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Objectives: Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups., Methods: We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination)., Results: Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results., Conclusions: Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices., (Copyright © 2020 World Health Organization. Published by Elsevier Inc. All rights reserved.)

Objectives: Traditional risk scores improved the definition of the initial therapeutic strategy in acute coronary syndrome (ACS), but they were not designed for predicting long-term individual risks and costs. In parallel, attempts to directly predict costs from clinical variables in ACS had limited success. Thus, novel approaches to predict cardiovascular risk and health expenditure are urgently needed. Our objectives were to predict the risk of major/minor adverse cardiovascular events (MACE) and estimate assistance-related costs., Methods: We used a 2-step approach that: (1) predicted outcomes with a common pathophysiological substrate (MACE) by using machine learning (ML) or logistic regression (LR) and compared with existing risk scores; (2) derived costs associated with noncardiovascular deaths, dialysis, ambulatory-care-sensitive-hospitalizations (ACSH), strokes, and MACE. With consecutive ACS individuals (n = 1089) from 2 cohorts, we trained in 80% of the population and tested in 20% using a 4-fold cross-validation framework. The 29-variable model included socioeconomic, clinical/lab, and coronarography variables. Individual costs were estimated based on cause-specific hospitalization from the Brazilian Health Ministry perspective., Results: After up to 12 years follow-up (mean = 3.3 ± 3.1; MACE = 169), the gradient-boosting machine model was superior to LR and reached an area under the curve (AUROC) of 0.891 [95% CI 0.846-0.921] (test set), outperforming the Syntax Score II (AUROC = 0.635 [95% CI 0.569-0.699]). Individuals classified as high risk (>90th percentile) presented increased HbA1c and LDL-C both at <24 hours post-ACS and 1-year follow-up. High-risk individuals required 33.5% of total costs and showed 4.96-fold (95% CI 3.71-5.48, P < .00001) greater per capita costs compared with low-risk individuals, mostly owing to avoidable costs (ACSH). This 2-step approach was more successful for finding individuals incurring high costs than predicting costs directly from clinical variables., Conclusion: ML methods predicted long-term risks and avoidable costs after ACS., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Purpose: To model Medicare Part B and patient savings associated with increased bevacizumab payment and use for intravitreal anti-vascular endothelial growth factor (VEGF) therapy., Design: Cost analysis., Participants: Intelligent Research in Sight (IRIS®) Registry data., Methods: Medicare claims and IRIS® Registry data were used to calculate Medicare Part B expenditures and patient copayments for anti-VEGF agents with increasing reimbursement and use of bevacizumab relative to ranibizumab and aflibercept., Main Outcome Measures: Medicare Part B costs and patient copayments for anti-VEGF agents in the Medicare fee-for-service population., Results: Increasing bevacizumab reimbursement to $125.78, equalizing the dollar margin with aflibercept, would result in Medicare Part B savings of $468 million and patient savings of $119 million with a 10% increase in bevacizumab market share., Conclusions: Increased use of bevacizumab achievable with increased reimbursement to eliminate the financial disincentive to its use would result in substantial savings for the Medicare Part B program and for patients receiving anti-VEGF intravitreal injections., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: We assessed the hypothesis that nonoperative management would be a viable treatment option for patients with underlying degenerative disease who have traumatic cervical spinal cord injury (TCSI) without neurological deterioration and/or spinal instability during hospitalization., Methods: Data were collected prospectively from 2011 to 2016. All the patients had been treated nonoperatively with hard cervical collar immobilization. The clinical parameters assessed included the Frankel grade at presentation and discharge, the occurrence of deep vein thrombosis, urinary tract infection, sphincter dysfunction, and pressure sores. The radiographic data collected included magnetic resonance imaging signal cord changes. P ≤ 0.05 represented a significant association between the Frankel grade at presentation and the outcome parameters., Results: A total of 28 patients were included in the present study. Of the patients who had presented with Frankel grade B, 85.71% had improved to a higher grade, 90.91% of the patients with Frankel grade C had improved to a higher grade, and 14.29% of the patients with Frankel grade D had improved to Frankel grade E. All the patients had satisfactory spinal stability, as evidenced by dynamic radiographs, after treatment., Conclusion: The findings from the present study have shown that nonoperative management can result in improved neurological outcomes for patients with underlying degenerative disease who have experienced TCSI without evidence of neurological deterioration and spinal instability. The Frankel grade at presentation was significantly associated with outcome parameters such as the neurological outcome on discharge and the occurrence of urinary tract infection. The results from the present study could be helpful to neurological surgeons in rural and other low-resource settings because the cost savings realized by nonoperative treatment will not sacrifice the provision of adequate care to their patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cryoablation is a new technology for ablation of atrial fibrillation (AF), effective and safe when compared with standard radiofrequency (RF) ablation. Nevertheless, the economic impact of its incorporation is unknown, especially considering the public health system of a developing country. This study analyzed the budget impact of cryoablation incorporation for treatment of paroxysmal AF in the Brazilian public health system., Methods: The budget impact was calculated as the cost difference between the current scenario (RF ablation guided by electroanatomic mapping) and the new scenario (cryoablation). The cost of each intervention was obtained by multiplying the price of a single procedure by the number of candidates for it. Other technologies (RF ablation guided by intracardiac echocardiography or with a nonirrigated catheter) were considered in a sensitivity analysis., Results: The budget impact showed savings of $43 097 096.84 with cryoablation. In the sensitivity analysis, cryoablation resulted in cost savings compared with RF ablation guided by intracardiac echocardiography, whereas in comparison to RF ablation with the nonirrigated catheter, cryoablation was more expensive. A market share assessment, performed using an incorporation rate of 3% per year, indicated savings of approximately $800 000 per 5 years., Conclusions: Cryoablation of AF resulted in cost savings compared with the current scenario (RF ablation guided by electroanatomic mapping). When alternative technologies were considered, cryoablation was more expensive than RF ablation with a nonirrigated catheter, but it also resulted in savings compared with RF ablation guided by intracardiac echocardiography. Overall, cryoablation of AF may reduce expenditures in the Brazilian public health system., (Copyright © 2019 ISPOR--The professional society for health economics and outcomes research. Published by Elsevier Inc. All rights reserved.)

Background: Acute kidney injury (AKI) is a public health problem that affects millions of hospitalized patients worldwide. In Argentina, evidence suggests that its incidence has risen in recent years. When severe, AKI may require a renal replacement therapy (RRT) where continuous RRT (CRRT) and intermittent RRT (IRRT) are plausible options for patients in the intensive care unit., Objective: To evaluate the cost utility of CRRT versus IRRT for the National Institute of Social Services for Retirees and Pensioners, the largest social security health insurance for elders in Argentina., Methods: This was a model-based cost-utility analysis. Long-term costs and health outcomes were estimated for a hypothetical cohort with a Markov model. Parameters used were obtained from published literature and validated with local experts. Local costs were estimated and expressed in $AR of 2016. Several sensitivity analyses were run to analyze the impact of uncertainty on results., Results: Continuous RRT dominated IRRT by cumulating over the model more quality-adjusted life years and less costs. Total discounted quality-adjusted life years for both cohorts were 1049 and 1034, respectively, and total costs were $95 362 and $103 871. Cost-effectiveness (CE) results reflect these differences in favor of CRRT with a deterministic cost-saving incremental CE ratio and a probability of CRRT being CE of 65.4%, considering a CE threshold of 1 gross domestic product per capita., Conclusions: Continuous RRT for patients with AKI eligible for CRRT or IRRT would probably be a cost-effective intervention for the National Institute of Social Services for Retirees and Pensioners' view. Nevertheless, there is considerable uncertainty around results, mainly due to the lack of adequate controlled studies and local data on the prognosis of these patients in Argentina., (Copyright © 2019 ISPOR--The professional society for health economics and outcomes research. Published by Elsevier Inc. All rights reserved.)

For data science tools to mature and become integrated into routine clinical practice, they must add value to patient care by improving quality without increasing cost, by reducing cost without changing quality, or by both reducing cost and improving quality. Artificial intelligence (AI) algorithms have potential to augment data-driven quality improvement for radiologists. If AI tools are adopted with population health goals in mind, the structure of value-based payment models will serve as a framework for reimbursement of AI that does not exist in the fee-for-service system., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Preoperative long-course chemoradiotherapy (CRT) and short-course radiotherapy (SCR) for locally advanced rectal cancer (LARC) were found to have equivalent outcomes in 3 randomized trials. SCR has not been widely adopted in the United States (US). Three-dimensional (3D) treatment planning is standard, whereas intensity-modulated radiotherapy (IMRT) is controversial. In this study, we assessed the economic impact of fractionation scheme and planning method for payers in the US., Materials and Methods: We performed a population-based analysis of the total cost of radiotherapy for LARC in the US annually. The national annual target population was calculated using the Surveillance, Epidemiology, and End Results database. Radiotherapy costs were based on billing codes and 2018 pricing by Medicare's Hospital Outpatient Prospective Payment System., Results: We estimate that 12,945 patients with LARC are treated with radiotherapy annually in the US. The cost of CRT with 3D or IMRT is US $15,882 and $23,745 per patient, respectively. With SCR, the cost with 3D or IMRT is $5,458 and $7,323 per patient, respectively. The use of SCR would lead to 53% to 77% annual savings of $106,168,871 to $232,105,727 compared with CRT. IMRT increases the total cost of treatment by 34% to 50%, and if adopted widely, would lead to an excess cost of $24,152,134 and $101,784,723 annually with SCR and CRT, respectively., Conclusions: SCR may have the potential to save approximately US $106 to t232 million annually in the US, likely without impacting outcomes. Lack of evidence showing benefit with costly IMRT should limit its use to clinical trials. It would be reasonable for public and private payers to consider which type of radiation is most suited to reimbursement., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Within a health care landscape characterized by increasing financial pressures, fluctuating payment models, and an increasing prevalence of clinician burnout, structures to strategically support innovation are imperative to financial and clinical success., Methods: We developed the Brigham Care Redesign Incubator and Startup Program (BCRISP), a flexible model to test, evaluate, and scale innovative care redesign proposals. We evaluated its impact via analysis of programmatic and financial data, as well as through exploration of individual project outcomes., Results: In 5 years, BCRISP has evaluated 283 innovations, piloted 25 projects, and generated $1.8 million in total medical expense reduction and $7.1 million in increased net revenue for our institution. Initially, it was conceived as a mechanism to engage staff in population health initiatives. As shifts toward risk-based reimbursement have slowed, we have observed a similar transition among proposed and supported innovation in the program., Conclusions: BCRISP enabled front-line clinical employees to design and pilot solutions to common and important clinical care problems, delivering financial return and improvements in care delivery. The underlying structure has been able to adapt to the changing political and economic climate, demonstrating a flexible and powerful approach to strategic investment that could be applied broadly by many health care provider organizations., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Objectives: A recent theoretical economic model suggested that oversized vials of cancer drugs lead to $1.8 billion of drug wastage annually in the United States. It is currently unknown how precisely this theoretical model is consistent with the real world. We performed a real-world analysis to assess the economic impact of drug wastage., Methods: We performed a systematic examination of the usage and wastage of all intravenous cancer drugs in the cancer center of a large tertiary care hospital in Israel. During a period of 1 month, we collected usage and wastage data from the hospital's pharmacy dispensing computerized logs. We calculated the local financial impact using Israeli drug prices list (June 2016) from the ministry of health. We performed an additional analysis using discounted U.S. prices, using the October 2016 Average Sales Prices from the Centers of Medicare and Medicaid Services., Results: Seventy-four injectable anticancer drugs were used during March 2016, and 68 Israeli drug prices were available. The total amount spent on wasted drugs in 1 month was then extrapolated to calculate the annual spending, which was $141,196 per month (5.11% of the total cost) or $1,694,352 per year. Using U.S. prices, the total wastage would be $2,208,876 annually. The 5 drugs that led to the highest expenditure on wastage were bortezomib, trastuzumab, azacytidine, pemetrexed and carfilzomib. There was no wastage of 24 of the 74 drugs., Conclusion: This real-world study demonstrates the economic impact of wastage of anticancer drugs on health systems. To decrease wastage, particular attention should be paid to drugs with high usage rates, high cost, and oversized vials., (Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to quantify the financial impact of a pharmacist-driven pilot medication therapy management (MTM) program within a visiting nurse service (VNS) and identify types of medication-related problems affecting the home health care population., Methods: Patients were contacted to schedule a home visit with the primary investigator. At the appointment, a comprehensive medication review (CMR) was completed, and data collected included primary reason for VNS care, comorbid diagnoses, number of prescription and nonprescription medications at time of visit, and type of pharmacist-identified medication therapy intervention(s). The VNS is a nonprofit independent home health care agency serving patients of all ages and health conditions. Patients admitted with primary insurance coverage through Blue Cross Blue Shield (BCBSRI) Blue Chip for Medicare and 65 years of age and older were eligible for inclusion. Intervention categories were aligned to coordinate with current billable OutcomesMTM claim categories. Dollar allocation for each intervention severity level was assigned according to the predetermined Medicare cost savings predicted value from BCBSRI. Interventions were assigned cost-saving value by the severity level to estimate savings., Results: Twenty-five patients received CMRs. Patients averaged 5.92 chronic health conditions, 8.48 Part D drugs, and 3.88 over-the-counter medications. Two hundred eighteen medication-related problems were identified spanning 13 intervention categories. Intervention severity level was assigned to the medication-related problems, with calculated cost savings from pharmacist interventions totaling $124,352., Conclusion: This pilot study demonstrated the positive economic impact of a pharmacist-run MTM program at VNS for patients with multiple chronic conditions and medication-related problems. Potential societal benefits include that community members admitted to VNS will continue to have access to a pharmacist as a standard of care with the continuation of this MTM program., (Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Purpose: The 2009 American College of Obstetricians and Gynecologists guidelines recommended no cervical cancer screening before age 21 years. We examined changes in screening, diagnostic, and treatment procedures for cervical dysplasia after guideline introduction, and cost implications., Methods: We studied Davidson County women aged 18-20 years, enrolled in Tennessee Medicaid, 2006-2014. We identified those with at least one Papanicolaou (Pap) test, human papillomavirus detection test, colposcopy, or excisional dysplasia treatment annually via Current Procedural Terminology coding. We used rate ratios with 95% confidence intervals to compare annual changes in procedure and treatment rates from 2014 to 2006. We counted total outcomes to estimate annual costs based on 2014 average procedural costs., Results: From 2006 to 2014, about 3,800 Davidson County women aged 18-20 years were enrolled in Medicaid annually. From 2006 to 2014, there were declines in Pap tests from 55.6 to 15.2 per 100 women (rate ratio .27, 95% confidence interval .25-.3); human papillomavirus tests from 13.8 to 5.9 per 100 (.42, .36-.5); colposcopy from 9.4 to 1.1 per 100 (.12, .08-.17); and dysplasia treatment from 1.1 to 0 per 100. The estimated cost of screening and procedures fell from $53 to $8 per enrolled woman, not accounting for changes in visits or complications associated with these procedures., Conclusions: The 2009 screening guidelines were associated with major declines in screening, diagnostic, and treatment procedures for cervical dysplasia. Minimum estimated procedure and treatment costs saved were $45 per enrolled woman age 18-20 years., (Copyright © 2017 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To (a) determine potential cost savings of a pharmacy outreach teleservice program conducting Medicare Part D plan reviews for a large population of beneficiaries allowing for comparison of multiple preferences; and (b) explore client demographic comparisons, plan features, and stratification by cost and number of medications., Methods: Retrospective cohort evaluation of a Medicare D review service during open enrollment period (October 15 to December 7, 2012). Reviews were conducted at a university-based pharmacy outreach program in Massachusetts and completed by pharmacists (17%), case managers (52%), and students (31%). Recommendations were created by entering medication regimens into the Medicare.gov plan finder, and factors including deductible, premium, and copayment or coinsurance, formulary restrictions, secondary assistance, and annual cost were considered. A comparison of the overall cost of the client's 2012 plan in 2013 with that of a lower-cost plan in the 2013 benefit year determined potential cost savings., Results: Demographic data were available for 1062 individuals, with the majority being women (66%), an overall mean age of 73 years, and most living in a single household. Clients (75%) were taking 5 or more medications. Lower-cost plans were recommended for 61% of clients with a median cost savings valued at $538 per member, per year. Cost was the leading consideration for plan change (87.4%), followed by deductible (32.7%) and premium (30.1%). Cost savings were analyzed by evaluating current plan versus alternate plan by sex, age, client type (repeat vs. referred vs. new), and according to number of medications. Lower-cost plans were identified for 75% of new members. Individuals taking 0-14 medications had a cost savings of approximately $833 per client per year., Conclusion: Teleservice pharmacy outreach programs create value by identifying therapeutically comparable alternative plans and reducing plan spending while efficiently consulting for a large number of Medicare Part D beneficiaries statewide., (Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objective: The primary objective was to determine total estimated cost savings based on a patient's current medication regimen after comparing available Medicare Part D plans for the upcoming year by using a plan comparison platform. The secondary objective was to determine patient-centered concerns when considering a change in Part D plans., Design: Review of an open enrollment service that included a patient survey and a Part D plan comparison., Setting: This study took place at a single independent community pharmacy in northwest Alabama., Participants: Fifty-four patients eligible for Medicare Part D were included in this study., Main Outcome Measures: The study was a review of an open enrollment service that aids Medicare beneficiaries in selecting a Part D plan that best fits their needs. It included a patient survey and plan comparison using a plan comparison platform, during the 2015 Medicare open enrollment period (October 15 to December 7). The survey assessed patient demographics, pharmacy preferences, and cost concerns. Survey data were used to aid in plan selection and analysis to determine the most common patient-centered concerns when considering a change in plans., Results: During the open enrollment period, 54 patients compared Medicare Part D plans. The majority of participants were female (57%) and ranged in age from 65-69 years (37%) to 70-74 years (25.9%). The majority of patients reported a preference for independent pharmacies (92.6%). Deductible (40.7%) was the biggest concern for patients when comparing the main cost variables for medication insurance. The average total cost difference per patient per year showed that each patient saved an average of $1166.46., Conclusion: The analysis of an independent pharmacy's open enrollment service determined that a plan comparison platform is a valuable tool in helping patients to compare and select cost-effective Medicare Part D prescription plans and in helping patients save money., (Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Purpose: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings for the United States Military Health Care System (MHS) and provide a safe alternative to performing similar procedures in the operating room., Methods: A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by using the Medical Expense and Performance Reporting System, the standard cost accounting system for the MHS, to compare procedures performed in the clinic versus the operating room during the study period. A study specific questionnaire was obtained for 66 procedures to evaluate the patient's experience., Results: For carpal tunnel release (n = 34) and A1 pulley release (n = 33), there were 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared with the main operating room, respectively. During the study period, carpal tunnel release, A1 pulley release, and de Quervain release performed in the clinic instead of the operating room amounted to $393,100 in cost savings for the MHS. There were no adverse events during the WALANT procedure., Conclusions: A clinic-based WALANT hand surgery program at a military medical center results in considerable cost savings for the MHS., Type of Study/level of Evidence: Economic/Decision Analysis IV., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Study Objective: Volatile anesthetic agents comprise a substantial portion of every hospital's pharmacy budget. Challenged with an initiative to lower anesthetic drug expenditures, we developed an education-based intervention focused on reducing volatile anesthetic costs while preserving access to all available volatile anesthetics. When postintervention evaluation demonstrated a dramatic year-over-year reduction in volatile agent acquisition costs, we undertook a retrospective analysis of volatile anesthetic purchasing data using time series analysis to determine the impact of our educational initiative., Design/setting: We obtained detailed volatile anesthetic purchasing data from the Central Supply of Wake Forest Baptist Health from 2007 to 2014 and integrated these data with the time course of our educational intervention., Patients: Aggregate volatile anesthetic purchasing data were analyzed for 7 consecutive fiscal years., Intervention: The educational initiative emphasized tissue partition coefficients of volatile anesthetics in adipose tissue and muscle and their impact on case management., Measurements: We used an interrupted time series analysis of monthly cost per unit data using autoregressive integrated moving average modeling, with the monthly cost per unit being the amount spent per bottle of anesthetic agent per month., Main Results: The cost per unit decreased significantly after the intervention (t=-6.73, P<.001). The autoregressive integrated moving average model predicted that the average cost per unit decreased $48 after the intervention, with 95% confidence interval of $34 to $62. As evident from the data, the purchasing of desflurane and sevoflurane decreased, whereas that of isoflurane increased., Conclusions: An educational initiative focused solely on the selection of volatile anesthetic agent per case significantly reduced volatile anesthetic expense at a tertiary medical center. This approach appears promising for application in other hospitals in the rapidly evolving, value-added health care environment. We were able to accomplish this with instruction on tissue partition coefficients and each agent's individual cost per MAC-hour delivered., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To determine the financial implications of switching technetium (Tc)-99m mercaptoacetyltriglycine (MAG-3) to Tc-99m diethylene triamine penta-acetic acid (DTPA) at certain renal function thresholds before renal scintigraphy., Methods: Institutional review board approval was obtained, and informed consent was waived for this HIPAA-compliant, retrospective, cohort study. Consecutive adult subjects (27 inpatients; 124 outpatients) who underwent MAG-3 renal scintigraphy, in the period from July 1, 2012 to June 30, 2013, were stratified retrospectively by hypothetical serum creatinine and estimated glomerular filtration rate (eGFR) thresholds, based on pre-procedure renal function. Thresholds were used to estimate the financial effects of using MAG-3 when renal function was at or worse than a given cutoff value, and DTPA otherwise. Cost analysis was performed with consideration of raw material and preparation costs, with radiotracer costs estimated by both vendor list pricing and proprietary institutional pricing. The primary outcome was a comparison of each hypothetical threshold to the clinical reality in which all subjects received MAG-3, and the results were supported by univariate sensitivity analysis., Results: Annual cost savings by serum creatinine threshold were as follows (threshold given in mg/dL): $17,319 if ≥1.0; $33,015 if ≥1.5; and $35,180 if ≥2.0. Annual cost savings by eGFR threshold were as follows (threshold given in mL/min/1.73 m(2)): $21,649 if ≤60; $28,414 if ≤45; and $32,744 if ≤30. Cost-savings inflection points were approximately 1.25 mg/dL (serum creatinine) and 60 mL/min/1.73m(2) (eGFR). Secondary analysis by proprietary institutional pricing revealed similar trends, and cost savings of similar magnitude. Sensitivity analysis confirmed cost savings at all tested thresholds., Conclusions: Reserving MAG-3 utilization for patients who have impaired renal function can impart substantial annual cost savings to a radiology department., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: The general inhalation anesthetic sevoflurane can be used for the topical treatment of complicated wounds. It is applied in liquid form and may be used to irrigate the inside of cavities. Sevoflurane also exhibits in vitro antimicrobial activity. Therefore, sevoflurane may be used as an alternative to typical antibiotic or surgical treatment of complicated, localized infections., Case Description: The case of a 61-year-old male patient who suffered a cranioencephalic trauma 18 years previously is presented. The patient underwent surgeries related to the trauma on numerous occasions. To date, he has suffered various recurrent epidural abscesses, which have been treated with surgical cleaning and antibiotic treatment. In the most recent episode, he presented a frontal epidural abscess 25 mm in diameter with fistulization of the skin. The patient gave written informed consent to be treated with sevoflurane irrigation, and the Pharmacy Service authorized the off-label use. Sevoflurane was applied via a catheter placed inside the cavity during weekly outpatient procedures. The procedures began 8 weeks after the clinically and radiologically verified recovery of the abscess. By avoiding surgery and the associated hospital admission, this novel alternative may prevent patient morbidity and, furthermore, may produce important economic savings., Conclusions: The treatment of complicated wounds with liquid sevoflurane may be an effective and economically efficient clinical alternative for some patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: At our institution, diagnostic hysteroscopy (DH), often combined with uterine curettage, commonly has been performed in the main OR with the patient under general anaesthesia. Our objective was to create targeted interventions aimed at decreasing the number of DHs performed in the OR by 75% over one year., Methods: This quality improvement initiative had a quasi-experimental (time-series) design. To obtain baseline numbers of DHs performed each month, we conducted a retrospective chart audit at a university teaching hospital. We implemented the following three groups of interventions: (1) staff education and case review, (2) accessible sonohysterography, and (3) an operative hysteroscopy education program. Procedures were tracked prospectively over a 12-month intervention period and an additional 12-month maintenance period., Results: One hundred eleven DHs were performed at baseline. During the intervention period, 33 DHs were performed, a 70% reduction from baseline. This resulted in related savings of $126 984 and 12.5 surgical days. In the final quarter of the intervention period, there was an 81% reduction in the number of DHs with adequate preoperative evaluation compared with baseline. Twenty DHs were performed in the maintenance period, an 82% reduction from baseline. The absolute number of complications from DH remained constant during the study period., Conclusion: Carefully planned and targeted interventions to change the culture at our institution decreased the number of DHs performed in the main OR. These initiatives improved patient care, saved costs, and improved OR utilization. Long-term follow-up showed maintenance of the improvements in the year subsequent to the interventions., (Copyright © 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to quantify the association between health information exchange (HIE) use and cost savings attributable to repeat imaging., Methods: Imaging procedures associated with HIE were compared with concurrent controls on the basis of propensity score matching over the period from 2009 to 2010 in a longitudinal cohort study. The study sample (n = 12,620) included patients ages 18 years and older enrolled in the two largest commercial health plans in a 13-county region of western New York State served by the Rochester Regional Health Information Organization. The primary outcome was a continuous measure of costs associated with repeat imaging. The determinant of interest, HIE use, was defined as system access after the initial imaging procedure and before repeat imaging., Results: HIE use was associated with an overall estimated annual savings of $32,460 in avoided repeat imaging, or $2.57 per patient. Basic imaging (radiography, ultrasound, and mammography) accounted for 85% of the estimated avoided cases of repeat imaging. Advanced imaging (CT and MRI) accounted for 13% of avoided procedures but constituted half of the estimated savings (50%)., Conclusions: HIE systems may reduce costs associated with repeat imaging. Although inexpensive imaging procedures constituted the largest proportion of avoided repeat imaging in our study, most of the estimated cost savings were due to small reductions in repeated advanced imaging procedures. HIE systems will need to be leveraged in ways that facilitate greater reductions in advanced imaging to achieve appreciable cost savings., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate potential cost savings based on estimated cost avoidance from medication therapy management (MTM) services delivered in safety-net clinics over 4 years., Methods: High-risk patients taking multiple medications and with chronic conditions were referred for MTM services in primary care safety-net clinics in Maryland from October 1, 2009, to September 30, 2013. Medication-related problems (MRPs) were identified and pharmacists' costs determined to evaluate the estimated cost savings and return on investment (ROI). A range of potential economic outcomes for each MRP identified was assigned to a cost avoidance for outpatient visit, urgent care visit, emergency department visit, and/or hospitalization., Results: Over 4 years, 246 patients received MTM, nearly 2,100 medications were reviewed, and 814 MRPs were identified. The most common MRPs identified were subtherapeutic doses, nonadherence, and untreated indications, with respective prevalences of 38%, 19%, and 16%. The corresponding costs of medical services were estimated at $115,220-$614,570 for all MRPs identified, yielding a mean of $141.55-$755.00 per identified MRP. Pharmacists' expenses for encounters were calculated at a total expenditure of $57,307.50 for 16,965 minutes. ROI based on the time spent during billable face-to-face encounters ranged from 1:5 to 1:25., Conclusion: Pharmacist-provided MTM in safety-net clinics yielded potential economic benefits to the organization. The Primary Care Coalition of Montgomery County plans to expand MTM services to additional clinics to improve patient care and increase cost savings through preventable medical services.

Objective: This study estimates how making oral contraceptive pills (OCPs) available without a prescription may affect contraceptive use, unintended pregnancies and associated contraceptive and pregnancy costs among low-income women., Study Design: Based on published figures, we estimate two scenarios [low over-the-counter (OTC) use and high OTC use] of the proportion of low-income women likely to switch to an OTC pill and predict adoption of OCPs according to the out-of-pocket costs per pill pack. We then estimate cost-savings of each scenario by comparing the total public sector cost of providing OCPs OTC and medical care for unintended pregnancy., Results: Twenty-one percent of low-income women at risk for unintended pregnancy are very likely to use OCPs if they were available without a prescription. Women's use of OTC OCPs varies widely by the out-of-pocket pill pack cost. In a scenario assuming no out-of-pocket costs for the over-the counter pill, an additional 11-21% of low-income women will use the pill, resulting in a 20-36% decrease in the number of women using no method or a method less effective than the pill, and a 7-25% decrease in the number of unintended pregnancies, depending on the level of use and any effect on contraceptive failure rates., Conclusions: If out-of-pocket costs for such pills are low, OTC access could have a significant effect on use of effective contraceptives and unintended pregnancy. Public health plans may reduce expenditures on pregnancy and contraceptive healthcare services by covering oral contraceptives as an OTC product., Implications: Interest in OTC access to oral contraceptives is high. Removing the prescription barrier, particularly if pill packs are available at low or zero out-of-pocket cost, could increase the use of effective methods of contraception and reduce unintended pregnancy and healthcare costs for contraceptive and pregnancy care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Little information is available on the relationship between hospital volume and the outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity. This study aimed to investigate the influence of hospital volume on patient outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity using a national administrative database., Methods: A total of 5941 comorbid patients treated with laparoscopic gastrectomy for gastric cancer were referred to 741 hospitals in Japan. We collected patients' data from the administrative database to compare laparoscopy-related complications, in-hospital mortality, length of stay (LOS), and medical costs during hospitalization in relation to hospital volume. Hospital volume was categorized into two groups: low (<40 cases in 3 years; n = 4111) and high (≥ 40 cases; n = 1830)., Results: There were no significant differences between the groups in laparoscopy-related complications and in-hospital mortality (p = 0.684 and p = 0.200, respectively). However, significant variations in mean LOS and medical costs were observed between hospital volume categories (26.1 days vs. 20.2 days and 16,163.9 US dollars vs. 14,345.9 US dollars, respectively; p < 0.001). Multiple linear regressions revealed that higher hospital volume was significantly associated with shorter LOS and lower medical costs during hospitalization. The unstandardized coefficient for LOS was -4.62 days (95% confidence interval = -5.63--3.60, p < 0.001), whereas that for medical costs was -1424.1 US dollars (95% confidence interval = -1962.5--885.6, p < 0.001)., Conclusion: Hospital volume was significantly associated with a decrease of LOS and medical costs of comorbid patients undergoing laparoscopic gastrectomy for gastric cancer., (Copyright © 2014. Published by Elsevier Taiwan.)

Background: Previous studies have reported that certain populations are sensitive to high out-of-pocket drug costs, and drug noncompliance leads to poorer health outcomes., Objective: Our aim was to measure patient awareness of discount pharmacy options, cost barriers to medication access, and beliefs about health care provider's use of low-cost medications., Methods: This cross-sectional 17-item survey was administered to patients in the emergency department of an urban trauma center in February 2011. Differences in responses by sex and race groups were assessed. A logistic regression model was created to estimate the association of sociodemographic factors and medication use with awareness of discount pharmacy options., Results: Five hundred and fifty-two surveys were analyzed. Among respondents who were prescribed medications within the past year, three fourths of patients felt comfortable asking physicians for cheaper medicines. Slightly more than half were aware of low-cost pharmacy options, and 78% of these respondents correctly listed at least one of these pharmacies. Caucasian patients were more comfortable than African American patients asking for cheaper medicines (82.5% vs. 72.2%; p < 0.05) and were more aware of low-cost prescription programs (63.9% vs. 43.5%; p < 0.001). When adjusted for insurance status and current medication use, Caucasian patients were 2.7 times more likely to name a valid discount pharmacy option compared to African Americans (95% confidence interval 1.85-4.07)., Conclusions: This study suggests populations may be more uncomfortable initiating a discussion about medication costs and selection of lower-cost alternatives. Health care providers may need to develop communication strategies in which medication cost is addressed with sensitivity and consistency., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A fundamental element of health care payment reform under the Affordable Care Act is the development of Accountable Care Organizations (ACOs). The ACO model employs shared-risk contracts to better align the interests of health care providers and payers with the intent of driving efficiency and quality in care. The Medicare Shared Savings Program is the most popular of the Medicare ACO programs, with over 200 health systems across the nation participating at this time. However, a pitfall in the way that the Medicare Shared Savings Program is structured, specifically the benchmarking and rebasing method, could make it difficult for even top-performing ACOs to achieve sustained success, thereby threatening the long-term viability of the program. In this paper, we present this pitfall to the radiology community as well as potential solutions that can be considered by CMS moving forward., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

A major motivation for managing the utilization of laboratory testing is to reduce the cost of medical care. For this reason it is important to understand the basic principles of cost accounting in the clinical laboratory. The process of laboratory testing includes three distinct components termed the pre-analytic, analytic and post-analytic phases. Utilization management efforts may impact the cost structure of these three phases in different ways depending on the specific details of the initiative. Estimates of cost savings resulting from utilization management programs reported in the literature have often been fundamentally flawed due to a failure to understand basic concepts such as the difference between laboratory costs versus charges and the impact of reducing laboratory test volumes on the average versus marginal cost structure in the laboratory. This article will provide an overview of basic cost accounting principles in the clinical laboratory including both job order and process cost accounting. Specific examples will be presented to illustrate these concepts in various different scenarios., (© 2013.)

Purpose: To provide insight into the preoperative factors that affect outcome after pneumatic retinopexy (PR) for treatment of primary rhegmatogenous retinal detachment repair. Additionally, we sought to analyze the cost of rhegmatogenous retinal detachment repair in the United States to determine potential cost savings with pneumatic retinopexy., Design: Single-center, retrospective, observational consecutive case series and third party payer-perspective comparative cost analysis., Participants: We included 141 eyes undergoing pneumatic retinopexy for the treatment of primary rhegmatogenous retinal detachment., Methods: Preoperative characteristics, anatomic outcomes, and best-available visual acuity were collected. Anatomic and visual outcomes were analyzed based on the presence of selected preoperative factors. The primary cohort was divided into 2 groups based on preoperative characteristics: (1) traditional pneumatic retinopexy and (2) nontraditional pneumatic retinopexy. Comparative cost analyses were performed between pneumatic retinopexy, scleral buckling, and vitrectomy., Main Outcome Measures: Anatomic and visual outcomes at 6 months., Results: Overall anatomic success was 78.7% and visual acuity improved significantly (logarithm of the minimum angle of resolution [logMAR] 0.48-0.25; P <0.005). A 97.6% final anatomic success rate was achieved. Anatomic outcomes were similar between traditional versus nontraditional (84.1% vs 74.4%; P = 0.16), phakic versus pseudophakic (79.1% vs 78.0%; P = 0.88), and macula-on versus macula-off (77.9% vs 81.1%; P = 0.68) groups. Anatomic failure was predicted by the presence of an inferior retinal break (P <0.005) or visible vitreous traction on a retinal break (P = 0.04). Visual outcomes were similar between each of the traditional versus nontraditional (logMAR 0.21 vs 0.27; P >0.05) and phakic versus pseudophakic groups (logMAR 0.23 vs 0.28; P >0.05). Visual outcomes were better in macula-on detachments compared with those in which the macula was detached (logMAR 0.18 vs 0.42; P <0.005). Annual health care cost savings in the United States ranging from $6 to $30 million are theoretically possible by increasing pneumatic retinopexy utilization from the current rate of 15% to 20%-35%., Conclusions: Pneumatic retinopexy is an effective treatment modality for primary rhegmatogenous retinal detachment. Anatomic and visual outcomes are similar for traditional and nontraditional preoperative inclusion criteria, as well as phakic and pseudophakic eyes. Inferior breaks and visible vitreous traction on a tear predicted failure. Increased utilization of pneumatic retinopexy would achieve significant cost savings while maintaining outcomes., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers., Study Design: We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively., Results: With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved., Conclusion: A revised Medicaid sterilization policy could potentially honor women's reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds., Implication: Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year., (© 2013.)

Objective: In the SAVE-trial we evaluated the safety, reliability and improvements of patient management using the BIOTRONIK Home Monitoring®-System (HM) in pacemaker (PM) and implanted cardioverter defibrillator (ICD) patients., Design: 115 PM (Module A) and 36 ICD-patients (Module B) were recruited 3 months after implantation., Patients: 65 patients in Module A were randomised to HM-OFF and had one scheduled outpatient clinic follow-up(FU) per year, whereas patients randomised to HM-ON were equipped with the mobile transmitter and discharged without any further scheduled in-office FU. In Module B 18 patients were randomised to HM-OFF and followed by standard outpatient clinic controls every 6 months; 18 patients were randomised to HM-ON receiving remote monitoring plus one outpatient clinic visit per year; unscheduled follow-ups were performed when necessary., Results: The average follow-up period was 17.1 ± 9.2 months in Module A and 26.3 ± 8.6 months in Module B. In both modules, the number of FUs per year was significantly reduced (Module A HM-ON 0.29 ± 0.6 FUs/year vs HM-OFF 0.53 ± 0.5 FUs/year; p b 0.001; Module B HM-ON 0.87 ± 0.25 vs HM-OFF 1.73 ± 0.53 FU/year,p b 0.001). Cost analysis was significantly lower in the HM-ON group compared to the HM-OFF group (18.0 ± 41.3 and 22.4 ± 26.9 € respectively; p b 0.003). 93% of the unscheduled visits in Module B were clinically indicated,whereas 55% of the routine FUs were classified as clinically unnecessary., Conclusion: Remote home monitoring of pacemaker and ICD devices was safe, reduced overall hospital visits, and detected events that mandated unscheduled visits.

Background: Inappropriate catheter requests at the McGill University Health Centre (MUHC) led to significantly increased costs and early catheter malfunction or infection. Dual-lumen catheters were often requested and inserted when only a single lumen was required, and inappropriate catheter care on the wards led to early infection or thrombosis., Methods: A full-time registered nurse was hired to analyze and transform the vascular access program of the MUHC. Catheter selection was streamlined on the basis of clinical unit need. Clinical and cost data were collected between May 2011 and January 2012., Results: Requests for vascular access at the MUHC have been standardized and centralized. Single-lumen catheters are inserted unless a specific indication for a dual-lumen catheter is provided. To date, data have been collected on >4,000 catheter insertions, both before and after the switch to the single-lumen program. Dual-lumen catheters have been required in only 50% of cases. Reinsertion rates have decreased, leading to the first year-over-year reduction in peripherally inserted central venous catheter insertion since data collection began in 2002. The program has also resulted in significant reductions in central line-associated bloodstream infection and catheter-related thrombosis. Decreased maintenance and reinsertion costs have led to overall savings for the MUHC of approximately $1.1 million., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Cancer treatments have improved outcomes but access to medications is an issue around the world and especially so in low- and middle-income countries, such as India. Generic substitution may lead to significant cost savings. The author aimed to compare the cost and estimate potential cost savings per cycle, per patient, and for the country as a whole with generic substitution of frequently used chemotherapy drugs in the treatment of common cancers in India. Generic paclitaxel (Taxol), docetaxel (Taxotere), gemcitabine, oxaliplatin and irinotecan cost from 8.9% to 36% of their equivalent branded originator drug, resulting in cost savings of ~ Indian Rupees (INR) 11,000 to >INR 90,000 (USD 200-1600, Euro 160-1300) per cycle; and ~INR 50,000 to >INR 240,000 (USD 900-4300, Euro 700-3400) per patient. Overall, potential yearly savings for health systems in India were nearly INR 47 billion (~USD 843 million, Euro 670 million). In conclusion, generic substitution for frequently used chemotherapy drugs in the treatment of common cancers has an enormous potential to generate significant cost savings and increase access to cancer treatments in India and other low- and middle-income countries.

Background: Although costs of providing care may decrease with hospital initiatives to improve obstetric and neonatal outcomes, the accompanying reduced adverse outcomes may negatively affect hospital revenues., Methods: In 2008 a Minnesota-based hospital system (Fairview Health Services) launched the Zero Birth Injury (ZBI) initiative, which used evidence-based care bundles to guide management of obstetric services. A pre-post analysis of financial impacts of ZBI was conducted by using hospital administrative records to measure costs and revenues associated with changes in maternal and neonatal birth injuries before (2008) and after (2009-2011) the initiative., Results: For the Fairview Health Services hospitals, after adjusting for relevant covariates, implementation of ZBI was associated with a mean 11% decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011 (adjusted odds ratio [AOR] = 0.89, p = .076). As a result of the adverse events avoided, the hospital system saved $284,985 in costs but earned $324,333 less revenue, which produced a net financial decrease of $39,348 (or a $305 net financial loss per adverse event avoided) in 2011, compared with 2008., Conclusions: Adoption of a perinatal quality and safety initiative that reduced birth injuries had little net financial impact on the hospital. ZBI produced better clinical results at a lower cost, which represents potential savings for payers, but the hospital system offering improved quality reaped no clear financial rewards. These results highlight the important role for shared-savings collaborations (among patients, providers, government and third-party payers, and employers) to incentivize QI. Widespread adoption of perinatal safety initiatives combined with innovative payment models may contribute to better health at reduced cost.

Objective: Delirium is a common problem associated with increased morbidity, mortality, and healthcare costs in the hospitalized elderly, yet there is little research outside of academic medical centers exploring methods to prevent its onset. The authors adapted the Hospital Elder Life Program (HELP) for use in a community hospital and assessed its impact on delirium rate, length of stay (LOS) and healthcare costs in elderly patients., Methods: Delirium episodes and duration, total patient-days with delirium and LOS were assessed in 595 patients 70 years of age or older admitted to a general medical floor at a community hospital. Pre-intervention outcomes were assessed on the medical floor for 4 months. Interventions adapted from HELP occurred over 9 months and included daily visits, therapeutic activities, and assistance with feeding, hydration, sleep, and vision/hearing impairment. Delirium was assessed on a daily basis with the Confusion Assessment Method (CAM)., Results: The rate of episodes of delirium decreased from 20% in the pre-intervention group to 12% in the intervention group, a relative 40% reduction (P = 0.019). Total patients days with delirium decreased from 8% in the usual care group to 6% in the intervention group (P = 0.005). LOS among all patients enrolled in the intervention group decreased by 2 days (P < 0.001). Interventions resulted in $841,000 cost savings over 9 months., Conclusions: HELP can be successfully adapted for implementation in a community hospital setting to decrease delirium episodes, total patient-days with delirium and LOS, and generate substantial cost savings., (Copyright © 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Optimizing the care management of patients is a major issue for our society. In Brittany-Pays-de-la-Loire (almost 10% of French population), an observatory of cancer has been created in 2003. Its main objective was the follow-up of expensive drugs. The knowledge of the use of these drugs in clinical practice has led to development of a thesaurus of good use. Thus, regular exchanges between clinicians have almost totally reduced not medically justified prescriptions by the thesaurus after and before administration to patient. The thesaurus has given away to national guidelines from 2007. For example, in these two regions, optimization of the use of gemcitabine and bevacizumab has allowed to save respectively 2.5 millions euros between 2005 and 2008 and 3 millions euros between 2009 and 2010 (breast cancer only). Optimizing the use of anticancer drugs has allowed a real health economy without any bad impact on patient management. Respecting medical ethics, the main objective remains to optimize health care. This highly participation of clinicians currently allows to reflect together on the relevance of the last chemotherapy.

Background: This study evaluated the total costs of unintended pregnancy (UP) in the United States (US) from a third-party health care payer perspective and explored the potential role for long-acting reversible contraception (LARC) in reducing UP and resulting health care expenditure., Study Design: An economic model was constructed to estimate direct costs of UP as well as the proportion of UP costs that could be attributed to imperfect contraceptive adherence. The model considered all women requiring reversible contraception in the US: the pattern of contraceptive use and the rates of UP were derived from published sources. The costs of UP in the United States and the proportion of total cost that might be avoided by improved adherence through increased use of LARC were estimated., Results: Annual medical costs of UP in the United States were estimated to be $4.6 billion, and 53% of these were attributed to imperfect contraceptive adherence. If 10% of women aged 20-29 years switched from oral contraception to LARC, total costs would be reduced by $288 million per year., Conclusions: Imperfect contraceptive adherence leads to substantial UP and high, avoidable costs. Improved uptake of LARC may generate health care cost savings by reducing contraceptive non-adherence., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: In breast cancer, adjuvant chemotherapy is often prescribed as a precautionary measure and sometimes unnecessarily. A diagnostic test based on estimating the risk of recurrence at 10 years for women with breast cancer in early stage has been developed (Oncotype DX(®))., Method: A Markov's model was adapted to evaluate the long-term effect of this test in terms of costs and life-years gained in French clinical practice for patients with ER+, HER2-, node-negative early-stage breast cancer. Input data were obtained from an international meta-analysis evaluating the proportions of patients in which the genetic test led to changes in the oncologist's decision. Costs and epidemiological data were specific to France. The analysis was conducted in accordance with methodological recommendations from the Haute Autorité de santé., Results: The test is associated with net cost savings of €570 per patient (€1,600 with productivity loss) from societal perspective and gains of 0.15 life-years and 0.14 quality-adjusted life-years per patient., Conclusions: The use of the test represents efficient use of health care resources in French practice. This test provides an opportunity to optimize treatment prescription by avoiding unnecessary chemotherapies and by prescribing chemotherapy to women who would not have received it based on standard decision criteria.

Purpose: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder of vascular development resulting in direct connections between the arterial and venous systems, bypassing capillaries. Symptoms and signs can appear throughout life and marked intrafamilial variability confounds diagnosis based purely on clinical criteria. We set out to determine the impact of genetic testing on the cost of screening for HHT in at-risk relatives., Methods: We performed economic modeling of idealized pedigrees following two scenarios: repeated clinical screening until an HHT diagnosis could be either affirmed or excluded, and mutation testing in the proband, followed by genetic testing of at-risk relatives and clinical monitoring of only those relatives who test positive for the familial mutation., Results: Based on actual reimbursement data from our region's largest health insurer, the molecular diagnostic model saved over $22,000 for a family with four relatives at risk for the initial diagnostic work-up. For a cohort of 100 probands, the total savings for the molecular diagnostic model over a reasonable period of follow-up was greater than $9 million., Conclusion: In this idealized setting in which all probands and at-risk relatives accepted molecular testing, the economic advantages of genetic screening over repeated clinical screening are substantial.

Objective: To determine the impact of telephone medication therapy management (MTM) on medication- and health-related problems (MHRPs), medication adherence, and total drug costs for Medicare Part D participants., Design: Quasiexperimental., Setting: Regional Medicare Part D plan in Texas in 2007., Participants: Medicare Part D beneficiaries who were MTM eligible., Intervention: Pharmacist-provided telephone MTM consultation., Main Outcome Measures: Change in MHRPs, medication adherence, and total drug costs from baseline to 12-month follow-up., Results: The intervention (n = 60) and control (n = 60) groups were similar in age (71.2 ± 7.5 years and 73.9 ± 8.0 years [mean ± SD], respectively), number of medications (13.0 ± 3.2 and 13.2 ± 3.4), chronic diseases (6.5 ± 2.3 and 7.0 ± 2.1), and medication regimen complexity index (21.5 ± 7.8 and 22.8 ± 6.9). Men made up 51% of the intervention group and 28% of the control group ( P = 0.009). MHRPs at baseline were 4.8 ± 2.7 in the intervention group and 9.2 ± 2.9 in the control group, with 2.2 ± 2.0 and 7.3 ± 3.0 at the 12-month follow-up. MHRPs decreased ( P = 0.01) in the intervention group. We found no predictors of change in medication adherence. Drug costs decreased by $682 ± 2,141 in the intervention group and increased by $119 ± 1,763 in the control group. A t test indicated that the cost difference was significant ( P = 0.03), but the adjusted regression analysis did not identify any significant predictors., Conclusion: A telephone MTM program reduced MHRPs. Unadjusted cost comparisons showed cost savings in the intervention group. Future research should focus on understanding how telephone MTM affects medication adherence.

Purpose: Radiology benefit managers (RBMs) are widely used by private payers to manage the utilization of imaging services through prior authorization, and they have been proposed for use in the Medicare program. The authors created a framework for evaluating the impact of key parameters on the ability of RBMs to lower costs and used decision-analytic modeling to simulate the net impact of RBMs on health care costs under uncertainty from a societal perspective., Methods: The authors' model of a "typical" RBM's prior authorization process used base-case values for each parameter (utilization rate and costs for MR, CT, and PET imaging; physician and staff time spent in complying with RBM requirements; approval and denial rates; and RBM fees to insurers) drawn from published data and the experience of a large, academic institution. Different values were tested in the sensitivity analysis to account for uncertainty in the parameter estimates. A hypothetical 100,000-member private health plan with an imaging utilization rate of 135 per 1,000 members per year was assumed., Results: Under the authors' base-case scenario, in which RBMs have no net impact on costs, they estimated that 28% ($182,066/$640,263) of the projected RBM-related savings are shifted to providers. RBMs were cost saving in 45% of simulations, and 95% of simulations fell between a cost decrease of $397,880 and a cost increase of $341,991. The probability of an initial approval by the RBM, the RBM's fee, and the imaging utilization rate and associated charges had the largest influence on the results., Conclusions: The authors' models shows that RBMs shift significant costs to physicians and that their net impact on societal costs depends on parameters for which supporting data are incomplete., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: To assess the effect of gastric bypass surgery on the total cost of medical care for morbidly obese members compared with obese members and a general population., Methods: We used an observational pre-post test design to analyze the administrative claim records of 224 gastric bypass patients during 3 periods (preoperative, surgical, and postoperative years) for a total of 7.5 years. The estimated future care costs for gastric bypass patients were determined from their preoperative cost trends, adjusting for the annualized actuarial trends. The general membership population actuarial trends and overweight/obese member medical expenditure data were used as comparison groups., Results: The inflation adjusted mean per member per year total paid decreased by $1895 in the fifth year after surgery. The mean costs for gastric bypass patients were lower within the first year after surgery than their preoperative costs. At 3.5 years after surgery, the surgical costs had been recouped for patients undergoing gastric bypass surgery, and by year 2, they had incurred fewer costs than the obese health plan population., Conclusion: Although gastric bypass is a costly surgical procedure, the longitudinal costs savings and overall health improvement for patients undergoing gastric bypass surgery are cost-effective within a closed, experienced network. Weight loss surgery decreased the annual costs per patient in the years after surgery. The costs were slightly elevated in the fifth year after surgery because of maternity cases and orthopedic surgeries.

Conceived as a World Health Organization demonstration project for public health initiatives at the end of life, the palliative care program in Catalonia illustrates the impact that similar initiatives may have in terms of cost savings for a regional health system. In a publicly funded and freely accessible health system, decreasing the number of hospital admissions, shortening the lengths of hospital stay, diminishing the frequency of emergency room consultations, shifting the use of acute hospital beds to palliative care beds for treating advanced disease inpatients, and substantially improving the use of opioids in the community are major determinants of the palliative care program's success. These features add to the opportunity the discipline offers to improve the quality of health care at the end of life. In this article, the information gathered over an 18-year trajectory of the program is summarized. Key features of the existing financial models used while developing palliative care in Catalonia are described, and the mechanisms by which palliative care may have contributed to increase savings for the health care system in end-of-life care, from euro3,000,000 in 1995 to euro8,000,000 in 2005, are discussed.

Objectives: Clinical trial data indicate that posaconazole is superior to fluconazole (FLU) or itraconazole (ITRA) in preventing invasive fungal infections (IFIs) among neutropenic patients. Our objective was to assess the cost-effectiveness of posaconazole versus FLU or ITRA for prevention of IFIs among neutropenic patients., Methods: We used modeling techniques to assess the cost-effectiveness of posaconazole versus FLU or ITRA in the prevention of IFIs among patients with acute myelogenous leukemia (AML) or myelodysplastic syndromes (MDS) and chemotherapy-induced neutropenia. The probabilities of experiencing an IFI, IFI-related death, and death from other causes over 100 days of follow-up were estimated from clinical trial data. Long-term mortality, drug costs, and IFI treatment costs were obtained from secondary sources., Results: Posaconazole is associated with fewer IFIs per patient (0.05 vs. 0.11) relative to FLU or ITRA over 100 days of follow-up, and lower discounted costs ($3900 vs. $4500) and increased life-years (2.50 vs. 2.43 discounted) over a lifetime horizon. Results from a probabilistic sensitivity analysis indicate that there is a 73% probability that posaconazole is cost saving versus FLU or ITRA and a 96% probability that the incremental cost-effectiveness ratio for posaconazole is at or below $50,000 per life-year saved., Conclusions: We conclude that posaconazole is very likely to be a cost-effective alternative to FLU or ITRA in the prevention of IFIs among neutropenic patients with AML and MDS, and may result in cost savings.

Data and financial models based on an operational health information exchange suggest that health care delivery costs can be reduced by making clinical data available at the time of care in urban emergency departments. Reductions are the result of decreases in laboratory and radiographic tests, fewer admissions for observation, and lower overall emergency department costs. The likelihood of reducing these costs depends on the extent to which clinicians alter their workflow and take into account information available through the exchange from other institutions prior to initiating a treatment plan. Far greater savings can be realized in theory by identifying individuals presenting to emergency departments whose acute and long-term care needs are more suitably addressed at lower costs in ambulatory settings or medical homes. These alternative ambulatory settings can more effectively address the chronic care needs of those who receive most of their care in emergency departments. To support a shift from emergency room care to clinic care, health care information available through the health information exchange must be made available in both emergency department and ambulatory care settings. If practice workflow and patient behavior can be changed, a more effective and efficient care delivery system will be made possible through the secure exchange of clinical information across regional settings. These projections support the case for the financial viability of regional health information exchanges and motivate participation of hospitals and ambulatory care organizations-particularly in urban settings.

Context: There is emerging evidence that disease management with self-management education provided by a case manager might benefit COPD patients., Objective: To determine whether disease management with self-management education is more cost-effective than usual care among previously hospitalized COPD patients., Design: Economic analysis in conjunction with a multicenter randomized clinical trial comparing patients conducting self-management with those receiving usual care over a 1-year follow-up period., Setting: Respiratory referral centers., Patients: One hundred ninety-one COPD patients who required hospitalization in the year preceding enrollment were recruited from seven respiratory outpatient clinics., Intervention: In addition to usual care, patients in the intervention group received standardized education on COPD self-management program called "Living Well with COPD" with ongoing supervision by a case manager., Main Outcome Measures: From the perspective of the health-care payer, we compared costs between the two groups and estimated the program cost per hospitalization prevented (incremental cost-effectiveness ratio of the program). We repeated these estimates for several alternate scenarios of patient caseload., Results: The additional cost of the self-management program as compared to usual care, $3,778 (2004 Canadian dollars) per patient, exceeded the savings of $3,338 per patient based on the study design with a caseload of 14 patients per case manager. However, through a highly plausible sensitivity analysis, it was showed that if case managers followed up 50 patients per year, the self-management intervention would be cost saving relative to usual care (cost saving of $2,149 per patient; 95% confidence interval, $38 to $4,258). With more realistic potential caseloads of 50 to 70 patients per case manager, estimated program costs would be $1,326 and $1,016 per prevented hospitalization, respectively., Conclusion: The program of self-management in COPD holds promise for positive economic benefits with increased patient caseload and rising costs of hospitalization.

Objective: To evaluate the expectations, experiences, and satisfaction with the Iowa Priority Prescription Savings (IPPS) program., Design: Longitudinal descriptive study., Setting: Iowa., Participants: Randomly selected Iowa Medicare beneficiaries who self-enrolled in the IPPS prescription discount card program., Interventions: Three self-administered surveys mailed in November 2002, June 2003, and September 2004, during the first, second, and third years of IPPS operation., Main Outcome Measures: Expectations of drug discounts, amount of discounts received, awareness of the IPPS preferred drug list (PDL), and satisfaction with the program., Results: Usable response rates for the three surveys were 43.5%, 31.0%, and 38.4%. About one fourth of members initially expected discounts of more than 20% on their prescription medications. After IPPS was implemented, many members were unaware of the discounts they were receiving, but the percentage of members reporting discounts of more than $20 per month increased from 7.4% in year 1 to 16.4% in year 3. More than one half of the members were unaware of which drugs were on the PDL in years 1 and 2, but this improved to 21% unawareness in year 3. Satisfaction with the program was low but improved over time. Members who received discounts, did not expect large discounts, or received a medication review were more satisfied with the program., Conclusion: Some IPPS members had unrealistic expectations about the amount of discounts they would receive, and expectations of large discounts decreased satisfaction. Satisfaction and amount of discounts improved over time, and beneficiaries whose medications were reviewed, usually by a pharmacist, were more satisfied with the program. PDL awareness was a problem despite substantial educational efforts by IPPS, a finding that has implications for the recently implemented Medicare Part D drug benefit.