Secondary Care Costs Research Articles

Healthcare Resource Utilization and Associated Costs in Patients With Chronic Graft-Versus-host Disease Postallogeneic Hematopoietic Stem Cell Transplantation in England

Limited evidence suggests chronic graft-versus-host disease (cGvHD) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) increases healthcare resource utilization (HCRU) and costs. However, this burden has not been well characterized in England. This study assesses secondary care HCRU and costs for patients following allo HSCT in England with cGvHD and patients who did not develop graft-versus-host disease (GvHD). Further stratification was performed among patients who did or did not subsequently receive high-cost therapies for the treatment of cGvHD. This descriptive, retrospective cohort study used Hospital Episode Statistics (HES) data from April 2017 to March 2022. HES data captures information on reimbursed diagnoses and procedures from all National Health Service (NHS) secondary care admissions and attendances in England. High-cost drugs as defined by NHS England are recorded in HES, these drugs and other procedures including plasma exchange, were used to identify patients with cGvHD who were in receipt of high-cost therapies. HCRU and costs were described for patients with cGvHD following allo-HSCT (n = 721) and were matched with patients with no evidence of GvHD following allo-HSCT (n = 718). HCRU and costs were also described for the subset of patients with cGvHD (n = 198) following receipt of high-cost therapies and patients with cGvHD prior to or without such therapies (n = 523). A higher proportion of patients with cGvHD had at least one inpatient or intensive care unit (ICU) admission or emergency care attendance than patients without GvHD (inpatient: 74.6% versus 66.6%; emergency care: 39.3% versus 30.5%; ICU: 7.4% versus 4.7%; respectively); whilst the proportion of patients with an outpatient attendance were similar for both groups (outpatient: 80.3% versus 84.1%; respectively). The cost across all secondary care settings was higher for patients with cGvHD than patients without GvHD, with a mean cost of inpatient admissions of £17,339 ppy for those with cGvHD versus £8548 ppy in patients without GvHD. A higher proportion of patients who received high-cost therapies for the treatment of cGvHD had at least one secondary care admission or attendance, than patients who did not (inpatient: 85.4% versus 66.4%; ICU: 7.1% versus 5.4%; outpatient: 87.9% versus 76.7%; emergency care: 44.4% versus 36.5%; respectively). Patients who were treated with high-cost therapies for the treatment of cGvHD had a greater mean number (14.6 versus 8.2 ppy, respectively) for all-cause inpatient admissions after treatment than patients who did not. In all secondary care settings, the total cost ppy was higher for patients who received high-cost therapies for the treatment of cGvHD, than for those who did not. Patients who were treated with high-cost therapies for the treatment of cGvHD had a greater mean cost (£21,137 versus £15,956 ppy, respectively) for all-cause inpatient admissions than patients who did not. This study demonstrates that cGvHD and the use of associated high-cost therapies impacts healthcare activity and costs across various secondary care settings in England more than patients without GvHD and patients with cGvHD who received no high-cost therapies.

Estimating the healthcare burden of Prurigo Nodularis in England: a CPRD database study

Purpose: Prurigo nodularis (PN) is a skin disease characterized by intensely itchy skin nodules and is associated with a significant healthcare resource utilization (HCRU). This study aimed to estimate the HCRU of patients in England with PN overall and moderate-to-severe PN (MSPN) in particular. Methods: This retrospective cohort study used data from the Clinical Practice Research Datalink and Hospital Episode Statistics in England. Patients with Mild PN (MiPN) were matched to patients with MSPN by age and gender for the primary analysis. Patients were enrolled in the study between 1st April 2007 and 1st March 2019. All-cause HCRU was calculated, including primary and secondary care contacts and costs (cost-year 2022). Results: Of 23,522 identified patients, 8,933 met the inclusion criteria, with a primary matched cohort of 2,479 PN patients. During follow up, the matched cohort’s primary care visits were 21.27 per patient year (PPY) for MSPN group and 11.35 PPY for MiPN group. Any outpatient visits were 10.72 PPY and 4.87 PPY in MSPN and MiPN groups, respectively. Outpatient dermatology visits were 1.96 PPY and 1.14 PPY in MSPN and MiPN groups, respectively. Conclusion: PN, especially MSPN, has a high HCRU burden in England, highlighting the need for new and improved disease management treatments.

Costs of care trajectories of people with dementia compared with matched controls. Longitudinal analysis of linked health and administrative data.

To provide insight into the health and social care costs during the disease trajectory in persons with dementia and the impact of institutionalization and death on healthcare costs compared with matched persons without dementia. Electronic health record data from family physicians were linked with national administrative databases to estimate costs of primary care, medication, secondary care, mental care, home care and institutional care for people with dementia and matched persons from the year before the recorded dementia diagnosis until death or a maximum of 4years after the diagnosis. Total mean health and social care costs among persons with dementia increased substantially during the disease trajectory, mainly due to institutional care costs. For people who remained living in the community, mean health and social care costs are higher for people with dementia than for those without dementia, while for those who are admitted to a long-term care facility, mean health and social care costs are higher for people without dementia than for those with dementia. The steep rise in health and social care costs across the dementia care trajectory is mainly due to increasing costs for institutional care. For those remaining in the community, home care costs and hospital care costs were the main cost drivers. Future research should adopt a societal perspective to investigate the influence of including social costs.

Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006-2017.

Frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population level use of health services and associated costs is needed to plan for ageing populations. To describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category. Retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017. Primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced. Individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for sociodemographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe. Increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level.

SAT357 Rising Incidence, Health Resource Utilization and Costs of Polycystic Ovary Syndrome in the United Kingdom

Abstract Disclosure: T. Berni: None. C. Morgan: None. A. Rees: None. Background: Polycystic Ovary Syndrome (PCOS) is a common disorder but trends in incidence and impact on health resource utilization are not known. Objectives: 1. To describe secular trends in prevalence and incidence of PCOS in the UK. 2. To establish healthcare resource use and associated primary and secondary care costs. Methods: Data were extracted from the Clinical Practice Research Datalink Aurum database and linked Hospital Episode Statistics (HES) database (2004-2021). Patients (≥18 yrs) of acceptable research quality and eligible for linkage to HES were included. A diagnosis of PCOS was established from medcode or ICD-10 codes. Point prevalence was assessed at the midpoint of each year from 2004-2020. Incident cases (2004-2021) were defined as a first diagnosis (index date) at least 90 days after practice registration. Costs from index date were compared for incident cases (n=132,925) and controls matched (1:1) by age, BMI category and primary care practice. Primary care contacts were assigned an average cost as listed in the Unit Costs of Health and Social Care 2019. Prescription items were assigned a net ingredient cost from the Prescription Cost Analysis for England 2019. Inpatient admissions and outpatient consultations were processed into Healthcare Resource Groups and costed to the National Tariff. Results: The incidence of diagnosed PCOS increased from 1.22 per 1000 person years in 2004 to 1.77 in 2012 and 2.20 in 2019. Point prevalence increased from 0.9% in 2004 to 2.1% in 2012 and 3.4% in 2020. Mean contacts per person year (ppy) for patients with PCOS versus controls were 0.43 vs 0.25 for inpatients (p<0.001), 3.29 vs 1.83 for outpatients (p<0.001) and 6.46 vs 4.71 (p<0.001) for primary care. Mean healthcare costs (ppy) were £748 vs £438 (p<0.001) for inpatients, £383 vs £216 (p<0.001) for outpatients, £156 vs £111 for primary care and £114 vs £87 (p<0.001) for primary care prescriptions. Total health care contacts ppy were 10.81 vs 6.21 (p<0.001) and total associated costs were £1400 vs £852 (p<0.001). Conclusion: The prevalence and incidence of diagnosed PCOS has risen significantly in the United Kingdom over the last two decades. This may be partly due to increased ascertainment and recording on computerised systems. Health resource utilization and costs were almost doubled in women with PCOS compared to controls. Presentation Date: Saturday, June 17, 2023

Smartphone-Based Remote Monitoring in Heart Failure With Reduced Ejection Fraction: Retrospective Cohort Study of Secondary Care Use and Costs.

Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospitalizations. Treatment optimization and admission avoidance rely on frequent symptom reviews and monitoring of vital signs. Remote monitoring (RM) aims to prevent admissions by facilitating early intervention, but the impact of noninvasive, smartphone-based RM of vital signs on secondary health care use and costs in the months after a new diagnosis of HFrEF is unknown. The purpose of this study is to conduct a secondary care health use and health-economic evaluation for patients with HFrEF using smartphone-based noninvasive RM and compare it with matched controls receiving usual care without RM. We conducted a retrospective study of 2 cohorts of newly diagnosed HFrEF patients, matched 1:1 for demographics, socioeconomic status, comorbidities, and HFrEF severity. They are (1) the RM group, with patients using the RM platform for >3 months and (2) the control group, with patients referred before RM was available who received usual heart failure care without RM. Emergency department (ED) attendance, hospital admissions, outpatient use, and the associated costs of this secondary care activity were extracted from the Discover data set for a 3-month period after diagnosis. Platform costs were added for the RM group. Secondary health care use and costs were analyzed using Kaplan-Meier event analysis and Cox proportional hazards modeling. A total of 146 patients (mean age 63 years; 42/146, 29% female) were included (73 in each group). The groups were well-matched for all baseline characteristics except hypertension (P=.03). RM was associated with a lower hazard of ED attendance (hazard ratio [HR] 0.43; P=.02) and unplanned admissions (HR 0.26; P=.02). There were no differences in elective admissions (HR 1.03, P=.96) or outpatient use (HR 1.40; P=.18) between the 2 groups. These differences were sustained by a univariate model controlling for hypertension. Over a 3-month period, secondary health care costs were approximately 4-fold lower in the RM group than the control group, despite the additional cost of RM itself (mean cost per patient GBP £465, US $581 vs GBP £1850, US $2313, respectively; P=.04). This retrospective cohort study shows that smartphone-based RM of vital signs is feasible for HFrEF. This type of RM was associated with an approximately 2-fold reduction in ED attendance and a 4-fold reduction in emergency admissions over just 3 months after a new diagnosis with HFrEF. Costs were significantly lower in the RM group without increasing outpatient demand. This type of RM could be adjunctive to standard care to reduce admissions, enabling other resources to help patients unable to use RM.

Impact of PSA testing on secondary care costs in England and Wales: estimates from the Cluster randomised triAl of PSA testing for Prostate cancer (CAP)

BackgroundScreening men for prostate cancer using prostate-specific antigen (PSA) testing remains controversial. We aimed to estimate the likely budgetary impact on secondary care in England and Wales to inform screening decision makers.MethodsThe Cluster randomised triAl of PSA testing for Prostate cancer study (CAP) compared a single invitation to men aged 50–69 for a PSA test with usual care (no screening). Routinely collected hospital care data were obtained for all men in CAP, and NHS reference costs were mapped to each event via Healthcare Resource Group (HRG) codes. Secondary-care costs per man per year were calculated, and cost differences (and population-level estimates) between arms were derived annually for the first five years following randomisation.ResultsIn the first year post-randomisation, secondary-care costs averaged across all men (irrespective of a prostate cancer diagnosis) in the intervention arm (n = 189279) were £44.80 (95% confidence interval: £18.30-£71.30) higher than for men in the control arm (n = 219357). Extrapolated to a population level, the introduction of a single PSA screening invitation could lead to additional secondary care costs of £314 million.ConclusionsIntroducing a single PSA screening test for men aged 50–69 across England and Wales could lead to very high initial secondary-care costs.

Health care costs and changes in subjective health-related quality of life among Finnish adolescents referred to secondary psychiatric out-patient services: a one-year follow-up study.

There has been growing interest in economic evidence regarding treatment of mental disorders. The purpose of this one-year follow-up study was to evaluate the secondary health care costs and changes in health-related quality of life (HRQoL) in three common adolescent psychiatric disorder groups. Further, HRQoL of patients was compared to that of population controls. Twelve- to fourteen-year-old adolescents with behavioral and emotional disorders (n = 37), mood disorders (n = 35), and anxiety disorders (n = 34), completed the 16D HRQoL questionnaire when they entered the adolescent psychiatric outpatient clinics (baseline) and at follow-up. The direct secondary health care costs were calculated using a clinical patient administration system. Population controls included 373 same-aged pupils from randomly selected 13 comprehensive schools. The direct secondary health care costs did not differ significantly between the three patient groups. However, in adolescents with mood disorders, this investment generated a significant and clinically important improvement in HRQoL, which was not observed in the other two patient groups. The costs of health care alone do not necessarily reflect its quality.

Smartphone-based remote monitoring (RM) in chronic heart failure reduces emergency hospital attendances, unplanned admissions and secondary care costs: a retrospective cohort study

Abstract Background Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospital attendances [1]. Treatment optimisation and admission avoidance relies on frequent symptom review and monitoring of vital signs [2]. RM programmes aim to prevent admissions and improve system efficiency by enabling self-management [3]. Few studies evaluate the economic impact of RM in HFrEF, compared to real-world matched controls [4]. We compare hospital attendances and costs between patients using Luscii, a novel smartphone-based RM platform, and matched controls receiving usual care for 3 months. Purpose To assess the impact of RM on emergency department (ED) attendances, unplanned admissions and associated healthcare costs over 3 months. Methods A retrospective cohort study of new HFrEF referrals to our service was undertaken using the Discover dataset [5] for two cohorts (i) “RM group”: patients who used the RM platform for at least 3 months and (ii) “control group”: consecutive patients referred before the RM platform was available. The groups were matched 1:1 for age, sex, ethnicity, New York Heart Association grade and left ventricular ejection fraction. Medical co-morbidities, ED attendances, unplanned admissions and costs were extracted over 3 months from platform onboarding (RM group) or accepted referral (control group). Platform costs were added for the RM group. Differences between outcomes were analysed using t-tests, Kaplan-Meier event analysis and Cox's proportional hazard modelling. Results 146 patients (mean age 63 years; 23% female) were included in the analyses (73 “RM group”; 73 “Control group”). The groups were well-matched for all baseline characteristics except hypertension (p=0.03). Compared to the control group, after 3 months follow-up the RM group had significantly fewer ED attendances (p<0.01) and unplanned admissions (p<0.01). Accounting for RM platform costs, there was no difference between ED costs (p=0.42), but significantly lower unplanned admissions costs in the RM group (p=0.02) (Table 1). RM was protective against ED attendances (HR=0.43, p=0.02) and unplanned admissions (HR=0.26, p=0.02), which was sustained after controlling for hypertension (Table 1). Kaplan-Meier analyses found significantly lower probability of ED attendances (p=0.02) and unplanned admissions (p=0.01) in the RM group (Figure 1). Conclusions HFrEF patients with RM were half as likely to attend ED and approximately four times less likely to need short-term unplanned admissions. The economic benefit of RM is driven by lower unplanned admission costs; the cost benefit is equivocal at the ED stage. Participants were younger than the typical HFrEF cohort. RM use could free up valuable resources to enhance standard care for older patients who decline or are unable to use RM. Further evaluation is required of the long-term impact of RM and its effect on outpatient encounters and costs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Discover data extraction and analyst time were funded by Astra Zeneca. Astra Zeneca did not have any input to study design, analyses or reporting.

Economic Implications of Endometriosis: A Review.

Endometriosis is a chronic inflammatory disease that can have serious physical and emotional consequences for patients in terms of pain, quality of life, and infertility. Despite affecting about 10% of women, the pathophysiology and economic impact of the disease are not fully understood. This study aimed to review and summarize research articles quantifying the direct and indirect costs of endometriosis in the context of current national and international treatment guidelines. A search including the terms 'endometriosis' AND 'costs' OR 'cost of illness' OR 'cost analysis' OR 'economic burden' was performed, focusing on studies published between January 2000 and May 2022. Total costs, costs of primary and secondary care, productivity losses, and indirect costs were reported. The medical costs of endometriosis were principally registered in secondary care settings, where surgery was the main cost driver. There was considerable variability of populations and study settings, with the overall direct medical cost range of endometriosis from US$1459 to US$20,239 (2022) per patient per year. An increasing trend has been reported in secondary care costs over time; however, not enough data were available at this time to evaluate inpatient and outpatient costs versus treatment strategies. Similarly, further research is required to evaluate the costs and potential savings associated with new therapies. Numerous studies have evaluated the indirect costs of endometriosis in recent years, finding costs between US$4572 and US$14,079 (2022). Currently, limited data are available on the economic burden of the disease at the patient level.

Primary Definitive Treatment versus Ureteric Stenting in the Management of Acute Ureteric Colic: A Cost-Effectiveness Analysis.

Objectives: To analyze the differences in cost-effectiveness between primary ureteroscopy and ureteric stenting in patients with ureteric calculi in the emergency setting. Patients and Methods: Patients requiring emergency intervention for a ureteric calculus at a tertiary centre were analysed between January and December 2019. The total secondary care cost included the cost of the procedure, inpatient hospital bed days, emergency department (A&E) reattendances, ancillary procedures and any secondary definitive procedure. Results: A total of 244 patients were included. Patients underwent ureteric stenting (62.3%) or primary treatment (37.7%), including primary ureteroscopy (URS) (34%) and shock wave lithotripsy (SWL) (3.6%). The total secondary care cost was more significant in the ureteric stenting group (GBP 4485.42 vs. GBP 3536.83; p = 0.65), though not statistically significant. While mean procedural costs for primary treatment were significantly higher (GBP 2605.27 vs. GBP 1729.00; p < 0.001), costs in addition to the procedure itself were significantly lower (GBP 931.57 vs. GBP 2742.35; p < 0.001) for primary treatment compared to ureteric stenting. Those undergoing ureteric stenting had a significantly higher A&E reattendance rate compared with primary treatment (25.7% vs. 10.9%, p = 0.02) and a significantly greater cost per patient related to revisits to A&E (GBP 61.05 vs. GBP 20.87; p < 0.001). Conclusion: Primary definitive treatment for patients with acute ureteric colic, although associated with higher procedural costs than ureteric stenting, infers a significant reduction in additional expenses, notably related to fewer A&E attendances. This is particularly relevant in the COVID-19 era, where it is crucial to avoid unnecessary attendances to A&E and reduce the backlog of delayed definitive procedures. Primary treatment should be considered concordance with clinical judgement and factors such as patient preference, equipment availability and operator experience.

Smartphone-based remote monitoring (RM) in chronic heart failure reduces emergency hospital attendances, unplanned admissions and secondary care costs: a retrospective cohort study

Abstract Background Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospital attendances [1]. Treatment optimisation and admission avoidance relies on frequent symptom review and monitoring of vital signs [2]. RM programmes aim to prevent admissions and improve system efficiency by enabling self-management [3]. Few studies evaluate the economic impact of RM in HFrEF, compared to real-world matched controls [4]. We compare hospital attendances and costs between patients using Luscii, a novel smartphone-based RM platform, and matched controls receiving usual care for 3 months. Purpose To assess the impact of RM on emergency department (ED) attendances, unplanned admissions and associated healthcare costs over 3 months. Methods A retrospective cohort study of new HFrEF referrals to our service was undertaken using the Discover dataset [5] for two cohorts (i) “RM group”: patients who used the RM platform for at least 3 months and (ii) “control group”: consecutive patients referred before the RM platform was available. The groups were matched 1:1 for age, sex, ethnicity, New York Heart Association grade and left ventricular ejection fraction. Medical co-morbidities, ED attendances, unplanned admissions and costs were extracted over 3 months from platform onboarding (RM group) or accepted referral (control group). Platform costs were added for the RM group. Differences between outcomes were analysed using t-tests, Kaplan-Meier event analysis and Cox's proportional hazard modelling. Results 146 patients (mean age 63 years; 23% female) were included in the analyses (73 “RM group”; 73 “Control group”). The groups were well-matched for all baseline characteristics except hypertension (p=0.03). Compared to the control group, after 3 months follow-up the RM group had significantly fewer ED attendances (p&amp;lt;0.01) and unplanned admissions (p&amp;lt;0.01). Accounting for RM platform costs, there was no difference between ED costs (p=0.42), but significantly lower unplanned admissions costs in the RM group (p=0.02) (Table 1). RM was protective against ED attendances (HR=0.43, p=0.02) and unplanned admissions (HR=0.26, p=0.02), which was sustained after controlling for hypertension (Table 1). Kaplan-Meier analyses found significantly lower probability of ED attendances (p=0.02) and unplanned admissions (p=0.01) in the RM group (Figure 1). Conclusions HFrEF patients with RM were half as likely to attend ED and approximately four times less likely to need short-term unplanned admissions. The economic benefit of RM is driven by lower unplanned admission costs; the cost benefit is equivocal at the ED stage. Participants were younger than the typical HFrEF cohort. RM use could free up valuable resources to enhance standard care for older patients who decline or are unable to use RM. Further evaluation is required of the long-term impact of RM and its effect on outpatient encounters and costs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Discover data extraction and analyst time were funded by Astra Zeneca. Astra Zeneca did not have any input to study design, analyses or reporting.

The Cost of Treating Adult Glioblastoma Patients in England

Abstract AIMS The GlioCova dataset uses linked English national cancer data on all 51,775 adult primary brain tumour patients diagnosed between 2013-2018, of which 15,277 patients were diagnosed with a cranial glioblastoma. Here we present data on the direct care costs of treatment, based on secondary care data. METHOD We examined data on inpatient and outpatient care for all cranial glioblastoma patients in the dataset. We used the NHS HRG4+ Reference Costs Grouper 2017-2018 to assign costs standardised to 2017-2018. RESULTS A total of 14,999 patients were admitted to hospital between the last three months of 2012 and up to the end of 2019, of which we were able to assign costs to 14,691 patients. Total inpatient cost was over £321 million (34% of which was attributed to direct costs of spells of neurosurgery, chemotherapy, and radiotherapy). 14,528 patients had outpatient care, of which we were able to assign costs to 14,419 patients. Total outpatient cost was over £92 million (41% of which was attributed to chemotherapy and radiotherapy). CONCLUSION The estimated secondary care costs for adult glioblastoma patients in England were over £414 million for patients diagnosed between 2013-2018, but do not include patient out-of-pocket costs, primary care, social care, or end of life care costs. Future work will examine variation in care and costs and extend it to the wider brain tumour cohort. We also hope these data will help make the economic argument for improvements in care for brain tumour patients. More information on GlioCova: https://blogs.imperial.ac.uk/gliocova/about-gliocova/

Multimorbidity and dementia risk in hospitalised patients: an administrative data linkage study of hospital patients in Northern Ireland.

IntroductionWhile chronic disease is a risk factor for dementia (Shang et al., 2020) studies addressing multimorbidity and dementia risk are limited. Multimorbidity leads to steeper dementia progression (Bauer, 2014; Haaksma, 2019) impacting cognitive dysfunction, cognitive decline and impairment (Wei, 2020; Vassilaki, 2015). Multimorbidity has generally been examined using a dose- response disease count, something cited as impractical for clinicians due to information deficits on identifying disease specific pathways (Whitty, 2020). Thus, differentiating disease clusters and dementia risk will provide insight into the pathophysiology of dementia, while informing priority targets for early intervention, potentially reducing burden and secondary care costs. AimTo investigate dementia risk and mortality in older adults with different disease patterns, characteristics of hospital admissions, medication use and the role of locale of residence. Data linkage and analysisWe used national data defined by the NHAIS, including basic demographics for all patients aged fifty-five plus and registered with a GP in Northern Ireland. The linked data comprised: Patient Admissions and Discharges (from 2013-2021); Electronically captured prescribing data, area-type of usual residence; Multiple Deprivation Indicators; and GRO mortality data (including cause of death). We identified multimorbidity through validated algorithms for ICD-10 coding of thirty morbidities in administrative hospital diagnostics data (Tonelli et al., 2019). The same data identified dementia-free patients at baseline. Latent Class Analysis assigned patient groups by the patterning of multimorbidity states, following them through the study period, with analysis in relation to subsequent diagnoses of both clinical dementia and mortality. As age has a potential modifier effect we tested through age group stratified analyses. A series of multinomial logistic regression models further examine (for the multimorbidity sub-groups of interest) risks associated socio-demographic, socio-economic, medication use and household indicators at the individual, family and area level. ResultsMultimorbidity occurs in two thirds, approximately, of this hospital population of older adults. By age sixty-five years, most people are multimorbid. We identify subgroups of multimorbidity associated with dementia onset and mortality, combinations of diabetes, hypertension, chronic kidney disease and cancer multimorbidity are highlighted as higher-risk conditions for increased dementia incidence and mortality. Greater disease burden is associated with frequent healthcare service use, medication use and is more common in the most socioeconomically deprived, compared with the least deprived. DiscussionEvidence on multimorbidity patterns and dementia is limited (Grande, 2021). Our study suggests that people with combinations of diabetes, hypertension, chronic kidney disease and cancer multimorbidity are associated with increased risks for dementia and socio demographic and economic circumstances further increase this risk. Overlapping combinations comprising chronic kidney disease + hypertension, or diabetes + hypertension, were a significant proportion of total secondary care costs for patients with multimorbidity; combinations comprising chronic heart failure + chronic kidney disease + hypertension had the highest proportion of total cost from potentially preventable emergency admissions (Stokes et al., 2021). Our finding support the body and mind connection in dementia development. Thus, we note that cardiovascular health is associated with dementia (Grande, 2021). Often described as a heart-brain connection, cardiovascular disease leads to higher dementia risk due to a number of mechanisms including but not limited to chronic inflammation (Grande, 2021). Identifying such high-risk groups will facilitate tailored interventions for dementia prevention and the reduction of healthcare use and costs.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Long-term effects and costs of pelvic floor muscle training for prolapse: trial follow-up record-linkage study

Introduction and hypothesisPelvic organ prolapse affects around 40% of women aged over 50 years. A multicentre parallel group randomised trial (the Pelvic Organ Prolapse PhysiotherapY (POPPY) trial) demonstrated that pelvic floor muscle training (PFMT) was effective in reducing prolapse symptoms compared with no treatment. However, insight into the long-term impact of PFMT on health outcomes and health-service utilisation is scarce.MethodsThis study utilised linkage of Scottish administrative health records to follow-up POPPY trial participants resident in Scotland over 11 years. Mixed effects logistic regression determined the likelihood of receiving further prolapse treatment for those in the PFMT and control groups. Analyses were adjusted for age group, prolapse stage, baseline symptom severity and attitude towards surgery. A cost assessment estimated longitudinal costs to the UK National Health Service (in Scotland) of accessing further prolapse treatment for each trial group.ResultsTwo hundred and ninety-three women, aged 25 to 79 years, were followed up. One hundred and forty-one women (48.1%) had received further prolapse treatment: 65 (of 149; 43.6%) in the PFMT group compared with 76 (of 144; 52.8%) in the control group. PFMT was associated with a reduction in the odds of any prolapse treatment during follow-up (AOR 0.61; 95% CI 0.37 to 0.99). Total cost of secondary care was £154,544 (GBP) in the PFMT group and £172,549 (GBP) in the control group.ConclusionsAlthough PFMT did not lead to significant differences in total costs for further prolapse treatment over a post-intervention period of more than 10 years, it reduced the overall long-term risk of requiring hospital-based treatment for pelvic floor disorders.

Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis".

BackgroundPatients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window.MethodsABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours.ObjectivesPrimary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs.DiscussionThis trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.

Healthcare resource utilisation and costs associated with a heart failure diagnosis: a retrospective, population-based cohort study in Sweden

ObjectivesTo examine healthcare resource use (HRU) and costs among heart failure (HF) patients using population data from Sweden.DesignRetrospective, non-interventional cohort study.SettingTwo cohorts were identified from linked national health registers (cohort...

MP65-17 IS PRIMARY URETEROSCOPY MORE COST-EFFECTIVE THAN URETERAL STENTING FOR OBSTRUCTING URETERAL CALCULI?

INTRODUCTION AND OBJECTIVE: The increasing prevalence of nephrolithiasis represents a significant economic burden worldwide making cost-reduction essential. Given that 20% of patients with ureteral colic require acute surgical intervention, there is a lack of data reviewing the cost-effectiveness of current treatment modalities. We present a costeffectiveness analysis between primary treatment and ureteral stenting in patients with ureteral stones in the emergency setting. METHODS: We performed a retrospective analysis of patients requiring emergency intervention for a ureteral calculus at a single institution between January and December 2019. All patients underwent ureteral stenting, primary ureteroscopy (URS) or shock wave lithotripsy (SWL). The overall secondary care cost was calculated to include the cost of the procedure, inpatient hospital bed days, emergency room (ER) attendances, additional procedures such as nephrostomy insertion and secondary definitive procedure. RESULTS: A total of 244 patients were included. Ureteral stenting was performed in 152 patients (62.3%) and primary treatment in 92 patients (37.7%), of those, 83 patients (34.0%) underwent primary URS and 9 patients (3.6%) had SWL. Those undergoing ureteral stenting had a significantly higher ER reattendance rate (25.7% vs 10.9%, >p=0.02). The overall secondary care cost was greater in the ureteral stenting group (£4485.42 vs £3536.83;>p=0.65). The average cost per patient related to ER reattendances was significantly higher in the ureteral stenting group compared with the primary treatment group (£61.05 vs £20.87;>p < 0.001). CONCLUSIONS: The current study highlights the potential overall cost-reduction when performing primary treatment in patients presenting with acute ureteral colic, predominantly related to reduced ER attendances. This is particularly relevant in the COVID-19 pandemic where it is crucial to avoid unnecessary attendances to the ER and reduce the backlog of delayed definitive procedures. Both primary URS and SWL in the acute setting should be considered, in concordance with clinical judgement and factors such as patient preference, equipment availability and operator experience.

Cost-effectiveness of a stepped care program to prevent depression among primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression in comparison with usual care

BackgroundPatients with diabetes mellitus type 2 (DM2) and/or coronary heart disease (CHD) are at high risk to develop major depression. Preventing incident major depression may be an important tool in reducing the personal and societal burden of depression. The aim of the current study was to assess the cost-effectiveness of a stepped care program to prevent major depression (Step-Dep) in diabetes mellitus type 2 and/or coronary heart disease patients with subthreshold depression in comparison with usual care.MethodsAn economic evaluation with 12 months follow-up was conducted alongside a pragmatic cluster-randomized controlled trial from a societal perspective. Participants received care as usual (n = 140) or Step-Dep (n = 96) which consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to a general practitioner. Primary outcomes were quality-adjusted life years (QALYs) and cumulative incidence of major depression. Costs were measured every 3 months. Missing data was imputed using multiple imputation. Uncertainty around cost-effectiveness outcomes was estimated using bootstrapping and presented in cost-effectiveness planes and acceptability curves.ResultsThere were no significant differences in QALYs or depression incidence between treatment groups. Secondary care costs (mean difference €1644, 95% CI €344; €3370) and informal care costs (mean difference €1930, 95% CI €528; €4089) were significantly higher in the Step-Dep group than in the usual care group. The difference in total societal costs (€1001, 95% CI €-3975; €6409) was not statistically significant. The probability of the Step-Dep intervention being cost-effective was low, with a maximum of 0.41 at a ceiling ratio of €30,000 per QALY gained and 0.32 at a ceiling ratio of €0 per prevented case of major depression.ConclusionsThe Step-Dep intervention is not cost-effective compared to usual care in a population of patients with DM2/CHD and subthreshold depression. Therefore, widespread implementation cannot be recommended.Trial registrationThe trial was registered in the Netherlands Trial Register (NTR3715).