Consultation Costs Research Articles

An early economic analysis of medical cannabis for the treatment of chronic pain

ABSTRACT Background Cannabis-based medicinal products (CBMPs) are increasingly demonstrating effectiveness in treating a wide range of conditions, with a relatively high safety profile in clinical usage compared to other prescription pain medications and few contraindications. Consultation and other prescription-related costs are, at present, higher for CBMPs than for some other treatment options, leading to some concern around wider prescribing. Research design and Methods An early cost-effectiveness model was developed to estimate the impact of prescribing CBMPs alone and/or in addition to analgesics, physiotherapy, and cognitive behavioral therapy for chronic pain in the UK for 1 year. Results Due to their comparative effectiveness, CBMPs were found to be cost saving. Various scenarios were model tested; in all scenarios where CBMPs decrease pain-level states, less resource use is required. Increased efficacy of 5% was conservatively assumed based on current Real-World Evidence. In this scenario, CBMPs were significantly more cost-effective, and as costs relating to the prescribing of these continue to fall, relative savings are predicted to increase. Conclusion These findings highlight the substantial cost saving that CBMPs may represent for the treatment of chronic pain patients, and the benefits for healthcare providers as a treatment for this often hard-to-treat population.

Systematic preoperative approach for bariatric surgery, perioperative results, and economic impact.

Obesity is a complex systemic condition, involving numerous anatomical and metabolic changes. Therefore, a comprehensive preoperative assessment is essential for each patient contemplating bariatric surgery. This study presents the findings of a proposed protocol designed to streamline the pre-anesthesia consultation process. Our aim was to compare the efficiency and costs of consultations guided by the protocol with those conducted without a specific strategy. The secondary outcomes assessed included postoperative (PO) length of hospital stay and surgical duration. We conducted a retrospective cross-sectional analysis involving 206 clinical cases. Statistical analyses, including the chi-squared test, Student's t-test, and Mann-Whitney U test, were utilized based on the type of variables. The results showed a significant reduction in the costs, pre-anesthesia consultation duration, time spent in the recovery unit, and the need for referrals. However, no statistically significant differences were observed in the delay before surgery and length of hospital stays, measured in days. This algorithm offers a promising approach for optimizing perioperative management in bariatric surgery, demonstrating its effectiveness in cutting costs and reducing the need for referrals.

Establishment of a platform based on dual RPA combined with CRISPR/Cas12a for the detection of Klebsiella pneumoniae and its KPC resistance gene.

Carbapenem resistant Klebsiella pneumoniae (CRKP) can cause serious hospital- and community-acquired infections. Treatment for CRKP infection is limited, resulting in prolonged hospitalization and high consultation costs. The KPC genotype has the highest detection rate of CRKP, and its mortality rate is higher than the overall mortality rate of CRKP. However, traditional testing methods have disadvantages such as long time and reliance on complex and sophisticated instruments, which are not conducive to rapid screening for CRKP. Therefore, this study aimed to establish a detection platform for early screening of CRKP so that effective antimicrobial therapy could be administered promptly to prevent the widespread spread of CRKP. We integrated dual RPA with CRISPR/Cas12a to establish a dual platform for the detection of K. pneumoniae (Kp) rcsA-specific gene and KPC resistance gene. Four result reading methods were established, including fluorescence detection (FD), blue light irradiation detection (BLID), ultraviolet irradiation detection (UID), and lateral flow test strips (LFTS). For the rcsA gene, the LOD of FD was 1 × 10pg/μL, and the other three methods could detect 1 × 101pg/μL of bacterial DNA. As for the KPC gene, four resultant readout methods were able to detect 1 × 102pg/μL of bacterial DNA. In 59 clinical strains tested, the dual RPA-CRISPR/Cas12a detection of the rcsA had 100% sensitivity, specificity, and accuracy compared to the culture method. Compared with the drug sensitivity test, the sensitivity of dual RPA-CRISPR/Cas12a detection for the KPC was 85.71%, the specificity was 100%, and the accuracy was 94.92%. In summary, our dual RPA-CRISPR/Cas12a platform proved to be rapid, precise, and convenient for the efficient detection of Kp with KPC in the laboratory or at the point of care.

Cost burden for healthcare and patients related to the unawareness towards laryngopharyngeal reflux.

To investigate the impact of physician unawareness towards laryngopharyngeal reflux (LPR) on healthcare costs. Patients with a confirmed LPR diagnosis were consecutively recruited from Belgian Hospitals. Demographics and clinical outcomes (impedance-pH testing features, reflux symptom score, and reflux sign assessment) were extracted. The past consultations and additional examinations dedicated to the investigation of laryngopharyngeal symptoms and findings without suspicion of LPR were collected. The estimated costs of consultations and procedures were those indicated in the National Health Insurance Institute's Charges for 2022. Part was reimbursed by the social security system, and the rest was paid by patients. Seventy-six patients were recruited. Seventeen patients (22.4%) had no previous consultation or additional examination for their LPR-symptoms. The estimated mean (standard deviation) costs related to the unawareness of LPR for the healthcare system and patient, were 310.06 ± 370.49 €, and 54.05 ± 46.28 €, respectively. The highest estimated costs were related to gastroenterology consultations and procedures, which did not lead to a confirmation of LPR diagnosis. The total estimated cost for the Belgian healthcare system and patients (11,590,000 million), could range from 359 359 540 € to 1 078 078 620 €; and 62 643 950 € to 187 931 850 €, respectively. The estimated costs related to gastroenterology practice of patients with severe disease were significantly higher than patients with mild disease. The unawareness of practitioners toward LPR leads to significant costs for healthcare system and patients. The teaching and awareness towards LPR need to be improved in medical schools and clinical practice.

Reducing economic burden through split-shared care model for people living with uncontrolled type 2 diabetes and polypharmacy: a multi-center randomized controlled trial

BackgroundInterprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy.MethodThis was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution’s financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs.ResultsA total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p < 0.001). Medication cost was the main driver in both groups. There were no significant changes in productivity loss and indirect costs in both groups.ConclusionImplementation of split-shared visits with frontline community partners may reduce economic burden for patient with uncontrolled type 2 diabetes and polypharmacy.Trial registrationClinicaltrials.gov Reference Number: NCT03531944 (Date of registration: June 6, 2018).

The Use of Artificial Intelligence for Skin Disease Diagnosis in Primary Care Settings: A Systematic Review.

The prevalence of dermatological conditions in primary care, coupled with challenges such as dermatologist shortages and rising consultation costs, highlights the need for innovative solutions. Artificial intelligence (AI) holds promise for improving the diagnostic analysis of skin lesion images, potentially enhancing patient care in primary settings. This systematic review following PRISMA guidelines examined primary studies (2012-2022) assessing AI algorithms' diagnostic accuracy for skin diseases in primary care. Studies were screened for eligibility based on their availability in the English language and exclusion criteria, with risk of bias evaluated using QUADAS-2. PubMed, Scopus, and Web of Science were searched. Fifteen studies (2019-2022), primarily from Europe and the USA, focusing on diagnostic accuracy were included. Sensitivity ranged from 58% to 96.1%, with accuracies varying from 0.41 to 0.93. AI applications encompassed triage and diagnostic support across diverse skin conditions in primary care settings, involving both patients and primary care professionals. While AI demonstrates potential for enhancing the accuracy of skin disease diagnostics in primary care, further research is imperative to address study heterogeneity and ensure algorithm reliability across diverse populations. Future investigations should prioritise robust dataset development and consider representative patient samples. Overall, AI may improve dermatological diagnosis in primary care, but careful consideration of algorithm limitations and implementation strategies is required.

Zoonotic Disease Risk Perception and Infection Control Practices amongst Veterinarians in Kerala, India

Abstract Introduction: Veterinarians could act as the sentinel for the study of zoonotic diseases. This study evaluates the prevalence of zoonoses amongst Kerala veterinarians and explores infection control measures they use to protect themselves and the factors influencing their infection control practices. Materials and Methods: It is a quantitative cross-sectional study using proportionate sampling with a self-administered questionnaire. Results: About 31.1% of veterinarians experienced symptoms of zoonotic diseases, with dermatophytosis being the most common. Handling tissues, bodily fluids and excretions of animals were the highest risk-carrying procedures. However, the majority of respondents did hand wash, whereas some never properly disposed of used needles. Factors such as heat stress, comfort, cost and time of consultation discouraged one-fourth of participants from using personal protective equipment. Conclusion: Failure to follow infection control practices contributes to the prevalence of zoonoses amongst veterinarians in Kerala. Reasons for this failure include the absence of better policies to address veterinarian’s issues. There is a need for more effective enforcement of infection control policy for the veterinarians.

Levelling up health in the early years: A cost-analysis of infant feeding and healthcare.

Although breastfeeding is recommended as the optimal form of nutrition in the first six months, it is not sustained as the predominant mode of feeding infants in Scotland. This study estimated the impact of infant feeding choices on primary and secondary healthcare service costs in a 13-year birth cohort. Using linked administrative datasets, in a retrospective cohort design of 502,948 singletons born in Scotland between 1997 and 2009, we estimated the cost of GP consultations and hospital admissions by area deprivation and mode of infant feeding up to 6-8 weeks for ten common childhood conditions from birth to 27 months. Additionally, we calculated the potential healthcare savings if all infants in the cohort had been exclusively breastfed at 6-8 weeks. Discounting of 1.5% was applied following current health economic conventions and 2009/10 used as the base year. Over the study period, the estimated cost of hospital admissions in the cohort was £111 million and £2 million for the 2% subset of the cohort with primary care records. Within each quintile of deprivation, exclusively breastfed infants used fewer healthcare services and incurred lower costs compared to infants fed (any) formula milk. At least £10 million of healthcare costs may have been avoided if formula-fed infants had been exclusively breastfed within the first 6-8 weeks of birth. This study using a representative birth cohort demonstrates how breastmilk can promote equitable child health by reducing childhood illness and healthcare utilisation in the early years.

Patients' experiences with tele-mental health services during COVID-19 in Pakistan.

Although the concept of telehealth is of great interest globally, its potential has not yet been realized in Pakistan. It is therefore essential to explore the perspectives of stakeholders on the technology, particularly for mental health, to be able to increase and improve its use. To assess the perceptions and experiences of patients receiving tele-mental health services, including telepsychiatry and tele-psychotherapy, in Pakistan. For this qualitative exploratory study, we conducted in-depth interviews with 49 individuals at a tertiary care hospital in Karachi, Pakistan. Using the Cresswell framework for content analysis, we identified 3 major themes that focused on the positive and negative aspects of tele-mental health services and made suggestions for enhancing them. Twenty-six of the participants received telepsychiatry, while the remaining 23 received tele-psychotherapy services. Technical literacy, cost of consultation, privacy, and therapeutic alliance were the major challenges identified by the patients, while convenience and the absence of stigma were highlighted as key facilitators for tele-mental health. Tele-consultations reduced travel and waiting time, thus improving access to healthcare. Participants suggested that the processes for booking appointments and making payments should be streamlined and the cost of tele-consultation reduced. This study provides insightful findings on tele-mental health services from the perspectives of patients living in an Asian culture. The major benefits highlighted were destigmatization of mental health and elimination of commuting costs and travel time. There were concerns about privacy, therapeutic alliance and availability and affordability of the technology.

Prevalence and Determinants of the Use of Antibiotics by Self-Medication in the Pediatric Population in Oujda, Morocco.

Antibiotic resistancedriven by antibiotic self-medication and inappropriate use of antibioticsis a growing global health threat. Our study aimed to describe parents' self-medication practices with antibiotics, determine the factors favoring their use in the pediatric population, and assess parents' knowledge of the role of antibiotics and antimicrobial resistance. We conducted a cross-sectional study over two months (September and October 2023). Data collection was performed using a questionnaire-guided interview. We included 460 parents of children consulting or hospitalized in the Pediatric Department of the University Hospital Mohammed VI in Oujda, Morocco. A total of 62% of parents questioned were mothers.Self-medication with antibiotics was noted in 313 families (68%). Parents used antibiotics mainly to treat cough (43%) and fever (24%).Betalactams were the antibiotic class most used by parents (72%). Information on dosageand methods of antibiotic administration was provided by pharmacy staff but was not respected by most parents (78%).Efficacy of treatment (58%), saving consultation costs and time (47%), and the ease of obtaining treatment without a prescription (42%) were reported in the majority of cases as reasons for using antibiotics by self-medication. In our context, the probability of self-medicating with antibiotics in the pediatric population is increased by female gender (OR=1.04), low level of education (OR=1.02), low socio-economic status (OR=1.09), and buying antibiotics without a prescription (OR=1.22). Although antibiotic self-medication in children is a worldwide phenomenon, influenced by several geographical, cultural, and economic factors, there is an urgent need to promote a global health strategy.

Analysis of the costs of teleconsultation for the treatment of diabetes mellitus in the SUS.

To present the results of a cost analysis of remote consultations (teleconsultations) compared to in-person consultations for patients with type 2 diabetes, in the Brazilian public healthcare system (SUS) in the city of Joinville, Santa Catarina (SC). In addition to the costs from the local manager's perspective, the article also presents estimates from the patient's perspective, based on the transportation costs associated with each type of consultation. Data were collected from 246 consultations, both remote and in-person, between 2021 and 2023, in the context of a randomized clinical trial on the impact of teleconsultation carried out in the city of Joinville, SC. Teleconsultations were carried out at Primary Health Units (PHU) and in-person consultations at the Specialized Health Center. The consultation costs were calculate by the method time and activity-based costing (TDABC), and for the estimate of transportation costs data was collected directly from the research participants . The mean costs and time required to carry out each type of consultation in different scenarios and perspectives were analyzed and compared descriptively. Considering only the local SUS manager's perspective, the costs for carrying out a teleconsultation were 4.5% higher than for an in-person consultation. However, when considering the transportation costs associated with each patient, the estimated value of the in-person consultation becomes 7.7% higher and, in the case of consultations in other municipalities, 15% higher than the teleconsultation. The results demonstrate that the incorporation of teleconsultation within the SUS can bring economic advantages depending on the perspective and scenario considered, in addition to being a strategy with the potential to increase access to specialized care in the public network.

IJCM_244A: Awareness on breast cancer and its screening methods among the women in urban field practice area, Government Medical College, Siddipet, Telangana.

Background: Breast cancer is the most common female cancer worldwide including India, where advanced stages at diagnosis, and rising incidence and mortality rates, make it essential to understand cancer literacy in women. An understanding of the awareness and predictors of breast examination is an important first step that may guide the design of interventions aimed at raising awareness across the general population. Objective: This study aimed to evaluate the level of awareness related to breast cancer risk factors, signs, symptoms, and methods of screening among women residing in the study area. Methodology: A cross-sectional study was conducted during October 2023 - November 2023 among women residing in the urban field practice study area in Siddipet. A semi-structured questionnaire consisting of socio-demographic characteristics, questions related to awareness of breast cancer, and various screening methods was administered to 225 women in the study area. Results: The study showed an overall knowledge level of 35.00% regarding breast cancer. Participants had average knowledge about risk factors, signs, and symptoms, whereas their awareness on various screening methods was weak. Conclusion: The current study concluded that public awareness of breast cancer remains relatively low, and still needs several public awareness initiatives using mass media, such as television, Internet, and social media. Indian breast cancer patients present with advanced disease stage and have numerous poor prognostic factors, hence knowledge regarding the prevalence of risk factors was necessary. Many women, once aware, state that they would be interested in taking preventative therapy when they feel the timing is more appropriate for them. Dedicated breast health clinics, providing information about preventative therapy, and risk-reducing lifestyle changes could empower women to make personalized choices. These could be cost-effective when comparing costs of a specialist consultation with the costs of potential breast cancer therapy and psychological harm caused by breast cancer.

A survey of cost, access and outcomes for cannabinoid-based medicinal product use by Australians with endometriosis.

People with endometriosis use cannabis to manage their symptoms. This study aimed to identify costs, modes of administration, product composition, and self-reported effectiveness for those accessing medicinal cannabis in Australia. There were 192 survey responses analysed. Most (63.5%) used a 'cannabis clinic' doctor, incurring an initial consultation cost of $100-$200+ (10.2% Medicare bulk-billed) and median cannabinoid medicine costs of $300AUD per month. Cost was a major barrier to access, necessitating reducing dosage (76.1%) and/or consuming illicit cannabis (42.9%), despite a prescription. Most (77%) medical consumers used two or more cannabis products, with delta-9-tetrahydrocannabinol predominant oil and flower products most frequently prescribed.

Study of the list of medicines for the acne treatment and their affordability

Among dermatological diseases, acne (acne vulgaris) is the most common skin disease, which affects almost 9.4% of the world's population, especially 70‒80% of teenagers and young people, as well as 11% of adults after 25 years. According to experts, the financial burden of acne, taking into account the costs of medicines, diagnostics and dermatologist consultations, is quite expensive for patients.&#x0D; The aim of the research was to study the list of medicines for the acne treatment on the domestic market, with an emphasis on dosage forms for external use, and to assess their affordability to the population.&#x0D; The objects of the study were medicines for the treatment of acne. Data analysis of group D10 from the "State Register of Medicinal Products of Ukraine" as of the end of 2023 was carried out. The following methods were used: content analysis, marketing, systematization and generalization, information search.&#x0D; It was investigated that there are 17 medicines for the topical treatment of acne on the market of Ukraine, of which only 11% are domestically produced, the remaining 89% are imported manufacturers, which indicates the high import dependence of this segment. It was found that there is only one domestic manufacturer that offers only one drug, so the development of domestic medicines is urgent.&#x0D; It was found that for the topical treatment of acne in the form of gel 59% of the assortment of drugs for external use, in the form of creams only 18%, in the form of lotion – 12%. Only one position is presented: skin solution and powder for preparation of the solution. The coefficient of adequacy of the solvency of medicines for external and systemic treatment of acne was calculated and it was shown that most of the medicines are expensive.&#x0D; It was found that 17.6% of the studied assortment for external treatment of acne and 50% of drugs for systemic use are not available in pharmacies. The pharmaceutical development of domestic mediсines and the availability of extemporaneous forms for the treatment of acne in pharmacies are relevant. Pharmacoeconomic studies of these medicines are needed to determine which is more cost-effective for the patient to reduce the financial burden. To ensure adherence to acne treatment, patients need to be provided with appropriate pharmaceutical care, especially with topical retinoids, which will help improve treatment outcomes.

Measuring health care access and its inequality: A decomposition approach

We introduce a new method for assessing health care access disparities, focusing on the ‘Access Gap’. This gap represents the difference between the (out-of-pocket) cost of access to adequate health care and available financial resources. Our method quantifies this gap for groups with similar characteristics, using indicators like the Gini coefficient and Entropy for overall inequality analysis. Applied to breast cancer treatment in Italy, we consider geographic location as the primary distinguishing characteristic for individual groups. The analysis covers costs of transportation, accommodation, doctor consultations, diagnostic tests, and non-oncology drugs. Financial resource distribution data comes from the Bank of Italy. Our findings show a pronounced Access Gap in Italy’s southern regions, particularly in Campania. We decompose this gap to understand the influence of supply-side (provider distribution) and demand-side (health spending capacity) factors. The results indicate that disparities in access are mainly driven by demand-side elements, specifically regional spending capacity variations.

Challenges and Opportunities in Attention Deficit Hyperactivity Disorder in Developing Countries.

In the developing country a physician is faced with many challenges when seeing patients on the neurodiverse spectrum. Despite many well-known tools available, time restraints and lack of resources often results in sub-par diagnoses and continuation of care. Fortunately, with modern technology and the ever growing fields of machine learning and artificial intelligence, new developments have the possibility to ensure wider access to simplified and efficient tools with decreased need for specialist referral, helping to facilitate diagnosis, to reduce consultation time and costs and to simplify follow-up and monitoring.

Assistance in the Development of Strategy and KPI of Muhammadiyah Mardhatillah Randudongkal Hospital, Pemalang

Abstract. This community service is a continuation of the previous community service in 2022, funded by LP3M UMY. The first stage of community service was done to develop trend-watching conditions. In the second stage, community service aims to develop strategies for the hospital’s Key Performance Indicator (KPI). The basis for strategic planning is a SWOT analysis. In order for a hospital to have competitiveness, a hospital should know its strengths, weaknesses, opportunities, and threats in the hospital industry. Therefore, a hospital needs to have good strategic planning that can bring the hospital to win the rivalry. Good business planning will be reflected in the hospital’s strategic plan. Nowadays, a strategic plan is not only a tool to compete and win the rivalry but also an important requirement for hospitals to be accredited. The methods used in preparing the strategy and KPI for community service are SWOT analysis, making Kartesius diagrams, making strategy using the TOWS method, making BSC, and lastly, budgeting, where all activities will be carried out through FGDs and Whatsapp Groups. The results of this assistance will help the hospital to make the required strategic plan. Aside from the completion of the hospital strategic plan, it appears that the hospital’s stakeholders have been able to increase their expertise in making strategic plans. In the future, these stakeholders are expected to be able to make their own strategic plan so the hospital can reduce the costs of consultants to make a strategic plan, which is usually expensive.

The cost of primary care consultations associated with long COVID in non-hospitalised adults: a retrospective cohort study using UK primary care data

BackgroundThe economic impact of managing long COVID in primary care is unknown. We estimated the costs of primary care consultations associated with long COVID and explored the relationship between risk factors and costs.MethodsData were obtained on non-hospitalised adults from the Clinical Practice Research Datalink Aurum primary care database. We used propensity score matching with an incremental cost method to estimate additional primary care consultation costs associated with long COVID (12 weeks after COVID-19) at an individual and UK national level. We applied multivariable regression models to estimate the association between risk factors and consultations costs beyond 12 weeks from acute COVID-19.ResultsBased on an analysis of 472,173 patients with COVID-19 and 472,173 unexposed individuals, the annual incremental cost of primary care consultations associated with long COVID was £2.44 per patient and £23,382,452 at the national level. Among patients with COVID-19, a long COVID diagnosis and reporting of longer-term symptoms were associated with a 43% and 44% increase in primary care consultation costs respectively, compared to patients without long COVID symptoms. Older age, female sex, obesity, being from a white ethnic group, comorbidities and prior consultation frequency were all associated with increased primary care consultation costs.ConclusionsThe costs of primary care consultations associated with long COVID in non-hospitalised adults are substantial. Costs are significantly higher among those diagnosed with long COVID, those with long COVID symptoms, older adults, females, and those with obesity and comorbidities.

Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya.

Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery. Five public health facilities in western Kenya. PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (β) of each attribute on clinic choice. Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (β = 0.15), postpartum visits with infant immunizations (β = 0.36), seeing a mentor mother and clinician each visit (β = 0.05 and 0.08, respectively), and 0 KSh cost (β = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum). PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.

Cost-effectiveness analysis of PCI in focal and diffuse coronary artery disease

Abstract Aims The pattern of CAD predicts angina relief after PCI. Our aim was to evaluate the cost-effectiveness of PCI in diffuse coronary artery disease (CAD) to deferral from PCI in these patients. Methods This is a sub-analysis of the TARGET-FFR randomized clinical trial (NCT03259815). The pullback pressure gradient (PPG) was calculated to differentiate focal from diffuse CAD. Healthcare resource use associated with the index hospitalization and with follow-up outpatient visits, medications, was recorded prospectively. We did not discount costs because of the limited follow-up period. Costs of procedures and follow-up consultations were derived from Healthcare Resource Group reference costs and drug costs from the National Health Service (NHS). Quality-adjusted life-years (QALYs) were derived from health-related quality of life and survival during the 3-month time horizon of the trial. Quality-of-life indexes (utilities) were evaluated at baseline and 3 months with the European Quality of Life–5 Dimensions (EQ-5D) instrument with UK weights scaled from 0 (death) to 1 (perfect health). The overall QALYs for each patient were estimated as the area under the curve determined by the utility values at baseline and 3 months. We computed confidence intervals for differences in costs and QALYs and in the incremental cost-effectiveness rate (ICER) using the bootstrap technique with the percentile method with 10 000 replications. A Markov model was used to simulate deferral of diffuse disease from PCI and not using PPG to select treatment. Probabilistic sensitivity analysis was undertaken to test the robustness of results to parameter uncertainty. Results Patients who underwent PCI for focal CAD had higher EQ-5D index values at follow-up (0.89 ± 0.18 vs 0.76 ± 0.28, p=0.004) and higher QALYs after 3 months follow-up (0.19 ± 0.06 vs 0.21 ± 0.04, p=0.022). Mean cumulative costs were £1574.3 ± 230.5 and significantly higher in patients treated for diffuse CAD as compared to patients treated for focal CAD (£1697 ± 293.4 vs £1393 ± 264.3; p&amp;lt;0.001). The ICER was £7746/QALY (95% CI 5024 – 11007). PCI in focal CAD saved £1522.2/QALY when compared to PCI in diffuse CAD (£7009.2 ± 1919.4 /QALY vs. £8531.4±2753.4 /QALY, p&amp;lt; 0.001). Deferring 30% of the diffuse CAD patients from PCI to optimized medical therapy would save £673.8/QALY (£7072.2 ± 1730.147 /QALY vs. £7746 ± 1943.5/QALY, p&amp;lt; 0.001). Conclusion PCI is more cost-effective in focal than diffuse CAD. Treatment of diffuse CAD results in worst QALYs and costlier procedures. Every 5% of the diffuse CAD patients that were deferred from PCI saved aproximately £100/QALY. Further trials are needed to determine if the cost-effectiveness of PCI can be improved by deferring patients with diffuse CAD.Quality of life in focal and diffuse CADCost-effectiveness focal vs diffuse CAD