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Robust methods are used to examine the effects of age and proximity to death on hospital costs. It is shown that the large tenfold increase in costs from 5 years prior to death to the last year of life overshadows the 30 percent increase in costs from age 65 to 85.

Care quality is important to patients and providers, but is hard to measure. This study aimed to examine changes in the frequency and severity of one quality measure - adverse events associated with medical care - in Great Britain over a 12-year period when available resources initially expanded and were subsequently constrained. Data on perceived adverse events, collected from two representative population surveys in 2001 and 2013, were analysed and compared. The samples consisted of 8202 adults aged 15 and over in 2001 and 19,746 adults aged 15 and over in 2013. The main outcome measures were self-reported illness, injury or impairment caused in the opinion of the respondent by medical treatment or care. Respondents were also asked about the perceived severity of harm in terms of health and work, and any actions taken in response. The proportion of all respondents reporting that over the last three years they had suffered some illness, injury or impairment that in their opinion was caused by their medical treatment or care was 2.5% (497/19746) in 2013, compared with 4.8% (391/8202) in 2001, a reduction of 33% after adjusting for age, gender, income and social class differences between the two surveys. Perceived impact on health and work of these events was similar in both surveys, as was the proportion of injured respondents who pursued a legal claim for financial compensation, at 11% (53/497) in 2013 and 10.5% (41/391) in 2001. We also report multivariate analyses of perceived harm rates and severity, and propensity to seek, and accept, compensation. Our results suggest that the NHS became significantly safer over this period when measured by patient perceived harm from medical care. Our survey method could provide a valuable contribution to the monitoring of trends in health-care related adverse events and the impact of patient safety initiatives. [ABSTRACT FROM AUTHOR]

Objectives: We applied principles for conducting economic evaluations of factorial trials to a trial-based economic evaluation of a cluster-randomized 2 × 2 × 2 factorial trial. We assessed the cost-effectiveness of atorvastatin, omega-3 fish oil, and an action-planning leaflet, alone and in combination, from a UK National Health Service perspective.Methods: The Atorvastatin in Factorial With Omega EE90 Risk Reduction in Diabetes (AFORRD) Trial randomized 800 patients with type 2 diabetes to atorvastatin, omega-3, or their respective placebos and randomized general practices to receive a leaflet-based action-planning intervention designed to improve compliance or standard care. The trial was conducted at 59 UK general practices. Sixteen-week outcomes for each trial participant were extrapolated for 70 years using the United Kingdom Prospective Diabetes Study Outcomes Model v2.01. We analyzed the trial as a 2 × 2 factorial trial (ignoring interactions between action-planning leaflet and medication), as a 2 × 2 × 2 factorial trial (considering all interactions), and ignoring all interactions.Results: We observed several qualitative interactions for costs and quality-adjusted life-years (QALYs) that changed treatment rankings. However, different approaches to analyzing the factorial design did not change the conclusions. There was a ≥99% chance that atorvastatin is cost-effective and omega-3 is not, at a £20 000/QALY threshold.Conclusions: Atorvastatin monotherapy was the most cost-effective combination of the 3 trial interventions at a £20 000/QALY threshold. Omega-3 fish oil was not cost-effective, while there was insufficient evidence to draw firm conclusions about action planning. Recently-developed methods for analyzing factorial trials and combining parameter and sampling uncertainty were extended to estimate cost-effectiveness acceptability curves within a 2x2x2 factorial design with model-based extrapolation. [ABSTRACT FROM AUTHOR]

The De-ESCALaTE HPV trial confirmed the dominance of cisplatin over cetuximab for tumour control in patients with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC). Here, we present the analysis of health-related quality of life (HRQoL), resource use, and health care costs in the trial, as well as complete 2-year survival and recurrence. Resource use and HRQoL data were collected at intervals from the baseline to 24 months post treatment (PT). Health care costs were estimated using UK-based unit costs. Missing data were imputed. Differences in mean EQ-5D-5L utility index and adjusted cumulative quality-adjusted life years (QALYs) were compared using the Wilcoxon signed-rank test and linear regression, respectively. Mean resource usage and costs were compared through two-sample t-tests. 334 patients were randomised to cisplatin (n = 166) or cetuximab (n = 168). Two-year overall survival (97·5% vs 90·0%, HR: 3.268 [95% CI 1·451 to 7·359], p = 0·0251) and recurrence rates (6·4% vs 16·0%, HR: 2·67 [1·38 to 5·15]; p = 0·0024) favoured cisplatin. No significant differences in EQ-5D-5L utility scores were detected at any time point. At 24 months PT, mean difference was 0·107 QALYs in favour of cisplatin (95% CI: 0·186 to 0·029, p = 0·007) driven by the mortality difference. Health care costs were similar across all categories except the procurement cost and delivery of the systemic agent, with cetuximab significantly more expensive than cisplatin (£7779 [P < 0.001]). Consequently, total costs at 24 months PT averaged £13517 (SE: £345) per patient for cisplatin and £21064 (SE: £400) for cetuximab (mean difference £7547 [95% CI: £6512 to £8582]). Cisplatin chemoradiotherapy provided more QALYs and was less costly than cetuximab bioradiotherapy, remaining standard of care for nonsurgical treatment of HPV-positive OPSCC. • Cisplatin was superior to cetuximab for tumour control. • Quality-adjusted survival was significantly higher with cisplatin. • Patients had similar medical resource utilisation in both arms. • Cetuximab was more costly due to higher procurement cost. • Chemoradiotherapy-related costs accounted for half of total per-patient costs. [ABSTRACT FROM AUTHOR]

Aims: There are few data available on the incremental benefits of risk factor modification in type 2 diabetes mellitus (T2DM). We simulated the potential benefits of achieving lower systolic blood pressure (SBP) and LDL-cholesterol targets.Methods: We used the UKPDS Outcomes Model v2.0 to estimate 10-year event rates for complications using baseline data from 5717 participants with T2DM in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin Study. All risk factor values were held constant over 10 years. In separate analyses, different levels of SBP between 160 and 120 mm Hg and LDL-cholesterol between 5.0 and 1.0 mmol/l were imposed on the cohort. Cumulative relative risk reductions (CRRR) at each 10 mm Hg and 1.0 mmol/l decrements respectively were compared using Kruskal-Wallis tests.Results: CRRRs for each 10 mm Hg SBP decrement from 160 mm Hg were 2.2%, 4.5%, 7.0% and 10.0% for myocardial infarction (MI); 12.5%, 24.8%, 35.6% and 44.9% for stroke; 5.4%, 10.9%, 16.2% and 20.9% for blindness; 7.4%, 14.7%, 21.6% and 27.4% for amputation, respectively. CRRRs for each 1.0 mmol/l LDL-cholesterol decrement from 5.0 mmol/l were 16.9%, 30.8%, 41.2% & 51.0% for MI; 9.2%, 19.7%, 29.6% & 38.8% for stroke (p < 0.001 in all cases).Conclusions: These simulated outcomes illustrate the potential benefits of targeting progressively lower SBP and LDL-cholesterol values. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: High hospitalization rates, prolonged length of stay, and increased risks of subsequent events mean a steep increase in health care usage after stroke. No study, however, has examined to what extent increased costs after transient ischemic attack (TIA) or stroke are due to hospitalizations for the initial event, recurrent events, and/or nonvascular hospitalizations, and how costs compare with the year prior to the event. Methods: We studied patients in a population-based cohort study (Oxford Vascular Study) in the United Kingdom from 2003 to 2007. Hospitalization and cost details were obtained from patients’ individualized Hospital Episode Statistics records. Results: A total of 295 incident TIA and 439 incident stroke patients were included. For patients with stroke, average costs increased from £1437 in the year pre-event to £6629 in the year post-event (P<0.0001). Sixty-four percent (£4224) of poststroke costs were due to hospitalizations linked to the index stroke, more than 30% of which were given nonvascular primary diagnoses on Hospital Episode Statistics, and £653 (10%) were due to hospitalizations linked to subsequent vascular events. For patients with TIA, costs increased from £876 1 year before the event to £2410 in the year post-event (P<0.0001). Patients with TIA incurred nonsignificantly higher costs due to hospitalizations linked to subsequent vascular events (£774) than for hospitalizations linked to the index TIA (£720). Conclusions: Hospital costs increased after TIA or stroke, primarily because of increased initial cerebrovascular hospitalizations. The finding that costs due to nonvascular diagnoses also increased after TIA or stroke appears, in part, to be explained by the miscoding of TIA/stroke-related hospitalizations in electronic information systems. [Copyright &y& Elsevier]

Background: Evidence is available on the effectiveness and costs of treatments to reduce stroke risk in long-term secondary prevention. However, there are few data on the costs and outcomes of urgent assessment and treatment after the onset of transient ischaemic attack (TIA) or minor stroke. The Early use of eXisting PREventive Strategies for Stroke (EXPRESS) study showed that urgent assessment and treatment reduced the 90-day risk of recurrent stroke by about 80%. We now report the effect of the EXPRESS intervention on admissions to hospital, costs, and disability.Methods: EXPRESS was a prospective population-based before (phase 1: April 1, 2002, to Sept 30, 2004) versus after (phase 2: Oct 1, 2004, to March 31, 2007) study of the effect of early assessment and treatment of TIA or minor stroke on the risk of early recurrent stroke. This report assesses the effect of the introduction of the phase 2 clinic on admissions to hospital within 90 days, hospital bed-days, hospital costs, and 6-month new disability (progression from no disability before event [modified Rankin scale score < or =2 points] to disability at 6 months [modified Rankin scale score >2 points]) or death, compared with the phase 1 clinic. To assess the main predictors of these outcomes, multivariate regression analyses were done.Findings: The 90-day risk of fatal or disabling stroke was reduced in phase 2 (1 of 281 vs 16 of 310; p=0.0005). Hospital admissions for recurrent stroke were also lower in phase 2 than in phase 1 (5 vs 25; p=0.001), which reduced the overall number of hospital bed-days compared with phase 1 (672 vs 1957 days; p=0.017). Hospital bed-days for admissions to hospital due to vascular causes were also lower in phase 2 (427 vs 1365 days; p=0.016), which generated savings of 624 pounds per patient referred to the phase 2 clinic (p=0.028). Results from the multivariate analyses showed that assessment in phase 2 was an independent predictor of reduced disability, days in hospital, and costs.Interpretation: Urgent assessment and treatment of patients with TIA or minor stroke who were referred to a specialist outpatient clinic reduced subsequent hospital bed-days, acute costs, and 6-month disability. [ABSTRACT FROM AUTHOR]