Health System Cost Savings Research Articles

Cost-effectiveness analysis of continuous positive airway pressure treatment for obstructive sleep apnea in Singapore from a health system perspective.

This study assessed the cost-effectiveness of continuous positive airway pressure treatment for obstructive sleep apnea in Singapore from a health system perspective. The analysis evaluated a 5-year care pathway using a Markov model, considering per-patient costs of treatment, health system cost savings of obstructive sleep apnea and attributed conditions, the effectiveness measured in disability-adjusted life years with a discount rate of 3% and a weighted 5-year continuous positive airway pressure adherence of 74.1% from Singapore studies. Per-patient costs of treatment were from a large public hospital in Singapore. Efficacy of continuous positive airway pressure treatment, health system costs and disability-adjusted life years were obtained from literature; costs are in US dollars. We conducted probabilistic sensitivity analysis, one-way sensitivity analysis and what-if analysis. Based on a willingness-to-pay threshold of US $50,000 per disability-adjusted life year in USA, continuous positive airway pressure therapy was highly cost-effective, with an incremental cost-effectiveness ratio of $13,822 per disability-adjusted life year averted. Compared with the annual total costs of $856 for patients with continuous positive airway pressure treatment diagnosed by an inpatient sleep study, the total costs for those diagnosed by a home sleep test were $625, resulting in a remarkable 27% reduction per patient per year. One-way sensitivity analysis indicated that costs of treatment, effectiveness of continuous positive airway pressure treatment and adherence had a higher impact on the cost-effectiveness of continuous positive airway pressure therapy. The what-if analysis suggested that for continuous positive airway pressure treatment to be cost-effective, adherence rate should be at least 16.1%. These findings provide valuable insights for policymakers in making informed decisions on funding diagnosis and continuous positive airway pressure therapy within Singapore's healthcare system.

The impact of capping health system cost savings on the projected cost-effectiveness of etranacogene dezaparvovec compared with factor IX prophylaxis for the treatment of hemophilia B.

This viewpoint discusses cost-effectiveness estimates for EtranaDez, a gene therapy for hemophilia B, using the Institute for Clinical and Economic Review's (ICER) framework for single and short-term therapies (SSTs). EtranaDez offers long-term benefits from a single administration, in contrast to the high costs and frequent dosing required by current factor IX prophylaxis. However, the projected gains in health from EtranaDez are small relative to the cost implications of the therapy, and consequently, how the cost offsets associated with EtranaDez are counted has a substantial impact on assessing its cost-effectiveness. Strategies for assessing cost offsets used in the ICER SST framework include a 50/50 cost-sharing model between the health care system and the manufacturer and a cap of $150,000 annually on health care cost offsets. Results from the standard full cost-offset analysis as reported by ICER depicted EtranaDez as a dominant therapy with substantial cost savings compared with factor IX prophylaxis. However, while considering the ICER SST framework, particularly the $150,000 annual cap scenario, the cost-effectiveness was significantly reduced. The incremental cost-effectiveness ratio varied notably between these scenarios, challenging the conventional perception of value of gene therapy in health care. These cost-sharing scenarios highlight the potential of the ICER SST framework to help curtail inefficient health care spending. In cases in which the cost of existing treatment is exceedingly high, the application of such frameworks would improve efficiency in resource allocation, fostering a balance between incentives for innovation and economic sustainability in managed care systems.

Alert-based remote monitoring: A model for increased reimbursement to meet device clinic workload while achieving overall health system cost savings

Alert-based remote monitoring: A model for increased reimbursement to meet device clinic workload while achieving overall health system cost savings

Telehealth for Equitable Obstetric Care: Addressing Gaps for Patients, Providers, and Payers

In June 2022, President Biden and Vice President Harris released their blueprint for addressing the maternal health crisis, stating their “vision for the future is that the United States will be considered the best country in the world to have a baby.” Currently, it is one of the worst among industrialized countries despite the US spending nearly double the average amount on healthcare per capita. The US is amidst a maternal mortality crisis, particularly for Black and American Indian/Alaska Native pregnant people, with more than 80% of the deaths preventable. Telehealth in obstetrics has the potential to reach pregnant people who are not currently being served by the medical system and to improve rates of severe maternal morbidity and mortality; however, more research is needed to understand and monitor its equity, costs, and optimal usage. Extant research shows that telehealth can produce a small positive effect for certain obstetric health outcomes, but these research findings are rarely stratified by pregnant patients’ demographics. To prevent the perpetuation of existing health inequities, gaps in obstetric telehealth research will need to be addressed. Key knowledge gaps for researchers and policy makers include outcomes, access, satisfaction by patients and providers, potential time savings for patients, and health system cost savings. Im​plementation of equitable obstetric coverage of telehealth services requires clarity from private and public payers for inter-state provisions of care, liability and risk, and service and payment parity.Note: While we use pregnant and postpartum people where possible here to recognize that not all pregnant people identify as women, we occasionally use maternal to reflect terminology used in federal, state, and local data.

Methods of Assessing Health Care Costs in a Changing Climate: A Case Study of Heatwaves and Ambulance Dispatches in Tasmania, Australia.

Anthropogenic climate change is causing a rise in global temperatures, with this trend projected to increase into the future. Rising temperatures result in an increase in the frequency and severity of heatwave events, with an associated increase in poor health outcomes for vulnerable individuals. This places an increasing strain on health care services. However, methods calculating future health care costs associated with this trend are poorly understood. We calculated health care costs attributable to heatwave events in Tasmania 2009-2019, using ambulance dispatches as a case study. We also modeled the expected health and economic burden for projected heatwave frequencies between 2010 and 2089. We developed our models based on two possible approaches to describing population adaptation to heatwaves-an adapted population calculated by determining heatwave episodes using a rolling baseline, and a non-adapted population calculated by determining heatwave episodes using a static baseline. Using a rolling baseline calculation for 2010 to 2089, we estimated additional ambulance costs averaging AUD$57,147 per year and totaling AUD$4,571,788. For the same period using a static baseline, we estimated additional ambulance costs averaging AUD$517,342 per year and totaling AUD$41,387,349. While this method is suitable for estimating the health care costs associated with heatwaves, it could be utilized for estimating health care costs related to other climate-related extreme events. Different methods of estimating heatwaves, modeling an adapted versus non-adapted population, provide substantial differences in projected costs. There is potential for considerable health system cost savings when a population is supported to adapt to extreme heat.

Weight-based vs fixed dosing of darbepoetin alfa for anemia following kidney transplantation.

Post-transplantation anemia (PTA) is common in kidney transplant recipients, with patients frequently treated with erythropoietin-stimulating agents such as darbepoetin alfa. The optimal dosing for darbepoetin alfa remains controversial. This retrospective cohort study involved kidney transplant recipients who received darbepoetin alfa at 2 clinics. Patients were stratified into 2 groups: those who received a fixed dose of 200 μg and those who received a weight-based dose of 0.45 μg/kg. The dosing interval varied depending on clinical response, clinic visit timing, and frequency allowed by insurance. The primary outcome was achieving a hemoglobin concentration of at least 10 g/dL without blood transfusion by 12 weeks after darbepoetin alfa initiation. Of the 110 patients in the study, 45% received weight-based dosing and 55% received fixed dosing. Darbepoetin alfa was initiated significantly earlier after transplantation in the fixed-dose group (median of 14 vs 20 days; P = 0.003). The weight-based group received more doses of darbepoetin alfa (median of 4 vs 2 doses; P = 0.002) and had a significantly lower cumulative exposure to darbepoetin alfa (125 vs 590 μg; P < 0.001). The median time between doses was 9 days (interquartile range, 7-14 days) in the weight-based group and 12 days (7-32 days) in the fixed-dose group (P = 0.04). Patients in the weight-based group more frequently achieved the primary outcome (67.3% vs 47.5%; P = 0.059). There was no significant difference in secondary or safety outcomes between the groups. Weight-based and fixed dosing approaches for darbepoetin alfa were not different in the achievement of a hemoglobin concentration of at least 10 g/dL without blood transfusion at 12 weeks after darbepoetin alfa initiation, with significantly lower cumulative darbepoetin alfa utilization in the weight-based group. Weight-based dosing of darbepoetin alfa in PTA appears to be safe and effective, with the potential for significant patient and health-system cost savings.

Enhancing Postoperative Pain Management and Decreasing Hospital Length of Stay on a Pediatric Orthopedic Unit: Implementation of an Ambulatory Continuous Peripheral Nerve Block Program

PurposePediatric Ambulatory Continuous Peripheral Nerve Block (ACPNB) programs are a safe and effective pain management modality that can reduce patient length of stay (LOS) while ensuring optimal, multimodal pain management at home after surgery. Our institution previously solely used electronic infusion pumps to deliver local anesthetic via peripheral nerve catheters, requiring postoperative inpatient admissions for pain management. We aimed to enhance postoperative pain management and decrease hospital LOS after orthopedic foot and ankle surgery through implementation of an ACPNB program. DesignAn ACPNB program was developed and implemented for pediatric patients undergoing foot and ankle reconstruction surgery. MethodsWe provide a detailed description of the multidepartment collaboration led by the acute pain service (APS) and orthopedics that resulted in the development and implementation of a pediatric ACPNB program using portable, elastomeric devices for patients undergoing reconstructive foot and ankle surgery. Implementation tools, including caregiver and nursing education resources, a data collection log, a process map, and staff surveys are shared. FindingsTwenty-eight patients received elastomeric devices during the 12 months of data collection. All 28 patients who required a continuous peripheral nerve block (CPNB) for pain management following foot and ankle reconstruction surgery received their block via an elastomeric device rather than an electronic hospital infusion pump. All patients and caregivers expressed positive satisfaction with pain management after hospital discharge. No patient with an elastomeric device required scheduled opioids for pain management by the end of their hospital admission. LOS on the orthopedic inpatient unit for foot and ankle surgery decreased by 58%, representing an estimated 29 days and $27,557.88 saved. A majority (96.4%) of staff survey respondents reported feeling satisfied with their overall experience working with an elastomeric device. ConclusionsThe successful implementation of a pediatric ACPNB program has led to positive patient outcomes, including a significant decrease in hospital LOS and health system cost savings for this patient population.

The neglected potential of red and processed meat replacement with alternative protein sources: simulation modelling and systematic review

What we eat is fundamental to human and planetary health, with the current global dietary transition towards increased red meat intakes and ultra-processed foods likely detrimental. We modelled five red and processed meat replacement scenarios to consider health, equity, greenhouse gas emissions (GHGe), and cost outcomes using an established multistate life table model using data from New Zealand as a case study of a developed, westernised country. Current red and processed meat intakes were replaced with: minimally or ultra-processed plant based meat alternatives, cellular meat, or diets in line with EAT-Lancet or Heart Foundation recommendations on red meat intake. We then conducted a systematic review of literature from database inception to 14 November 2022 to identify implemented population-level meat replacement strategies which could inform evidence-based recommendations to achieve any benefits observed in modelling. PROSPERO CRD42020200023. When compared with current red and processed meat intakes, all red and processed meat replacement scenarios were nutritionally adequate and improved overall Quality Adjusted Life Years (159-297 per 1000 people over life course for the five scenarios modelled). Age standardised per capita health gain for Māori was 1.6-2.3 times that of non-Māori. Health system cost savings were $2530-$5096 per adult, and GHGe reduced 19-35%. Finally, grocery cost varied (↓7%-↑2%) per modelled scenario when compared with baseline costs. The greatest benefits for all outcomes were achieved by meat replacement with minimally-processed plant-based foods, such as legumes. The systematic review identified only two implemented population-level strategies to reduce meat intakes within the academic literature. All meat replacement scenarios considered indicated appreciable health gains and GHGe reductions. Replacement with minimally-processed plant-based foods appeared consistently superior than other scenarios. Evidence of real-world population strategies to achieve these benefits however is currently lacking. Healthier Lives National Science Challenge (Grant UOOX1902).

Cost-effectiveness of a gene sequencing test for Alzheimer's disease in Ontario.

Alzheimer's f disease (AD) affects approximately 250,000 Ontarians, a number that is expected to double by 2040. The Ontario Neurodegenerative Disease Research Initiative has developed an in-province genetic test (ONDRISeq), which currently runs in Ontario in an experimental capacity. The aim of this study is to estimate the costs and health outcomes associated with ONDRISeq to diagnose AD relative to out-of-country (OOC) testing (status quo). A cost-utility analysis was developed for a hypothetical cohort of 65-year-olds at risk of AD in Ontario over a 25-year time horizon. Costs and health outcomes (quality-adjusted life years (QALYs)) were assessed from a healthcare payer perspective. Cost-effectiveness was assessed with a $50,000 cost-effectiveness threshold. Probabilistic sensitivity analyses were conducted to evaluate parameter uncertainty. ONDRISeq saved $54 per patient relative to OOC testing and led to a small QALY gain in the base case (0.0014 per patient). Results were most sensitive to testing costs, uptake rates, and treatment efficacy. ONDRISeq represented better value for money relative to OOC testing throughout 75% of 10,000 probabilistic iterations. Using ONDRISeq is expected to provide health system cost savings. Switching to ONDRISeq for AD genetic testing in Ontario would be dependent on the ability to accommodate the expected testing volumes.

Assessing the Health and Environmental Benefits of a New Zealand Diet Optimised for Health and Climate Protection

Population diets have impacts on both human and planetary health. This research aims to optimise a New Zealand (NZ) version of the EAT-Lancet diet and to model the impact of this diet on population health if it was adopted in NZ. The optimisation methods used mathematical equations in Excel to ensure: population diets met the nutritional recommendations; diet-related greenhouse gas (GHG) emissions did not exceed the NZ GHG boundary; and diet costs did not exceed baseline costs of the average diet. The EAT-Lancet diet was also directly mapped onto the NZ adult nutrition survey food groups, as another estimate of a NZ EAT-Lancet diet. Both diets were modelled using a DIET multi-state life-table model to estimate lifetime impacts on quality adjusted life years (QALYs), ethnic health inequities and health system costs. The optimised diet differed greatly from baseline intake with large amounts of fruits and vegetables, some fish but no beef, lamb, pork or poultry. Modelling nationwide adoption of the NZ EAT-Lancet diets generated large health savings (approximately 1.4 million QALYs), and health system cost savings (around NZD 20 billion). A healthy, climate-friendly, cost-neutral diet is possible for NZ and, if adopted, could provide large health gain, cost savings and reductions in ethnic health inequities.

The true cost of hidden waiting times for cataract surgery in Australia.

Cataract surgery is a safe, effective and common elective procedure in Australia but access is inequitable. True waiting times for cataract care are undisclosed or inconsistently reported by governments. Estimates of true waiting times range from 4 to 30 months and have been extended during the coronavirus disease 2019 (COVID-19) pandemic. Comparative analysis revealed that reducing waiting periods from 12 to 3 months would result in estimated public health system cost savings of $6.6 million by preventing 50 679 falls. Investment in public cataract services to address current unmet needs would prevent avoidable vision impairment and associated negative consequences.

Implementing Home Health Monitoring for Chronic Disease Management in British Columbia

Home health monitoring (HHM) enables health care providers to monitor a patient’s health status remotely using digital technology. In 2013, the government of British Columbia (BC) partnered with a telecommunications provider and invested $52M in HHM programs for patients with complex care needs. Telehealth has evolved over the past two decades to improve access and delivery of care, with HHM emerging as a strategy for proactive chronic disease management. The goals of the provincial HHM initiative are to reduce acute care utilization, reduce health system costs and improve patient self-management of chronic conditions. Following a series of successful pilot projects, funding for expanded HHM initiatives was made available through a provincial Strategic Investment Fund and continued support from Canada Health Infoway. Evaluations of several HHM programs demonstrated high levels of patient satisfaction, reduced emergency department visits, health system cost savings, and improved patient self-care and quality of life. Optimizing referral rates and expanding HHM programs to include a wider range of chronic conditions are opportunities for future growth, with sustainability dependent on securing long-term funding sources.

Updated Health and Cost Impacts of Electronic Nicotine Delivery Systems, Using Recent Estimates of Relative Harm for Vaping Compared to Smoking.

Measuring population health and costs effects of liberalizing access to electronic nicotine delivery systems (ENDS) is an evolving field with high persisting uncertainty. A critical area of uncertainty for policy-makers are estimates of net harms from ENDS relative to cigarettes, therefore, we model these harms using updated estimates incorporating disease specificity. We use updated estimates of relative harm of vaping vs smoking, based upon relevant biomarker studies to model the impact of liberalizing access to ENDS in New Zealand (NZ), relative to a ban (where ENDS are not legally available), in an existing proportional multi-state life-table model of 16 tobacco-related diseases. This modeling suggests that ENDS liberalization results in an expected gain of 195 000 quality-adjusted life-years (QALYs) over the remainder of the NZ population's lifespan. There was wide uncertainty in QALYs gained (95% uncertainty interval [UI] = -8000 to 406 000) with a 3.2% probability of net health loss (based upon the number of simulation runs returning positive QALY gains). The average per capita health gain was 0.044 QALYs (equivalent to an extra 16 days of healthy life). Health system cost-savings were expected to be NZ$2.8 billion (US$2.1 billion in 2020 US$; 95%UI: -0.3 to 6.2 billion [2011 NZ$]), with an estimated 3% chance of a net increase in per capita cost. This updated modeling around liberalizing ENDs in NZ, still suggests likely net health and cost-saving benefits-but of lesser magnitude than previous work and with a small possibility of net harm to population health. This study found evidence using updated biomarker studies that ENDS liberalization could result in QALY gains across the New Zealand population lifespan that are also cost-saving to the health system. Governments should include the information from these types of modeling studies in their decision-making around potentially improving access to ENDS for existing smokers, while at the same further reducing access to tobacco.

Estimating the Public Health and Economic Impact of Introducing the 13-Valent Pneumococcal Conjugate Vaccine or 10-Valent Pneumococcal Conjugate Vaccines into State Immunization Programs in India.

IntroductionAlthough the pneumococcal conjugate vaccine (PCV) has been introduced into select state immunization programs (SIPs) in India, many children remain unvaccinated. Recently, India’s Advisory Committee on Vaccines & Immunization Practices recommended PCV on the pediatric immunization schedule nationally. This study estimates the public health and economic impact of introducing either Pfizer’s 13-valent PCV (PCV13-PFE), GlaxoSmithKline’s 10-valent PCV (PCV10-GSK), or Serum Institute of India’s 10-valent PCV (PCV10-SII) into every pediatric SIP.MethodsA model was developed to predict the disease cases, deaths, and costs associated with implementing PCV13-PFE, PCV10-GSK, or PCV10-SII in SIPs compared to no vaccination program across a 5-year period (2021–2025). State and national-level uptake rate and clinical and economic input parameters were collected from published literature. Disease outcomes included invasive pneumococcal disease, inpatient and outpatient pneumonia, and otitis media. Costs were estimated as vaccine-related costs and direct medical costs incurred to the healthcare system. Results were reported by individual state and aggregated nationally. ResultsEstimated over 5 years, implementing PCV13-PFE in SIPs could avert 12.1 million cases and save 626,512 lives among children under 5 years old compared to no vaccination. This corresponds to net national cost savings of over $1.0 billion. Both lower-valent PCVs are estimated to provide less economic savings than PCV13-PFE inclusive of vaccine-related costs. Compared with PCV13-PFE, implementing PCV10-GSK or PCV10-SII nationally is estimated to have a smaller public health impact, with PCV10-GSK averting 8.4 million cases (436,577 deaths) and PCV10-SII preventing 10.3 million cases (531,545 deaths) in India compared to no vaccination, respectively.ConclusionImplementation of PCV13-PFE throughout India is estimated to provide greater public health and economic benefits than PCV10-GSK or PCV10-SII SIPs. Our analysis highlights the substantial disease cases, deaths, and health system cost savings that may be realized from implementing PCV programs throughout India.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00498-4.

A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations.

BackgroundExperimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies.MethodsThis is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a ‘virtual program’ using only telephone or internet-based communication for screening, assessments, or intervention was introduced.ConclusionThis pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.

PMU35 MODELING POTENTIAL HEALTH GAINS AND HEALTH SYSTEM SAVINGS ASSOCIATED WITH VAPORIZED NICOTINE PRODUCTS IN CANADA

To model population-wide health and cost impacts of vaporized nicotine products (VNPs) for Canadian adults 20 years and older from 2015 onwards, with associated uncertainty. A multi-state life-table model including 14 tobacco-related (TR) diseases was used to model potential changes in life expectancy and health-system costs, overall and by province/territory, using a 0% discount rate. The simulated population was divided into 68 cohorts by gender, ethnicity, and age. Each year, individuals could either remain in their current state, or transition to one of six smoking/vaping states. Input data including smoking/vaping prevalence by state, transition matrices, and relative risks of TR diseases by smoking/vaping state were estimated using data from Statistics Canada and literature. For each TR disease, incidence, prevalence, and direct healthcare and indirect costs were calculated. Three scenarios were modeled to reflect a range of uncertainty: Status Quo (“SQ”, VNPs commercialized as they are currently in Canada); No-Vaping (“NV”, assuming VNPs never entered the Canadian market); and Liberalized (“LIB”, VNPs commercialized in a policy environment similar to the United Kingdom context). The model performed well against validation with publicly available data. Preliminary results indicate that compared to the NV scenario, the SQ scenario projected to decrease life-years lost due to TR diseases, while the LIB scenario would lower them further. The SQ scenario projected a C$55.5 billion reduction in cumulative lifetime costs (life-years lost due to TR diseases, incremental direct health-system and indirect productivity costs) compared to the NV scenario. Statistical variability was assessed using sensitivity analyses on input parameters and Monte-Carlo simulations. Accessibility to VNPs in Canada may generate net public-health gains and health-system cost savings. These projected health and economic consequences are sensitive to assumptions about accessibility and use by adult smokers, and may vary by type of policy environment.

Cost-minimization analysis of community pharmacy-based point-of-care testing for strep throat in 5 Canadian provinces.

Strep throat point-of-care (POC) testing in community pharmacies will enable pharmacist-based care for this condition. Our objective was to conduct an economic evaluation of treating severe sore throat when this service was offered in pharmacies in 5 Canadian provinces. We conducted 5 separate cost-minimization analyses for the provinces of Alberta, British Columbia, Nova Scotia, Ontario and Saskatchewan, from the public payer perspective, to estimate mean cost per patient of treating severe sore throat in 2 scenarios: 1) physician-based usual care in a family physician's office, a walk-in clinic or an emergency room (ER) and 2) a new scenario where patients received care described above or in a pharmacy offering strep throat POC testing. One-way sensitivity analyses were conducted to account for model uncertainty. Mean cost per patient for each pathway in the base-case analyses for the 5 provinces ranged from 1) $37.55 to $61.57 for family physician, 2) $37.55 to $61.57 for walk-in clinic, 3) $38.88 to $57.56 for ER and 4) $19.12 to $21.83 for pharmacy, representing savings ranging from $12.47 to $24.36 per patient for the new scenario. Approximate total cost savings range from $1.3 million to $2.6 million per year across the 5 provinces. All sensitivity analyses yielded cost savings for the new scenario. Across 5 provinces, strep throat POC testing in pharmacies was cost saving compared to physician-based care. Sensitivity analyses demonstrated the robustness of these results. Funding strep throat POC testing in community pharmacies in these 5 provinces would lead to public health system cost savings and potentially improve patients' access to care for severe sore throat.

Floseal only versus in combination in spine surgery: a comparative, retrospective hospital database evaluation of clinical and healthcare resource outcomes

ABSTRACTObjective: Flowable agents such as Floseal® (F) are often reserved as adjuncts to non-flowable agents (i.e. gelatin (G) sponges and thrombin (T)) when bleeding is not sufficiently controlled. Based on their perceived positive impact, it is postulated that flowable agents alone may result in better clinical and resource utilization outcomes. Clinical and health-care utilization outcomes were compared in this retrospective analysis of spine surgery cases with charges for Floseal only (FO) and F + G/T.Methods: The United States Premier Hospital Database was searched for adult spine surgeries performed between October 2010 and September 2015 with FO or F and G/T charges. To obtain an unbiased treatment estimate, 1:1 propensity-score matching was used to identify FO and F + G/T cohorts. The cohorts were compared for rates of intraoperative, perioperative, postoperative and transfusion; blood loss-related, serious and other complications; hospital length-of-stay (LOS), surgical time, and volume of hemostat charged.Results: Among 40,335 spine surgeries, 15,105 FO and F + G/T matched pairs were compared. Significantly (p < 0.0001) lower percentages of FO than F + G/T cases received intraoperative (1.4% vs. 2.5%), perioperative (1.6% vs. 2.8%), postoperative (1.6% vs 3.0%), and any transfusion (2.3% vs. 4.3%). FO cases had significantly less blood loss complications than F + G/T cases (0.5% vs. 0.8%, p = 0.0022) and significantly (p < 0.0001) shorter hospital LOS (−0.45 days), surgical time (−39.0 min), and used less hemostat (−12.5 mL).Conclusions: Results from this observational hospital database analyses indicate that FO use in spine surgery is associated with lower blood transfusion use and blood loss complications compared to its use with adjunct non-flowable hemostatic agents. The shorter hospital stay, reduced surgical time, and less hemostat volume health-care utilization outcomes that favored FO versus combination use may translate to health system cost savings. Further validation of these findings using controlled clinical trials and cost-consequence studies is warranted.Clinical relevance: The use of flowable hemostatic agents alone may result in better clinical and possibly economic outcomes in spine surgery.

Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries

BackgroundTask shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings.MethodsUsing the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC.ResultsWe identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels.ConclusionsTask shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.

Toward a Broader Concept of Value: Identifying and Defining Elements for an Expanded Cost-Effectiveness Analysis.

This commentary identifies and defines potentially useful expansions to traditional cost-effectiveness analysis as often used in health technology assessment. Since the seminal 1977 article by Weinstein and Stason, the recommended approach has been the use of the incremental cost-effectiveness ratio based on the metric of the cost per quality-adjusted life-year gained, allowing comparisons across different technologies. An expanded framework, incorporating a wider range of the elements of value, is proposed. In addition to the core value drivers of health gain and other health system cost savings (if any), we propose adding other less recognized elements related to the value of knowing and informational externalities. We describe each of five factors related to the value of knowing: 1) a reduction in uncertainty, reflecting the benefit of a companion diagnostic increasing the certainty of a patient׳s response to a medicine; 2) insurance value related to greater peace of mind due to protection against catastrophic health and financial loss; 3) the value of hope for a "cure," leading individuals to become risk seekers in some circumstances; 4) real option value due to life extension opening possibilities for individuals to benefit from future innovation; and 5) spillovers or externalities arising from benefits of scientific advances that cannot be entirely appropriated by those making the advances. Further thought and research are needed on how best to measure and integrate these elements into an incremental value framework and on coverage and pricing decisions.