay costs of these patients, given that more than 44% of the observed variability was not determined by the clinical conditions of the patients but rather by the behavior of the hospitals.
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Affiliation(s)
- Carmen Herrera-Espiñeira
- Servicio Reanimación de Traumatología, Hospital Universitario Virgen de las Nieves de Granada, Granada, Spain.
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Adler KG. Transitional care management: why bother? Fam Pract Manag 2013; 20:6. [PMID: 23939728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Smith S, Horgan F, Sexton E, Cowman S, Hickey A, Kelly P, McGee H, Murphy S, O'Neill D, Royston M, Shelley E, Wiley M. The future cost of stroke in Ireland: an analysis of the potential impact of demographic change and implementation of evidence-based therapies. Age Ageing 2013; 42:299-306. [PMID: 23302602 DOI: 10.1093/ageing/afs192] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND PURPOSE this paper examines the impact of demographic change from 2007 to 2021 on the total cost of stroke in Ireland and analyses potential impacts of expanded access to stroke unit care and thrombolytic therapy on stroke outcomes and costs. METHODS total costs of stroke are estimated for the projected number of stroke cases in 2021 in Ireland. Analysis also estimates the potential number of deaths or institutionalised cases averted among incident stroke cases in Ireland in 2007 at different rates of access to stroke unit care and thrombolytic therapy. Drawing on these results, total stroke costs in Ireland in 2007 are recalculated on the basis of the revised numbers of incident stroke patients estimated to survive stroke, and of the numbers estimated to reside at home rather than in a nursing home in the context of expanded access to stroke units or thrombolytic therapy. RESULTS future costs of stroke in Ireland are estimated to increase by 52-57% between 2007 and 2021 on the basis of demographic change. The projected increase in aggregate stroke costs for all incident cases in 1 year in Ireland due to the delivery of stroke unit care and thrombolytic therapy can be offset to some extent by reductions in nursing home and other post-acute costs.
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Affiliation(s)
- Samantha Smith
- Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland.
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Thelian J. Transitional care management services: everything you need to know. J Med Pract Manage 2013; 28:382-384. [PMID: 23866657] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Tired of providing medical services without reimbursement? Learn how to document and code for Transitional Care Management, and start receiving reimbursement for services you may have been providing gratis.
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Hussain R, Finer LB. Unintended pregnancy and unsafe abortion in the Philippines: context and consequences. Issues Brief (Alan Guttmacher Inst) 2013:1-8. [PMID: 24006559] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Despite advances in reproductive health law, many Filipino women experience unintended pregnancies, and because abortion is highly stigmatized in the country, many who seek abortion undergo unsafe procedures. This report provides a summary of reproductive health indicators in the Philippines—in particular, levels of contraceptive use, unplanned pregnancy and unsafe abortion—and describes the sociopolitical context in which services are provided, the consequences of unintended pregnancy and unsafe abortion,and recommendations for improving access to reproductive health services.
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De Salas-Cansado M, Belén Ruiz Antorán M, Ramírez E, Dudley A. [Utilization of health care resources and cost associated to fasciectomy in Dupuytren's disease in Spain]. Farm Hosp 2013; 37:41-9. [PMID: 23461499 DOI: 10.7399/fh.2013.37.1.40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To estimate the healthcare resource utilization and their associated costs secondary to fasciectomy of Dupuytren s disease (DD) treated under usual medical practice in Spain. METHODS This multicenter, observational, retrospective cohort study, extracted data through the revision of medical records of three tertiary public hospitals. Each center should recruit 40 patients operated for DD, as principal diagnose of Minimum Data Set, in which the surgical procedure conducted was fasciectomy, during 2007-2009. To collect all the resources used during surgery, a specific chart form was designed. Demographic (age, gender, occupational status), clinical (stage of contracture and comorbilities) and healthcare utilization (hospitalizations, medical visits, tests, drugs) data were collected under medical routine. Comparisons between stage of contracture grouped (I: stage N, 1 & 2; II: stage 3 & 4) and centers were made. RESULTS A total of 123 subjects (52% group I; 86.2% men; 35.8% active workers) were identified. 81.3% of patients presented at least one comorbidity, being hypertension the most frequent. 28.4% of patients were operated in ambulatory surgery and 71.6% hospitalized. All the patients had follow-up visits after surgery, 27% needed physical therapy, 88% performed preoperative tests and 8% visit the emergency room after surgery. Healthcare mean (SD) costs were as follows: fasciectomy €1,074 (0); hospitalizations €978 (743); ambulatory €186 (10); follow-up visits €260 (173); emergency rooms €13 (53); tests €78(43); drugs €7 (9); physical therapy €46 (134). Mean total costs were €2,250 (839). There were no significant differences between study groups grouped by stage of contracture. However, the center and the severity of the CD seem explanatory variables of cost, p<0.05. CONCLUSIONS Healthcare resources utilization for surgical treatment of Dupuytren's disease may cost €2,250 (839) per fasciectomy treated under usual medical practice.
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New Medicare provisions to recognize and pay for core nursing services. ANA advocated including care coordination, transitional care in reimbursement policies. Okla Nurse 2013; 58:12. [PMID: 23547426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Affiliation(s)
- Andrew B Bindman
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington DC, USA
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López ME, Kaplan CP, Nápoles AM, Livaudais JC, Hwang ES, Stewart SL, Bloom J, Karliner L. Ductal carcinoma in situ (DCIS): posttreatment follow-up care among Latina and non-Latina White women. J Cancer Surviv 2013; 7:219-26. [PMID: 23408106 DOI: 10.1007/s11764-012-0262-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [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: 09/20/2012] [Accepted: 12/20/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a lack of information about posttreatment care among patients with ductal carcinoma in situ (DCIS). This study compares posttreatment care by ethnicity-language and physician specialty among Latina and White women with DCIS. METHODS Latina and White women diagnosed with DCIS between 2002 and 2005 identified through the California Cancer Registry completed a telephone survey in 2006. Main outcomes were breast surveillance, lifestyle counseling, and follow-up physician specialty. KEY RESULTS Of 742 women (396 White, 349 Latinas), most (90 %) had at least one clinical breast exam (CBE). Among women treated with breast-conserving surgery (BCS; N = 503), 76 % had received at least two mammograms. While 92 % of all women had follow-up with a breast specialist, Spanish-speaking Latinas had the lowest specialist follow-up rates (84 %) of all groups. Lifestyle counseling was low with only 53 % discussing exercise, 43 % weight, and 31 % alcohol in relation to their DCIS. In multivariable analysis, Spanish-speaking Latinas with BCS had lower odds of receiving the recommended mammography screening in the year following treatment compared to Whites (OR 0.5; 95 % CI, 0.2-0.9). Regardless of ethnicity-language, seeing both a specialist and primary care physician increased the odds of mammography screening and CBE (OR 1.6; 95 % CI, 1.2-2.3 and OR 1.9; 95 % CI, 1.3-2.8), as well as having discussions about exercise, weight, and alcohol use, compared to seeing a specialist only. CONCLUSIONS Most women reported appropriate surveillance after DCIS treatment. However, our results suggest less adequate follow-up for Spanish-speaking Latinas, possibly due to language barriers or insurance access. IMPLICATIONS FOR CANCER SURVIVORS Follow-up with a primary care provider in addition to a breast specialist increases receipt of appropriate follow-up for all women.
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Affiliation(s)
- Mónica E López
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, 1545 Divisadero Street, San Francisco, CA 94143-0320, USA
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Hussain R. Unintended pregnancy and abortion in Uganda. Issues Brief (Alan Guttmacher Inst) 2013:1-8. [PMID: 23550324] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Unintended pregnancy is common in Uganda, leading to high levels of unplanned births, unsafe abortions, and maternal injury and death. Because most pregnancies that end in abortion are unwanted, nearly all ill health and mortality resulting from unsafe abortion is preventable. This report summarizes evidence on the context and consequences of unintended pregnancy and unsafe abortion in Uganda, points out gaps in knowledge, and highlights steps that can be taken to reduce levels of unintended pregnancy and unsafe abortion, and, in turn, the high level of maternal mortality.
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Shay PD, Mick SS. Post-acute care and vertical integration after the Patient Protection and Affordable Care Act. J Healthc Manag 2013; 58:15-28. [PMID: 23424816] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The anticipated changes resulting from the passage of the Patient Protection and Affordable Care Act-including the proposed adoption of bundled payment systems and the promotion of accountable care organizations-have generated considerable controversy as U.S. healthcare industry observers debate whether such changes will motivate vertical integration activity. Using examples of accountable care organizations and bundled payment systems in the American post-acute healthcare sector, this article applies economic and sociological perspectives from organization theory to predict that as acute care organizations vary in the degree to which they experience environmental uncertainty, asset specificity, and network embeddedness, their motivation to integrate post-acute care services will also vary, resulting in a spectrum of integrative behavior.
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Ledger K. Slowing the revolving door: Minnesota's hospitals are leading the way in reducing preventable readmissions. Minn Med 2011; 94:24-29. [PMID: 22039680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Affiliation(s)
- Vincent Mor
- Center for Gerontology and Health Care Research, Brown University, Providence, RI, USA.
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