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Background: Changes to prescribing policies in England have restricted or stopped access to gluten‐free food on prescription for people with coeliac disease in some geographical areas. The present study aimed to explore the impact of these changes on the affordability and obtainability of gluten‐free foods for adults with coeliac disease. Methods: Semi‐structured qualitative interviews (n = 24) were conducted with people with coeliac disease living in areas where prescriptions for gluten‐free foods were no longer available, were restricted or followed national guidelines. Interviews explored the impact of gluten‐free prescribing changes on the affordability and obtainability of gluten‐free food, as well as dietary adherence. Results: All participants considered gluten‐free substitute foods to be expensive. Participants felt the availability of gluten‐free foods has improved over time, also acknowledging some challenges remain, such as limited local availability. For most, the withdrawal of prescriptions had minimal impact requiring small adjustments such as reducing the quantity of foods obtained. However, greater challenges were faced by those less mobile, permanently sick or disabled and/or on lower incomes. Conclusions: The majority of participants affected by the withdrawal of prescriptions were able to adapt to cope with these changes. However, participants with mobility issues, who are permanently sick or disabled and/or on lower incomes were struggling to afford and obtain gluten‐free substitute foods from elsewhere. The withdrawal of prescriptions may further widen health inequalities. Further research should focus on the long‐term impacts of prescription withdrawal for the vulnerable groups identified. Key points: Prescriptions for gluten‐free substitute foods have been restricted or withdrawn in some areas of England, but the impact of these changes on people with coeliac disease is unknown.The present study found that the majority of people with coeliac disease were able to adapt to cope with prescribing changes, but certain groups (people with mobility issues, who are permanently sick or disabled and/or on lower incomes) were struggling to afford and obtain gluten‐free foods.Future research should focus on the longer‐term impacts of no access or restricted access to gluten‐free substitute foods on prescription, with specific focus on the groups identified above. [ABSTRACT FROM AUTHOR]

Background: Vaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries (LMICs). Universal access to vaccination, besides improved health outcomes, would substantially reduce VPD-related out-of-pocket (OOP) expenditures and associated financial risks. This paper aims to estimate the extent of OOP expenditures and the magnitude of the associated catastrophic health expenditures (CHEs) for selected VPDs in Ethiopia. Methods and findings: We conducted a cross-sectional costing analysis, from the household (patient) perspective, of care-seeking for VPDs in children aged under 5 years for pneumonia, diarrhea, measles, and pertussis, and in children aged under 15 years for meningitis. Data on OOP direct medical and nonmedical expenditures (2021 USD) and household consumption expenditures were collected from 995 households (1 child per household) in 54 health facilities nationwide between May 1 and July 31, 2021. We used descriptive statistics to measure the main outcomes: magnitude of OOP expenditures, along with the associated CHE within households. Drivers of CHE were assessed using a logistic regression model. The mean OOP expenditures per disease episode for outpatient care for diarrhea, pneumonia, pertussis, and measles were $5·6 (95% confidence interval (CI): $4·3, 6·8), $7·8 ($5·3, 10·3), $9·0 ($6·4, 11·6), and $7·4 ($3·0, 11·9), respectively. The mean OOP expenditures were higher for inpatient care, ranging from $40·6 (95% CI: $12·9, 68·3) for severe measles to $101·7 ($88·5, 114·8) for meningitis. Direct medical expenditures, particularly drug and supply expenses, were the major cost drivers. Among those who sought inpatient care (345 households), about 13·3% suffered CHE, at a 10% threshold of annual consumption expenditures. The type of facility visited, receiving inpatient care, and wealth were significant predictors of CHE (p-value < 0·001) while adjusting for area of residence (urban/rural), diagnosis, age of respondent, and household family size. Limitations include inadequate number of measles and pertussis cases. Conclusions: The OOP expenditures induced by VPDs are substantial in Ethiopia and disproportionately impact those with low income and those requiring inpatient care. Expanding equitable access to vaccines cannot be overemphasized, for both health and economic reasons. Such realization requires the government's commitment toward increasing and sustaining vaccine financing in Ethiopia. In a cross-sectional costing analysis, Solomon Tessema Memirie and colleagues explore out-of-pocket expenditures and financial risks associated with treatment of vaccine-preventable diseases in Ethiopia. Author summary: Why was this study done?: Despite a rapid expansion in access to vaccines in the past 2 decades, vaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries. Out-of-pocket (OOP) medical expenditures can lead to catastrophic health expenditures and impoverishment. Studies on household healthcare expenditures and associated financial risks for VPDs among children in sub-Saharan African countries are scarce. What did the researchers do and find?: We collected OOP expenditures data from 995 households to estimate medical impoverishment associated with the following vaccine-preventable childhood diseases: measles, pertussis, pneumonia, diarrhea, and meningitis. Households incur substantial OOP expenditures for the treatment of VPDs in Ethiopia. Poor families and those with sick children requiring inpatient care are likely to be impoverished. What do these findings mean?: Expanding access to vaccination has the potential to protect families from OOP expenditures related to the treatment of VPDs and its associated catastrophic and impoverishing financial consequences. The financial risk benefits primarily accrue among the poorest. Universal access to vaccines requires the government's commitment toward increasing and sustaining vaccine financing. [ABSTRACT FROM AUTHOR]

The article presents the discussion on assessing the direct costs of the association of radiotherapy (RT) to immunotherapy (IT) in cancer patients. Topics include effects of ionizing radiation being recognized as contributing to systemic antitumor immunity; and bias being minimized by the use of the same comparator pembrolizumab in all trials.

Healthcare systems face challenges due to budget constraints, complex therapies, and new treatments for rare diseases. One of the most successful patient advocacy campaigns of all times was initiated by people living with HIV and AIDS in African countries. Facing industry giants, they won court cases allowing governments to ignore intellectual property rights when the price of a medicine was abnormally high. This led to the approval of the international 'Agreement on Trade Related aspects of Intellectual Property Rights', which contributed to improving the availability of AIDS treatments for millions of people. Beyond this successful patient advocacy campaign, patient organisations have an important role to play in national discussions on prices of treatments and pharmaceuticals, especially for rare diseases. This article first discusses the specificity of the pricing of orphan medicinal products, and then provides an overview of some of the important actions that can be carried out by patients' organisations. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID-19) is now a global public threat. Given the pandemic of COVID-19, the economic impact of COVID-19 is essential to add value to the policy-making process. We retrospectively conducted a cost and affordability analysis to determine the medical costs of COVID-19 patients in China, and also assess the factors affecting their costs. Methods: This analysis was retrospectively conducted in Shandong Provincial Chest Hospital between 24 January and 16 March 2020. The total direct medical expenditures were analyzed by cost factors. We also assessed affordability by comparing the simulated out-of-pocket expenditure of COVID-19 cases relative to the per capita disposable income. Differences between groups were tested by student t test and Mann-Whitney test when appropriate. A multiple logistic regression model was built to determine the risk factors associated with high cost. Results: A total of 70 COVID-19 patients were included in the analysis. The overall mean cost was USD 6827 per treated episode. The highest mean cost was observed in drug acquisition, accounting for 45.1% of the overall cost. Total mean cost was significantly higher in patients with pre-existing diseases compared to those without pre-existing diseases. Pre-existing diseases and the advanced disease severity were strongly associated with higher cost. Around USD 0.49 billion were expected for clinical manage of COVID-19 in China. Among rural households, the proportions of health insurance coverage should be increased to 70% for severe cases, and 80% for critically ill cases to avoid catastrophic health expenditure. Conclusions: Our data demonstrate that clinical management of COVID-19 patients incurs a great financial burden to national health insurance. The cost for drug acquisition is the major contributor to the medical cost, whereas the risk factors for higher cost are pre-existing diseases and severity of COVID-19. Improvement of insurance coverage will need to address the barriers of rural patients to avoid the occurrence of catastrophic health expenditure. [ABSTRACT FROM AUTHOR]

Diseases can be interconnected. In the recent years, there has been a surge of multidisease studies. Among them, HDN (human disease network) analysis takes a system perspective, examines the interconnections among diseases along with their individual properties, and has demonstrated great potential. Most of the existing HDN analyses are based on either molecular information (which may be unreliable and have limited clinical relevance) or phenotypic measures (which may have limited implications for disease management and not directly reflect disease severity). In this study, we take advantage of the uniquely valuable Taiwan NHIRD (National Health Insurance Research Database) data and conduct an HDN analysis of disease treatment cost. Complementing the existing literature, treatment cost can serve as a surrogate of disease severity (and hence be clinically highly relevant) and also directly describe the financial burden of illness (and hence be uniquely informative for disease management). With inpatient and outpatient treatment data on close to 1 million randomly selected subjects and collected during the period of 2000 to 2013, the human disease cost network is constructed using a novel copula-based approach and the weighted correlation-based network construction technique. Extensive analysis is conducted, and the results are found to be biomedically sensible. [ABSTRACT FROM AUTHOR]

Osteoporosis (OP) is a major public health concern, but still OP care does not meet guidelines. Interventions have been developed to improve appropriate OP management. The objective of the present study was to systematically review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility. Studies published from 2003 to 2018 were retrieved from PubMed/MEDLINE, Science Direct, Web of Science, Cochrane, and Wiley Online Library databases. Screening of references and quality assessment were independently performed by two reviewers. We classified interventions into three types according to the target of the intervention: health system (structural interventions), healthcare professional (HCP), and patient. Meta-analysis was performed by type of intervention and their effect on two outcomes: prescription of BMD measurement and prescription of OP therapy. A total of 4268 records were screened; 32 studies were included in the qualitative analysis and 29 studies in the quantitative analysis. Structural interventions strongly and significantly improved prescription of BMD measurement (OR = 9.99, 95% CI 2.05; 48.59) and treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). The impact of HCP-centered interventions on BMD measurement prescription did not reach statistical significance (OR = 2.19, 95% CI 0.84; 5.73) but significantly improved treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). Interventions involving patients significantly improved the prescription of BMD measurement (OR = 2.16, 95% CI 1.62; 2.89) and treatment prescription (OR = 1.70, 95% CI 1.35; 2.14). Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription. [ABSTRACT FROM AUTHOR]

Background: Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost. Methods: The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters. Results: One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p =.005) and flow diversion was 1.7× more expensive than clipping (p <.001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p <.05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p =.05) and increased (p <.001) total costs, respectively. Patients with severe vasospasm (p <.005), those that received shunts (p <.001), and those who had complications (p <.001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost. Conclusions: These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN: Two‐year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING: A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS: Nursing staff and medical care providers in the participating NHs. INTERVENTION: Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS: Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin‐resistant Staphylococcus aureus (MRSA) infections. RESULTS: Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69‐0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65‐0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92‐0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2‐year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS: Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46–54, 2019 See related editorial by Furuno et al. in this issue. [ABSTRACT FROM AUTHOR]

Oral sotalol, used in adults for sinus rhythm control, is initiated at 80 mg b.i.d. and titrated to a maximum safe dose. The US Food and Drug Administration recommends monitoring the corrected QT interval (QTc) for at least 3 days, until steady‐state exposure of the drug is reached, before patient discharge, which can significantly impact the total cost of treatment. The objectives of this research were to design an accelerated intravenous sotalol loading and maintenance therapy that will reduce the hospital length of stay and to also evaluate the pharmacoeconomic impact in a hospital setting. Pharmacokinetic simulations of sotalol plasma concentrations vs. times profiles were performed to determine the optimal intravenous/oral transition regimen. A cost minimization analysis from the health sector perspective was conducted to assess the cost savings for these proposed accelerated regimens. For a chosen target dose of 120 mg b.i.d., two infusions of 40 mg over 1 hour and 20 mg over 0.5 hour, each followed up by an evaluation of QTc, can be administered followed immediately by the target oral maintenance dose of 120 mg at the end of the second infusion. Consequently, steady‐state exposure and, therefore, steady‐state QTc are obtained on the first day of therapy, facilitating an earlier hospital discharge. Two and 1‐day mean total cost of −$3,123 (95% confidence interval (CI), −$3,640, −$2,607) −$4,820 (95% CI, −$5,352, −$4,288) were observed for this strategy, respectively. We are proposing an intravenous to oral transition strategy for sotalol that has the potential to significantly reduce cost and increase patient convenience. [ABSTRACT FROM AUTHOR]

In Malaysia, there is exponential growth of patients on dialysis. Dialysis treatment consumes a considerable portion of healthcare expenditure. Comparative assessment of their cost effectiveness can assist in providing a rational basis for preference of dialysis modalities. A cost utility study of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) was conducted from a Ministry of Health (MOH) perspective. A Markov model was also developed to investigate the cost effectiveness of increasing uptake of incident CAPD to 55% and 60% versus current practice of 40% CAPD in a five-year temporal horizon. A scenario with 30% CAPD was also measured. The costs and utilities were sourced from published data which were collected as part of this study. The transitional probabilities and survival estimates were obtained from the Malaysia Dialysis and Transplant Registry (MDTR). The outcome measures were cost per life year (LY), cost per quality adjusted LY (QALY) and incremental cost effectiveness ratio (ICER) for the Markov model. Sensitivity analyses were performed. LYs saved for HD was 4.15 years and 3.70 years for CAPD. QALYs saved for HD was 3.544 years and 3.348 for CAPD. Cost per LY saved was RM39,791 for HD and RM37,576 for CAPD. The cost per QALY gained was RM46,595 for HD and RM41,527 for CAPD. The Markov model showed commencement of CAPD in 50% of ESRD patients as initial dialysis modality was very cost-effective versus current practice of 40% within MOH. Reduction in CAPD use was associated with higher costs and a small devaluation in QALYs. These findings suggest provision of both modalities is fiscally feasible; increasing CAPD as initial dialysis modality would be more cost-effective. [ABSTRACT FROM AUTHOR]

The economic issues related to medical treatments in youth with type 2 diabetes (T2D) are rarely reported and thus not fully understood. The Treatment Options for type 2 Diabetes in Adolescents and Youth clinical trial of youth recently diagnosed with T2D collected healthcare and related cost information from the largest cohort studied to date. Costs related to medical treatments and expenses faced by caregivers were identified over a 2‐year period from 496 participants. Data were collected by surveys and diaries to document frequency of use of diabetes care (excluding study laboratory tests), non‐diabetes care services and treatments, caregiver time, and expenses related to exercise and dietary activities recommended for patients. Economic costs were derived by applying national cost values to the reported utilization frequency data. Annual medical costs in the first year varied by the treatment group, averaging $1798 in those assigned to metformin alone (M), $2971 to combination drug therapy with metformin + rosiglitazone (M + R), and $2092 to metformin + an intensive lifestyle and behavior change program (M + L). Differences were primarily due to costs related to combination drug therapy. Adult caregiver support costs were higher for participants in the lifestyle program, which was delivered in weekly sessions in the first 6 months. Expenses for purchases to enhance diet and exercise change did not vary by treatment assignment. In year 2, medication costs increased in M and M + L due to the initiation of insulin in subjects who failed to maintain glycemic control on the assigned treatment. Data are reported for use by researchers and those providing healthcare to this vulnerable patient population. [ABSTRACT FROM AUTHOR]

Purpose Results of a study incorporating real-world results into a predictive model to assess the cost-effectiveness of procalcitonin (PCT)-guided antibiotic use in intensive care unit patients with sepsis are reported. Methods A single-center, retrospective cross-sectional study was conducted to determine whether reductions in antibiotic therapy duration and other care improvements resulting from PCT testing and use of an associated treatment pathway offset the costs of PCT testing. Selected base-case cost outcomes in adults with sepsis admitted to a medical intensive care unit (MICU) were assessed in preintervention and postintervention cohorts using a decision analytic model. Cost-minimization and cost–utility analyses were performed from the hospital perspective with a 1-year time horizon. Secondary and univariate sensitivity analyses tested a variety of clinically relevant scenarios and the robustness of the model. Results Base-case modeling predicted that use of a PCT-guided treatment algorithm would results in hospital cost savings of $45 per patient and result in a gain of 0.0001 quality-adjusted life-year. After exclusion of patients in the postintervention cohort for PCT test ordering outside of institutional guidelines, the mean inpatient antibiotic therapy duration was significantly reduced in the postintervention group relative to the preintervention group (6.2 days versus 4.9 days, p = 0.04) after adjustment for patient sex and age, Charlson Comorbidity Index score, study period, vasopressor use, and ventilator use. Total annual hospital cost savings of $4,840 were predicted. Conclusion Real-world implementation of PCT-guided antibiotic use may have improved patients' quality of life while decreasing hospital costs in MICU patients with undifferentiated sepsis. [ABSTRACT FROM AUTHOR]

Background: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. Methods: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. Results: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €−1969, 95%CI= −3680 to −939) and third (mean difference €−2298, 95%CI= −4092 to −1288) compared to the first dislocation. Conclusions: Nonoperative treatment of shoulder instability has substantial societal costs. Level of Evidence: III, economic analysis. [ABSTRACT FROM AUTHOR]

Background: The long‐acting oxytocic agent; carbetocin, has been consistently shown to reduce the need for additional uterotonics at caesarean section, but not postpartum haemorrhage (PPH). While promising, current evidence is limited by heterogenicity in study design and findings. Aims: To examine whether carbetocin confers clinical or economic benefit compared to oxytocin at caesarean section in an all‐risk Australian population. Materials and Methods: A retrospective cohort study was undertaken of all singleton caesarean sections at a public tertiary hospital from 2008 to 2010 (n = 2499). From 1 January 2008 to 24 March 2009 all women received prophylactic oxytocin 5–10 units slow push intravenously at delivery, after which all patients received 100 μg intravenous carbetocin. Outcomes were PPH (≥1000 mL) and the requirement of secondary uterotonics. A post hoc cost analysis was also performed. Results: A total of 1467 and 1024 patients received carbetocin and oxytocin, respectively. Incidence of PPH ≥1000 mL was 7.8% for carbetocin compared to and 9.7% for oxytocin (odds ratio (OR) 0.79, 95% CI 0.59–1.05). Moderate blood loss >500 mL was significantly reduced with carbetocin; occurring in 27.3% versus 39.4% (OR 0.57, 95% CI 0.49–0.68). There was a 20.0% reduction in secondary uterotonic treatment with carbetocin (OR 0.42, 95% CI 0.35–0.49). Average drug costs were lower with oxytocin at $4.74 versus $36.42/patient. However, the 1.9% reduction in PPH with carbetocin resulted in a $63.46 reduction in cost per patient, with a cost‐effectiveness ratio of $1667 to prevent one case of PPH ≥1000 mL. Conclusions: Carbetocin reduced moderate blood loss >500 mL, but not PPH ≥1000 mL. Carbetocin conferred a 20% reduction in secondary uterotonic treatment, as well as lowering direct medical costs. [ABSTRACT FROM AUTHOR]

Background: The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years. Methods and findings: This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy. Conclusions: At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up. [ABSTRACT FROM AUTHOR]

Background: Drug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment. Objective: Estimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis. Methods: Data are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients' medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen. Results: We enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment ("production cost") in the cohort is $6,684. Conclusions: Decentralized, outpatient RR/MDR-TB care under South Africa's 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length. [ABSTRACT FROM AUTHOR]

Introduction: Cost efficiency is important for hospitals in order to provide high-quality health care for all patients. As hemihepatectomies are increasingly being performed laparoscopically, the aims of this study were to evaluate the costs of laparoscopic hemihepatectomy and to compare them to conventional open techniques. Patients and methods: This is a retrospective analysis of clinical outcomes and financial calculations of all patients who underwent hemihepatectomy between January 2015 and December 2016 at the Department of Surgery, Campus Charité Mitte and Campus Charité Virchow-Klinikum, Berlin, Germany, being allocated to the DRG (diagnosis-related group) H01A (complex operations of the liver and pancreas with complex intensive care treatment) or H01B (operations of the liver and pancreas without complex intensive care treatment). To overcome selection bias, a 1:1 propensity score matching (PSM) analysis was performed. Results: After PSM, a total of 64 patients were identified; 32 patients underwent laparoscopic hemihepatectomy (LH); and 32 patients received open hemihepatectomy (OH). After PSM, no significant differences were observed in clinical baseline characteristics. The duration of surgery was significantly longer for patients undergoing LH compared to OH (LH, 334 min, 186–655 min; OH, 274 min, 176–454 min; p = 0.005). Patients in the LH group had a significantly shortened median hospital stay of 5 d, when compared to OH (LH, 9.5 d, 3–35 d; OH, 14.5 d, 7–37d; p = 0.005). We observed a significant higher rate of postoperative complication in the OH group (p = 0.022). Cost analysis showed median overall costs of 17,369.85€ in the LH group and 16,103.64€ in the OH group (p = 0.390). Conclusion: Our data suggest that higher intraoperative costs of laparoscopic liver surgery, e.g., for surgical devices and due to longer operation times, are compensated by fewer postoperative complications and consecutive shorter length of stay when compared with OH. [ABSTRACT FROM AUTHOR]

Health care costs comprise a substantial portion of total national expenditure. Although interest in cost-effectiveness analysis in neurosurgery has increased, there has been little cross-comparison of neurosurgical procedures. The aim of this study was to compare costs across elective neurosurgical procedures to understand whether drivers of cost differ. The Value Driven Outcomes database was used to evaluate treatment costs for resection of vestibular schwannoma, intracranial meningioma, gliomas, and pituitary adenoma; anterior cervical discectomy and fusion and lumbar spinal fusion; and aneurysm treatment. A total of 1997 patients (mean age 54.6 ± 14.5 years; 45.2% male) were evaluated. The mean length of stay (LOS) was 4.0 ± 4.4 days. For cases involving hardware implantation, including spine fusion or aneurysm treatment, supplies and implants (49.1%) accounted for the largest fraction of costs followed by facility costs (37.9%). For cases that did not involve hardware, including tumor cases, facility costs (63.9%) were the largest fraction, followed by supplies and implants (16.2%). Aneurysm treatment and lumbar fusion were 1.5–3 times more costly than cranial tumor resection and anterior cervical discectomy and fusion per patient. Multivariate linear regression demonstrated that LOS (β = 0.7, P = 0.0001) and patient treatment type (β = 0.2, P = 0.0001) had the greatest effect on costs. LOS correlated with cost differently depending on case type; its effect was largest for patients with meningioma and smallest for patients with vestibular schwannoma. Costs across time increased similarly for all case types. Costs for neurosurgical procedures vary widely depending on treatment type and correlated directly with LOS. Strategies to reduce cost may require different approaches depending on procedure type. [ABSTRACT FROM AUTHOR]

The article focuses on chimeric antigen receptor (CAR) T-cell therapy and biosimilars. It refers to a comment by Oncology Nursing Society (ONS) member Misty Lamprecht regarding the need for nurses to make sure patients understand about CAR T cells. It highlights the U.S. Food and Drug Administration's (FDA) approval of two indications for CAR T-cell therapy.

CONTEXT: Palivizumab prophylaxis is used as passive immunization for respiratory syncytial virus (RSV). However, because of its high cost, the value of this intervention is unclear. OBJECTIVE: To systematically review the cost-effectiveness of palivizumab prophylaxis compared with no prophylaxis in infants <24 months of age. DATA SOURCES: Medline, Embase, and Cochrane Library up to August 2018. STUDY SELECTION: Two reviewers independently screened results to include economic evaluations conducted between 2000 and 2018 from Organization for Economic Cooperation and Development countries. DATA EXTRACTION: Two reviewers independently extracted outcomes. Quality appraisal was completed by using the Joanna Briggs Institute checklist. Costs were adjusted to 2017 US dollars. RESULTS: We identified 28 economic evaluations (20 cost-utility analyses and 8 costeffectiveness analyses); most were from the United States (n = 6) and Canada (n = 5). Study quality was high; 23 studies met >80% of the Joanna Briggs Institute criteria. Palivizumab prophylaxis ranged from a dominant strategy to having an incremental cost-effectiveness ratio of $2 526 203 per quality-adjusted life-year (QALY) depending on study perspective and targeted population. From the payer perspective, the incremental cost-effectiveness ratio for preterm infants (29-35 weeks' gestational age) was between $5188 and $791 265 per QALY, with 90% of estimates <$50 000 per QALY. Influential parameters were RSV hospitalization reduction rates, palivizumab cost, and discount rate. LIMITATIONS: Model design heterogeneity, model parameters, and study settings were barriers to definitive conclusions on palivizumab's economic value. CONCLUSIONS: Palivizumab as RSV prophylaxis was considered cost-effective in prematurely born infants, infants with lung complications, and infants from remote communities. [ABSTRACT FROM AUTHOR]

Purpose: A cost minimisation analysis compares the costs of different interventions' to ascertain the least expensive over time. We compared different prostate targeted drug treatments with TURP to identify the optimal cost saving duration of a medical therapy for symptomatic benign prostatic enlargement (BPE). Methods: The Evolution registry is a prospective, multicentre registry, conducted by the European Association of Urology Research Foundation (EAUrf) for 24 months in 5 European countries. Evolution was designed to register the management of symptomatic BPE in clinical practice settings in 5 European countries. Direct cost evaluation associated with prostate targeted medical therapies and TURP was also recorded and analysed. Results: In total, 1838 men were enrolled with 1246 evaluable at 24 months. Medical therapies were more cost saving than TURP for treatment durations ranging from 2.9 to 70.4 years. Cost saving depended on both medication class and individual country assessed. Daily tamsulosin monotherapy was more cost saving than TURP for ≤ 13.9 years in Germany compared to ≤ 32.7 years in Italy. Daily finasteride monotherapy was more cost saving for ≤ 5.9 years in France compared to ≤ 36.9 years in Spain. Combination therapy was more cost saving for ≤ 5.9 years for Italian patients versus ≤ 13.8 years in Germany. Conclusions: BPE medical management was more cost saving than TURP for different specific treatment durations. Information from this study will allow clinicians to convey medical and surgical costs over time, to both patients and payors alike, when considering BPE treatment. [ABSTRACT FROM AUTHOR]

Objective: Renal replacement therapy (RRT) is the treatment of choice for severe acute kidney injury, but there are no firm guidelines as to the time of initiation of RRT in the critically ill. The primary objective of this study is to determine 1-month mortality rates of early versus late dialysis in critical care. As secondary end points, we provide a cost analysis of early versus late RRT initiation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and number of patients on dialysis at day 60 postrandomization. Data Sources: We identified all randomized controlled trials (RCTs) through EMLINE and MEDBASE that examined adult patients admitted to critical care who were randomized to receiving early dialysis versus standard of care. Study Selection: Inclusion criteria: (1) RCTs conducted after the year 2000, (2) the population evaluated had to be adults admitted to ICU, (3) the intervention had to be early RRT versus standard care, and (4) outcomes had to measure patient mortality. Data Extraction: Two independent investigators reviewed search results and identified appropriate studies. Information was extracted using standardized case report forms. Data Synthesis: Overall, 7 RCTs were included with a total of 1400 patients. Early RRT showed no survival benefit when compared to standard treatment (odds ratio [OR], 0.90 95% confidence interval [95% CI] 0.70-1.15, P = .39). There was no significant difference in length of hospital stay in patients with early RRT (−1.55 days [95% CI −4.75 to 1.65, P = .34]), in length of ICU stay (−0.79 days [95% CI −2.09 to 0.52], P = .24), or proportion of patients on dialysis at day 60 (OR 0.93 [95% CI 0.62 to 1.43], P = .79). Per patient, there is likely a small increase in costs (

PURPOSE: The Oncology Care Model (OCM) must be clinically relevant, accurate, and comprehensible to drive value-based care. METHODS: We studied OCM data detailing observed and expected expenses for 6-month-long episodes of care for patients with prostate cancer. We constructed seven disease state–treatment dyads into which we grouped each episode on the bases of diagnoses, procedures, and medications in OCM claims data. We used this clinical-administrative stratification model to facilitate a comparative cost analysis, and we evaluated emergency department and hospital utilization and drug therapy as potential drivers of cost. RESULTS: We examined 377 episodes of care, pertaining to 210 patients, that took place within our health system from January 2012 to June 2015. Ninety-six percent of episodes were assigned to clinically meaningful dyads. Excessive expenses were seen in metastatic, castration-resistant dyads containing second-line hormone therapy (ratio of observed to expected expenses [O/E], 2.66), chemotherapy (O/E, 2.09), and radium-223/sipuleucel-T (O/E, 3.01). An OCM update correcting for castration-resistant prostate cancer led to small differences in observed expenses (0% to +2%) but large changes in expected expenses (−17% to −27% for hormone-sensitive dyads and +136% to +141% for castration-resistant dyads). O/E increased up to 38% for hormone-sensitive dyads and decreased up to 58% for castration-resistant dyads. Emergency department and hospital utilization seems to drive cost for castration-resistant dyads but not for hormone-sensitive dyads. In the revised OCM model, overall O/E for all episodes improved by 22%, from 1.48 to 1.15. CONCLUSION: Our experience with OCM highlights the limitations of administrative claims data within this model and illustrates a method of translating these data into clinically meaningful information to improve value. [ABSTRACT FROM AUTHOR]

Objective  To quantify the potential cost savings if azithromycin is substituted for erythromycin in women with preterm premature rupture of membranes (PPROM). Study Design  Secondary analysis of a multicentered study investigating magnesium sulfate for the prevention of cerebral palsy in premature infants. All patients with PPROM who received antibiotics for prophylaxis were included in the analysis. The number of expected doses each patient would have received was calculated for erythromycin, multidose azithromycin, and single-dose azithromycin regimens accounting for latency from PPROM to delivery. The wholesale acquisition cost was used to calculate the expected cost of each regimen. Results  There were 981 PPROM patients who received a penicillin class antibiotic and erythromycin. Patients would have received 7,528 intravenous doses and 10,194 oral doses of erythromycin at a combined cost of $357,169. In comparison, patients would have received 6,422 and 3,942 doses at a cost of $15,669 and $9,574 for the multidose and single-dose azithromycin regimens respectively, which represents a more than 95% cost reduction for either regimen compared with erythromycin. Conclusion  The use of azithromycin substituted for erythromycin in the standard antibiotic regimen of women with PPROM represents a potential for substantial cost reduction. [ABSTRACT FROM AUTHOR]

Introduction The oil and gas industry employs approximately 390,000 people in Canada and these workers are often exposed to substantial workplace risks. Trauma centres treat a significant number of industry-related injuries; however, studies characterizing these traumatic events are lacking. Methods A retrospective study was conducted of workers in the oil and gas industry admitted to major trauma centres in Edmonton, Alberta from January 2009 to December 2014. Patients were identified from Alberta Trauma Registry and Worker's Compensation Board data. Inclusion criteria were: age ≥16 years, trauma occurring in the oil and gas industry, and Injury Severity Score (ISS) ≥ 12 or Modified Abbreviated Injury Scale (MAIS) ≥ 3. Descriptive analysis and cost estimation were performed. Results There were 182 major traumas occurring primarily in young males. Blunt trauma was the primary mechanism (90.1%), and alcohol levels were positive in 4.8% of patients. The overall complication rate was 32.4% with a mortality rate of 6%. The majority of patients were discharged home (64.3%), however a large proportion (29.7%) required further care at another facility post-acute care. The median days missed from work were 85 (IQR 7–214.5). Total cost of injury from the societal perspective ranged from $109 965 to $332 098 USD per person. Conclusion Oil and gas industry trauma has a high economic and societal cost. Strategies to prevent injuries in this field should be undertaken including promotion and support of drug-free programmes given the rate of positive alcohol screening in this population. [ABSTRACT FROM AUTHOR]

Introduction: Cost of illness studies are essential to estimate societal costs of chronic inflammatory demyelinating polyneuropathy (CIDP) and identify cost-driving factors.Methods: In total, 108 patients were recruited from 3 specialized neuroimmunological clinics. Costs were calculated for a 3-month period, including direct and indirect costs. The following outcomes were assessed: inflammatory neuropathy cause and treatment disability scale, Mini-Mental State Examination, Beck Depression Inventory, Charlson comorbidity index, EuroQol-5D, World Health Organization quality of life instrument, and socioeconomic status. Univariate and multivariate analyses were applied to identify cost-driving factors.Results: Total quarterly costs were €11,333. Direct costs contributed to 83% of total costs (€9,423), whereas indirect costs accounted for 17% (€1,910) of total costs. The cost of intravenous immunoglobulin (IVIg) was the main determinant of total costs (67%). Reduced health-related quality of life and depressive symptoms were identified as independent predictors of higher total costs.Discussion: CIDP is associated with high societal costs, mainly resulting from the cost of IVIg treatment. Muscle Nerve 58: 681-687, 2018. [ABSTRACT FROM AUTHOR]

Rising mortality in the United States due to alcoholic liver disease (ALD) and the dearth of effective treatments for ALD have led to increased research in this area, particularly in alcoholic hepatitis. To understand the burden of illness and potential economic value of effective treatments, we conducted a health care claims analysis of over 15,000 commercially insured adults who were hospitalized with alcoholic hepatitis (AH) between 2006 and 2013 and followed for up to 5 years. Their average age was 54 years and 68% were male. Over 5 years, about two-thirds of these adults died (44% in the first year), and fewer than 500 received liver transplants. There were nearly 40,000 re-hospitalizations, with over 50% of the survivors re-hospitalized within a year and nearly 75% through the second year. The total costs were nearly $145,000 per patient, with costs decreasing over time from over $50,000 in the first year (including the index hospitalization) to about $10,000 per year in the later years. Total costs for the cohort over 5 years were $2.2 billion. Patients who received a liver transplant averaged about $300,000 in transplant-related costs and over $1,000,000 in total health care costs over 5 years. Average costs in years following the index hospitalization were similar to diabetes. AH has a high mortality and is a high-cost condition. [ABSTRACT FROM AUTHOR]

Hypoplastic left heart syndrome (HLHS) is a highly resource-intensive diagnosis. Geographic variation in cost and length of stay (LOS) in HLHS is not well described. Neonates diagnosed with HLHS between 2000 and 2012 were identified using the Kids’ Inpatient Database. Hospitalizations were stratified into two groups: (1) birth and (2) secondary. United States regional differences in hospital charges and LOS were compared using adjusted linear regression. Of 2431 birth hospitalizations, 449 neonates (18.5%) died while inpatient and mortality rates differed by region (p = 0.02). After birth, 40.5% (n = 985) of neonates were transferred; transfers were most common in the Midwest (p < 0.0001). Adjusted average LOS was shortest in the West and longest in the South (26.1 days; 95% CI 24.0, 35.1 vs. 34.9 days; 95% CI 31.8, 38.1). Average adjusted charges were lowest in the Northeast ($324,600; 95% CI $271,400, $377,900) and highest in the West ($400,500; 95% CI $346,700, $454,300, p = 0.05). Among 1895 secondary hospitalizations, 24.9% of neonates died as inpatients, and the average adjusted LOS was shortest in the West (26.8 days; 95% CI 23.9, 29.7) and longest in the South (38.5 days; 95% CI 34.4, 42.4). Average adjusted charges were lowest in the Northeast ($326,900; 95% CI $270,700, $383,100) and highest in the South ($505,900; 95% CI $450,200, $561,500, p < 0.0001). Significant geographic variations in mortality, LOS, and hospital charges exist in care of US HLHS neonates. Reducing variation in care should remain a priority in national quality efforts in congenital heart disease. [ABSTRACT FROM AUTHOR]

Aims: TECOS, a cardiovascular safety trial ( ClinicalTrials.gov identifier: NCT00790205) involving 14 671 patients with type 2 diabetes and cardiovascular disease, demonstrated that sitagliptin was non‐inferior to placebo for the primary composite cardiovascular outcome when added to best usual care. This study tested hypotheses that medical resource use and costs differed between these 2 treatment strategies. Materials and methods: Information concerning medical resource use was collected on case report forms throughout the trial and was valued using US costs for: Medicare payments for hospitalizations, medical procedures and outpatient visits, and wholesale acquisition costs (WAC) for diabetes‐related medications. Hierarchical generalized linear models were used to compare resource use and US costs, accounting for variable intercountry practice patterns. Sensitivity analyses included resource valuation using English costs for a UK perspective. Results: There were no significant differences in hospitalizations, inpatient days, medical procedures, or outpatient visits during follow‐up (mean and median 3.0 years in both groups). Hospitalization rates appeared to diverge after 2 years, with lower rates among sitagliptin‐treated vs placebo patients after 2.5 years (relative rate, 0.90 [95% CI, 0.83‐0.97]; P = .01). Mean medical costs, exclusive of study medication, were 11 937 USD in the sitagliptin arm and 12 409 USD in the placebo arm (P = .06). Mean sitagliptin costs based on undiscounted WAC were 9978 USD per patient. Differential UK total costs including study drug costs were smaller (911 GBP), primarily because of lower mean costs for sitagliptin (1072 GBP). Conclusions: Lower hospitalization rates across time with sitagliptin slightly offset sitagliptin treatment costs over 3 years in type 2 diabetes patients at high risk for cardiovascular events. [ABSTRACT FROM AUTHOR]

Introduction: catheter-related bloodstream infections (CRBSI) are one of the most serious concerns in patients on home parenteral nutrition (HPN) which involve high morbidity and cost for the healthcare system. In the last years, taurolidine lock has proven to be beneficial in the prevention of CRBSI; however, the evidence of its efficiency is limited.Objective: to determine if taurolidine lock is a cost-effective intervention in patients on HPN.Materials and Methods: retrospective study in patients on HPN with taurolidine lock. We compared the CRBSI rate and cost of its complications before and during taurolidine lock.Results: thirteen patients, six (46%) males and seven (54%) females, with a mean age of 61.08 (SD = 14.18) years received taurolidine lock. The total days of catheterization pre and per-taurolidine were 12,186 and 5,293, respectively. The underlying disease was benign in five patients (38.5%) and malignant in eight (61.5%). The CRBSI rate pre vs per-taurolidine was 3.12 vs 0.76 episodes per 1,000 catheter days (p = 0.0058). When the indication was a high CRBSI rate, this was 9.72 vs 0.39 (p < 0.001) in pre and per-taurolidine period respectively. No differences have been observed in the occlusion rates. None of the patients reported any adverse effects. The total cost of CRBSI in the pre-taurolidine period was 151,264.14 euros vs 24,331.19 euros in the per-taurolidine period.Conclusions: our study shows that taurolidine lock is a cost-effective intervention in patients on HPN with high risk of CRBSI. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous transluminal angioplasty (PTA) and surgical bypass (BYP) are treatment options for symptomatic peripheral arterial disease (PAD). PTA and BYP have different clinical outcomes and cost implications. This paper aims to compare hospital-related costs of PTA and BYP for PAD of the lower limbs in an Australian health service.Methods: A retrospective cost analysis using clinical and financial data from an urban, tertiary hospital was performed. Patient cohorts were matched to existing published studies and 3-year findings were calculated. Outcomes measured were mean initial admission cost; mean bed stay; mean complication rate; mean cost of re-intervention at 12 months and extrapolated mean cost at 3 years.Results: The mean total admission costs for PTA compared to BYP were $8758 vs. $27,849 (P < 0.001). Patients undergoing BYP were admitted for 10.25 vs. 3.77 nights (P < 0.001). The complication rate was greater in the BYP group for infection only. Re-intervention was required by 13% of the PTA group and 16% of the BYP group, at a mean cost of $11,798 and $14,728, respectively (P = 0.453). The extrapolated total mean cost at 3 years was higher in the BYP group for patients with both intermittent claudication ($26,764 vs. $11,402) and critical limb ischaemia ($27,719 vs. $12,655).Conclusions: In this cohort, PTA is a favourable alternative to BYP for PAD of the lower limbs as it is less costly, does not result in a greater re-intervention rate at 1 year and has been previously demonstrated to have comparable clinical outcomes. Given the limitations of this retrospective analysis, a prospective cost-effectiveness analysis is recommended. [ABSTRACT FROM AUTHOR]

Introduction: It is hypothesized that using fluocinolone acetonide (FAc) implants such as Iluvien for the treatment of diabetic macular edema (DME) may reduce the total number of intravitreal injections and clinic visits, resulting in an overall treatment cost reduction. The primary aim of this study is to identify the real-world cost savings achievable in a tertiary National Health Service (NHS) hospital.Methods: A retrospective cost analysis study was conducted. The inclusion criteria were patients with refractory DME who were switched to Iluvien. The average yearly costs were calculated both before and after the switch to Iluvien. All costs including medicines, investigations, clinics, and management of raised intraocular pressure (IOP) were calculated. The cost differences over the 3 years’ worth of Iluvien treatment were calculated and analyzed. To ensure non-inferiority of this treatment intervention, the best corrected visual acuity (BCVA) and central retinal thickness (CRT) were also analyzed. Statistical analysis was conducted with a Student t test where appropriate and statistical significance is identified where p < 0.05.Results: Fourteen eyes of 13 patients met the inclusion criteria. Switching patients to Iluvien achieved on average a saving of £2606.17 per patient (p = 0.33) over the 3 years. However, seven cases (50%) had a rise in IOP after Iluvien that warranted medical treatment and two cases (14.3%) required glaucoma surgery. Incorporating the costs of glaucoma management reduced the overall savings over 3 years to £1064.66 per patient. The BCVA and CRT analysis showed a non-inferiority relationship between Iluvien and any previous treatment.Conclusions: The use of Iluvien in refractory DME patients represents a cost- and time-saving procedure, while showing non-inferiority in terms of efficacy. [ABSTRACT FROM AUTHOR]

Background: The current state of health care encompasses highly acute, complex patients, managed with ever-changing technology. The ability to function proficiently in critical care relies on knowledge, technical skills, and interprofessional teamwork. Integration of these factors can improve patient outcomes. Simulation provides "hands-on" practice and allows for the integration of teamwork into knowledge/skill training. However, simulation can require a significant investment of time, effort, and financial resources. The Institute of Medicine recommendations from 2015 include "strengthening the evidence base for interprofessional education (IPE)" and "linking IPE with changes in collaborative behavior." In one surgical-trauma-burn intensive care unit (STBICU), no IPE existed. The highly acute and diverse nature of the patients served by the unit highlights the importance of appropriate training. This is heightened during critical event situations where patients deteriorate rapidly and the team intervenes swiftly. Purpose: The aims of this study were to (1) evaluate knowledge retention and analyze changes in perceptions of teamwork among nurses and resident physicians in a STBICU setting after completion of an interprofessional critical event simulation and (2) provide insight for future interprofessional simulations (IPSs), including the ideal frequency of such training, associated cost, and potential effect on nursing turnover. Design: A comparison-cohort pilot study was developed to evaluate knowledge retention and analyze changes in perceptions of teamwork. Methods: A 1-hour critical event IPS was held for nurses and resident physicians in a STBICU setting. A traumatic brain injury patient with elevated intracranial pressure, rapid deterioration, and cardiac arrest was utilized for the simulation scenario. The simulation required the team to use interventions to reduce elevated intracranial pressure and then perform cardiac resuscitation according to Advanced Cardiac Life Support guidelines. A semistructured debriefing guided by the TENTS tool highlighted important aspects of teamwork. Participants took knowledge and Teamwork Skills Scale (TSS) pretests, posttests, and 1-month posttests. Mean scores were calculated for each time point (pre, post, and 1-month post), and paired t tests were used to evaluate changes. Results: Mean knowledge test and TSS scores both significantly increased after the simulation and remained significantly elevated at 1-month follow-up. Participants recommended retraining intervals of 3 to 6 months. Cost of each simulation was estimated to be $324.44. Analysis of nursing turnover rates did not demonstrate a statistically significant reduction in turnover; however, confounding factors were not controlled for. Conclusion: Significant improvements on both knowledge test and TSS scores demonstrate the effectiveness of the intervention, and retention of the information gained and teamwork skills learned. Participants valued the intervention and recommended to increase the frequency of training. Future studies should develop a framework for "best practice" IPS, analyze the relationship with nursing turnover, and ultimately seek correlations between IPS and improved patient outcomes. [ABSTRACT FROM AUTHOR]

Precision medicine endeavors to leverage all available medical data in pursuit of individualized diagnostic and therapeutic plans to improve patient outcomes in a cost-effective manner. Its promise in the field of critical care remains incompletely realized. The Department of Defense has a vested interest in advancing precision medicine for those sent into harm's way and specifically seeks means of individualizing care in the context of complex and highly dynamic combat clinical decision environments. Building on legacy research efforts conducted during the Afghanistan and Iraq conflicts, the Uniformed Service University (USU) launched the Surgical Critical Care Initiative (SC2i) in 2013 to develop clinical- and biomarker-driven Clinical Decision Support Systems (CDSS), with the goals of improving both patient-specific outcomes and resource utilization for conditions with a high risk of morbidity or mortality. Despite technical and regulatory challenges, this military-civilian partnership is beginning to deliver on the promise of personalized care, organizing and analyzing sizable, real-time medical data sets to support complex clinical decision-making across critical and surgical care disciplines. We present the SC2i experience as a generalizable template for the national integration of federal and non-federal research databanks to foster critical and surgical care precision medicine. [ABSTRACT FROM AUTHOR]

Objective: Overactive bladder (OAB) affects 16.9% of women in the United States. Percutaneous tibial nerve stimulation (PTNS) is a thirdline treatment for patients who are refractory to behavioral and pharmacologic therapies. We aimed to evaluate the effects of PTNS on urinary symptoms in patients diagnosed as having refractory OAB and investigate the cost of medications and clinical visits before and after PTNS treatment. Material and Methods: We reviewed 60 women with refractory OAB treated with PTNS. Episodes of urinary frequency, leakage, urgency, and nocturia; number of follow-up visits; and medications were recorded. The mean quarterly drug, physician, nurse, and provider costs were calculated. The episodes of urinary symptoms, numbers of follow-up visits, and costs of medications and visits before and after PTNS were compared. Results: Of the 60 patients with refractory OAB, 24 patients who completed 12 weekly sessions of initial PTNS were evaluated. The number of urinary symptoms and follow-up visits significantly decreased after PTNS (p<0.05). The average quarterly medication cost decreased from $656.36±292.45 to $375.51±331.79 after PTNS (p=0.001). After PTNS, quarterly physician and nurse visit costs decreased from $81.73±70.39 to $25.89±54.40 and from $55.23±38.32 to $15.53±19.58, respectively (p<0.05). The quarterly total provider cost was similar before and after PTNS. Conclusion: PTNS treatment significantly improved urinary symptoms of patients with refractory OAB and reduced the costs of medications and physician and nurse visits. [ABSTRACT FROM AUTHOR]

Background: In a previous single center study we found that a standardized drug treatment algorithm (ALGO) was more cost effective than treatment as usual (TAU) for inpatients with major depression. This report aimed to determine whether this promising initial finding could be replicated in a multicenter study.Methods: Treatment costs were calculated for two time periods: the study period (from enrolment to exit from study) and time in hospital (from enrolment to hospital discharge) based on daily hospital charges. Cost per remitted patient during the study period was considered as primary outcome.Results: 266 patients received ALGO and 84 received TAU. For the study period, ALGO costs were significantly lower than TAU (ALGO: 7 848 ± 6 065 €; TAU: 10 033 ± 7 696 €; p = 0.04). For time in hospital, costs were not different (ALGO: 14 734 ± 8 329 €; TAU: 14 244 ± 8 419 €; p = 0.617). Remission rates did not differ for the study period (ALGO: 57.9%, TAU: 50.0%; p=0.201). Remission rates were greater in ALGO (83.3%) than TAU (66.2%) for time in hospital (p = 0.002). Cost per remission was lower in ALGO (13 554 ± 10 476 €) than TAU (20 066 ± 15 391 €) for the study period (p < 0.001) and for time in hospital (ALGO: 17 582 ± 9 939 €; TAU: 21 516 ± 12 718 €; p = 0.036).Limitations: Indirect costs were not assessed. Different dropout rates in TAU and ALGO complicated interpretation.Conclusions: Treatment algorithms enhance the cost effectiveness of the care of depressed inpatients, which replicates our prior results in an independent sample. [ABSTRACT FROM AUTHOR]

Background: Little progress has been made towards community participation of people with intellectual disability despite it being a policy aim since the 1980s. We aimed to identify the features of programmes designed to support community participation. Method: A scoping review was conducted of peer‐reviewed literature between 2000 and 2015, about interventions to support community participation for adults with intellectual disability. Results: A small body of evidence relates to the design and effectiveness of interventions to enhance community participation. Seventeen studies reported programmes reflecting three conceptualizations of community participation (as social relationships, as convivial encounter and as belonging) that used strategies such as active mentoring, facilitative support worker practice and arts‐based programmes. Conclusions: Studies showed the diverse and person‐centred nature of community participation and demonstrated the need for larger‐scale studies of promising interventions that include details of costs, and strategies to guide implementation of policies to support community participation. [ABSTRACT FROM AUTHOR]

Background: In this study, the patients who were operated in two clinics due to traumatic cranial epidural hematoma (EDH) were assessed retrospectively and the factors that increase the costs were tried to be revealed through conducting cost analyses. Methods: The patients who were operated between 2010 and 2016 with the diagnosis of EDH were assessed in terms of age, sex, trauma etiology, Glasgow coma scale (GCS) at admission, the period from trauma to hospital arrival, trauma-related injury in other organs, the localization of hematoma, the size of hematoma, length of stay in the intensive care unit (ICU), length of antibiotherapy administration, number of consultations conducted, total cost of in-hospital treatments of the patients and prognosis. Results: Distribution of GCS were, between 13-15 in 18 (36%) patients, 9-13 in 23 (46%) patients and 3-8 in 9 (18%) patients. The reasons for emergency department admissions were fall from high in 29 (58%) patients, assault in 11 (22%) patients and motor vehicle accident in 10 (20%) patients. The average cost per ICU stay was 2838 $ (range=343-20571 $). The average cost per surgical treatment was 314 $. ICU care was approximately 9 times more expensive than surgical treatment costs. The mortality rate of the study cohort was 14% (7 patients). Conclusion: The prolonged period of stay in the ICU, antibiotherapy and repeat head CTs increase the costs for patients who are surgically treated for EDH. [ABSTRACT FROM AUTHOR]

Introduction Home-based telebehavioural healthcare improves access to mental health care for patients restricted by travel burden. However, there is limited evidence assessing the economic value of home-based telebehavioural health care compared to in-person care. We sought to compare the economic impact of home-based telebehavioural health care and in-person care for depression among current and former US service members. Methods We performed trial-based cost-minimisation and cost-utility analyses to assess the economic impact of home-based telebehavioural health care versus in-person behavioural care for depression. Our analyses focused on the payer perspective (Department of Defense and Department of Veterans Affairs) at three months. We also performed a scenario analysis where all patients possessed video-conferencing technology that was approved by these agencies. The cost-utility analysis evaluated the impact of different depression categories on the incremental cost-effectiveness ratio. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model assumptions. Results In the base case analysis the total direct cost of home-based telebehavioural health care was higher than in-person care (US$71,974 versus US$20,322). Assuming that patients possessed government-approved video-conferencing technology, home-based telebehavioural health care was less costly compared to in-person care (US$19,177 versus US$20,322). In one-way sensitivity analyses, the proportion of patients possessing personal computers was a major driver of direct costs. In the cost-utility analysis, home-based telebehavioural health care was dominant when patients possessed video-conferencing technology. Results from probabilistic sensitivity analyses did not differ substantially from base case results. Discussion Home-based telebehavioural health care is dependent on the cost of supplying video-conferencing technology to patients but offers the opportunity to increase access to care. Health-care policies centred on implementation of home-based telebehavioural health care should ensure that these technologies are able to be successfully deployed on patients' existing technology. [ABSTRACT FROM AUTHOR]

Background Standard treatment for deep venous thromboembolism involves parenteral anticoagulation overlapping with a vitamin K antagonist, an approach that is effective but associated with limitations including the need for frequent coagulation monitoring. The direct oral anticoagulant rivaroxaban is similarly effective to standard therapy as a single-drug treatment for venous thromboembolism and does not require routine coagulation monitoring. The aim of this analysis was to project the long-term costs and outcomes for rivaroxaban compared to standard of care (tinzaparin/warfarin). Methods A total of 184 patients who were under anticoagulant therapy with warfarin or rivaroxaban for extended deep venous thromboembolism were retrospectively evaluated; 59 received rivaroxaban and 125 received warfarin therapy. Assessments were made on age, gender, place of residence, the duration of anticoagulation, mean international normalized ratio value, the effective rate of international normalized ratio (time in the therapeutic range), bleeding-related complication rate, duration of hospitalization due to complications, the number of annual outpatient department admission, cost for drug, cost for hospitalization, cost for outpatient department admission and international normalized ratio measurements. Results The annual outpatient cost is higher in warfarin group (147.09 ± 78 vs. 62.32 ± 19.79 USD p < 0.001). But annual drug cost is higher in rivaroxaban group (362.6 vs. 71.55 ± 31.01 USD p < 0.001). Overall cost of rivaroxaban group is higher than warfarin group (476.25 ± 36.78 vs. 364.82 ± 174.44 USD). Warfarin is not cost-effective when non-drug costs (342.5 ± 174.44 vs. 113.65 ± 36.77) and hospital costs (173.85 ± 122.73 vs. 64.9 ± 23.55 USD) were analyzed. Conclusion This analysis suggests that rivaroxaban has lower costs than warfarin in terms of outpatient department admission and hospital costs due to complications; however, warfarin was more economic when all cost parameters were considered. Time in the therapeutic range was found as 56% for warfarin that should be taken into account while analyzing costs and benefits. [ABSTRACT FROM AUTHOR]

Burkitt lymphoma is an aggressive B cell malignancy accounting for 1-2% of all adult lymphomas. Treatment with dose-intensive, multi-agent chemotherapy is effective but associated with considerable toxicity. In this observational study, we compared real-world efficacy, toxicity, and costs of four frequently employed treatment strategies for Burkitt lymphoma: the Lymphome Malins B (LMB), the Berlin-Frankfurt-Münster (BFM), the HOVON, and the CODOX-M/IVAC regimens. We collected data from 147 adult patients treated in eight referral centers. Following central pathology assessment, 105 of these cases were accepted as Burkitt lymphoma, resulting in the following treatment groups: LMB 36 patients, BFM 19 patients, HOVON 29 patients, and CODOX-M/IVAC 21 patients (median age 39 years, range 14-74; mean duration of follow-up 47 months). There was no significant difference between age, sex ratio, disease stage, or percentage HIV-positive patients between the treatment groups. Five-year progression-free survival (69%, p = 0.966) and 5-year overall survival (69%, p = 0.981) were comparable for all treatment groups. Treatment-related toxicity was also comparable with only hepatotoxicity seen more frequently in the CODOX/M-IVAC group (p = 0.004). Costs were determined by the number of rituximab gifts and the number of inpatients days. Overall, CODOX-M/IVAC had the most beneficial profile with regards to costs, treatment duration, and percentage of patients completing planned treatment. We conclude that the four treatment protocols for Burkitt lymphoma yield nearly identical results with regards to efficacy and safety but differ in treatment duration and costs. These differences may help guide future choice of treatment. [ABSTRACT FROM AUTHOR]

Background: In this study, the patients who were operated in two clinics due to traumatic cranial epidural hematoma (EDH) were assessed retrospectively and the factors that increase the costs were tried to be revealed through conducting cost analyses. Methods: The patients who were operated between 2010 and 2016 with the diagnosis of EDH were assessed in terms of age, sex, trauma etiology, Glasgow coma scale (GCS) at admission, the period from trauma to hospital arrival, trauma-related injury in other organs, the localization of hematoma, the size of hematoma, length of stay in the intensive care unit (ICU), length of antibiotherapy administration, number of consultations conducted, total cost of in-hospital treatments of the patients and prognosis. Results: Distribution of GCS were, between 13-15 in 18 (36%) patients, 9-13 in 23 (46%) patients and 3-8 in 9 (18%) patients. The reasons for emergency department admissions were fall from high in 29 (58%) patients, assault in 11 (22%) patients and motor vehicle accident in 10 (20%) patients. The average cost per ICU stay was 2838 $ (range=343-20571 $). The average cost per surgical treatment was 314 $. ICU care was approximately 9 times more expensive than surgical treatment costs. The mortality rate of the study cohort was 14% (7 patients). Conclusion: The prolonged period of stay in the ICU, antibiotherapy and repeat head CTs increase the costs for patients who are surgically treated for EDH. [ABSTRACT FROM AUTHOR]

Aims: The objective of this study was to evaluate diabetes-related healthcare resource use and associated costs in patients with type 2 diabetes (T2DM) treated with a sulfonylurea (SU), with and without hypoglycemia.Methods: In this retrospective cohort study, patients 18years or older receiving SU monotherapy or as add-on to metformin were identified from a US healthcare claims database (MarketScan®). Of 113,743 patients (56.8% male, average age 62.6years), 61.6% were on SU/metformin dual therapy and 38.4% were on SU monotherapy, and 5% had one or more episodes of hypoglycemia during the 12-month follow-up period.Results: Adjusted for baseline characteristics, patients with hypoglycemia were three times more likely than those without to use emergency room services (OR 3.04, 95% CI: 2.82, 3.25), almost four times more likely to have inpatient admissions (OR 3.84, 95% CI: 3.58, 4.12), and had more frequent physician office visits (4.3 vs 3.0 visits, p<0.01) in the 12-month follow-up period. The adjusted annual diabetes-related medical expenditure was three times higher in patients with hypoglycemia compared with those without ($6884 vs $2392, p<0.001).Conclusions: This study demonstrated the higher healthcare utilization and costs associated with hypoglycemia in patients with T2DM treated with an SU. [ABSTRACT FROM AUTHOR]

Background: Providing HIV testing at health facilities remains the most common approach to ensuring access to HIV treatment and prevention services for the millions of undiagnosed HIV-infected individuals in sub-Saharan Africa. We sought to explore the costs of providing these services across three southern African countries with high HIV burden. Methods: Primary costing studies were undertaken in 54 health facilities providing HIV testing services (HTS) in Malawi, Zambia and Zimbabwe. Routinely collected monitoring and evaluation data for the health facilities were extracted to estimate the costs per individual tested and costs per HIV-positive individual identified. Costs are presented in 2016 US dollars. Sensitivity analysis explored key drivers of costs. Results: Health facilities were testing on average 2290 individuals annually, albeit with wide variations. The mean cost per individual tested was US$5.03.9 in Malawi, US$4.24 in Zambia and US$8.79 in Zimbabwe. The mean cost per HIV-positive individual identified was US$79.58, US$73.63 and US$178.92 in Malawi, Zambia and Zimbabwe respectively. Both cost estimates were sensitive to scale of testing, facility staffing levels and the costs of HIV test kits. Conclusions: Health facility based HIV testing remains an essential service to meet HIV universal access goals. The low costs and potential for economies of scale suggests an opportunity for further scale-up. However low uptake in many settings suggests that demand creation or alternative testing models may be needed to achieve economies of scale and reach populations less willing to attend facility based services. [ABSTRACT FROM AUTHOR]

Background: Disease-related malnutrition is highly prevalent, and has prognostic implications for patients with chronic kidney disease (CKD); however, few studies have investigated the impact of malnutrition, or protein-energy wasting (PEW), on healthcare utilization and medical expenditure among CKD patients.Methods: Using claim data from the National Health Insurance in Taiwan, this study identified patients with CKD between 2009-2013 and categorized them into those with mild, moderate, or severe CKD. Cases with PEW after CKD was diagnosed were propensity-score matched with controls in a 1:4 ratio. Healthcare resource utilization metrics were compared, including outpatient and emergency department visits, frequency and duration of hospitalization, and the cumulative costs associated with different CKD severity.Results: From among 347,501 CKD patients, eligible cohorts of 66,872 with mild CKD (49.2%), 27,122 with moderate CKD (19.9%), and 42,013 with severe CKD (30.9%) were selected. Malnourished CKD patients had significantly higher rates of hospitalization (p < .001 for all severities) and re-admission (p = .015 for mild CKD, p = .002 for severe CKD) than non-malnourished controls. Cumulative medical costs for outpatient and emergency visits, and hospitalization, were significantly higher among all malnourished CKD patients than non-malnourished ones (p < .001); total medical costs were also higher among malnourished patients with mild (62.9%), moderate (59.6%), or severe (43.6%) CKD compared to non-malnourished patients (p < .001).Conclusions: In a nationally-representative cohort, CKD patients with PEW had significantly more healthcare resource utilization and higher aggregate medical costs than those without, across the spectrum of CKD: preventing PEW in CKD patients should receive high priority if we would like to reduce medical costs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the costs associated with induction of labour in intrauterine growth restriction fetuses comparing different procedures.Study Design: 150 pregnancies at term diagnosed with intrauterine growth restriction and indication for induction of labour were included. 24 were ripened with misoprostol 25 μg tablets, 24 with dinoprostone 10 mg vaginal insert, and 77 with Cook® cervical ripening balloon. To determine the costs of induction of labour, method of induction, intrapartum medication, epidural analgesia, type of delivery, and maternal and neonatal admissions were considered. Statistical analysis was performed using the G-Stat 2.0 free statistical software. ANOVA test was used for comparisons between quantitative parametric variables. Chi-squared test or Fisher test was used for qualitative variables. A value of p < 0.05 was considered statistically significant.Results: Up to 70.83% women in dinoprostone group gave birth within the first 24 h compared to 42.66% in misoprostol group and 36.36% in CG (p < 0.01). Misoprostol tablets were cheaper (9.45 ± 1.52 US dollars) than dinoprostone or Cook® balloon (41.67 ± 0 and 59.85 ± 0 54.45 ± 0 US dollars, respectively) (p < 0.01). Costs related to maternal admissions were higher in CG (475.13 ± 146.95$) than dinoprostone group (475.13 ± 146.95$) or MG (427.97 ± 112.65$) (p = 0.03). Total costs in misoprostol group (2765.18 ± 495.38$) were lower than in the dinoprostone group (3075.774 ± 896.14$) or Cook® balloon group (3228.02 ± 902.06$) groups.Conclusions: Misoprostol for induction of labour had lower related costs than dinoprostone or Cook® balloon, with similar obstetrical and perinatal outcomes. [ABSTRACT FROM AUTHOR]

Introduction Preterm birth is the leading cause of U.S. infant morbidity and mortality; Medicaid enrollees disproportionately experience preterm deliveries. Data suggest that progesterone—an evidence-based therapy for preventing preterm birth—is not accessible to all eligible Medicaid beneficiaries. This study aimed to identify variation in progesterone coverage guidelines in a sample of state Medicaid managed care organizations (MMCOs). Material and Methods Using a cross-sectional design, participation in a web-based survey was offered to 20 MMCO members of the Medicaid Health Plans of America. The survey assessed coverage guidelines for progesterone and associated interventions to prevent preterm birth. MMCOs identified key barriers in providing progesterone. Descriptive analyses were performed. Results Analyses included data from 18 plans providing coverage in 31 of the 39 states with MMCOs (response rate, 90.0%). Responding MMCOs were diverse: 55.6% were multistate, 33.3% were nonprofit, and 31.2% covered more than 1,000,000 lives. Most respondents (87.5%) covered branded progesterone, and 81.3% covered compounded progesterone. Prior authorization was required by most plans for branded progesterone (86.7%) or compounded progesterone (75.0%). The MMCO gestational age restrictions for initiating progesterone varied from 22 to 37 weeks of gestation, even within the same state. MMCO-identified barriers to providing progesterone included cost, lack of clinician knowledge of indications and coverage, and variation in billing procedures. Discussion Marked variation in MMCO coverage policies and procedures for progesterone and related interventions to prevent preterm birth was noted. Implications for Practice and Policy Standardizing MMCO coverage policies may be one way to improve access to evidence-based interventions that prevent preterm birth. [ABSTRACT FROM AUTHOR]