Optimal Use Of Healthcare Resources Research Articles

Applying an Improved Stacking Ensemble Model to Predict the Mortality of ICU Patients with Heart Failure.

Cardiovascular diseases have been identified as one of the top three causes of death worldwide, with onset and deaths mostly due to heart failure (HF). In ICU, where patients with HF are at increased risk of death and consume significant medical resources, early and accurate prediction of the time of death for patients at high risk of death would enable them to receive appropriate and timely medical care. The data for this study were obtained from the MIMIC-III database, where we collected vital signs and tests for 6699 HF patient during the first 24 h of their first ICU admission. In order to predict the mortality of HF patients in ICUs more precisely, an integrated stacking model is proposed and applied in this paper. In the first stage of dataset classification, the datasets were subjected to first-level classifiers using RF, SVC, KNN, LGBM, Bagging, and Adaboost. Then, the fusion of these six classifier decisions was used to construct and optimize the stacked set of second-level classifiers. The results indicate that our model obtained an accuracy of 95.25% and AUROC of 82.55% in predicting the mortality rate of HF patients, which demonstrates the outstanding capability and efficiency of our method. In addition, the results of this study also revealed that platelets, glucose, and blood urea nitrogen were the clinical features that had the greatest impact on model prediction. The results of this analysis not only improve the understanding of patients' conditions by healthcare professionals but allow for a more optimal use of healthcare resources.

The cost effectiveness of lenvatinib versus atezolizumab and bevacizumab or sorafenib in patients with unresectable hepatocellular carcinoma (uHCC) in Canada.

4098 Background: Hepatocellular carcinoma (HCC) represents 72% of liver cancers in Canada. In the phase III REFLECT trial, lenvatinib met the primary endpoint of non-inferiority in overall survival (OS) versus sorafenib and demonstrated superiority in secondary endpoints of progression free-survival (PFS), time to progression and objective response rate. Based on the REFLECT trial, lenvatinib has become the standard of care in the treatment of Canadian patients with unresectable HCC (uHCC). In the Phase III IMbrave150 trial, the use of the combination of atezolizumab and bevacizumab (atezo+bev) resulted in statistically significant improvement in OS and PFS versus sorafenib for patients with uHCC. The aim of this analysis was to estimate the cost-effectiveness of lenvatinib versus atezo+bev or sorafenib as first-line treatment for patients with uHCC from the perspective of Ministry of Health in Canada. Methods: A cost-utility analysis was conducted using a partitioned survival analysis. Health state membership for lenvatinib and sorafenib were estimated based on patient level data and clinical inputs from REFLECT and extrapolated using parametric survival models. Relative efficacy for atezo+bev was estimated from a de novo network meta-analysis. In the base-case analysis, estimates from REFLECT used in the NMA were adjusted for imbalances in baseline characteristics. Sensitivity analyses included the use of alternative approaches to determine relative efficacy. Health state utility values were determined with EQ-5D data collected in REFLECT. Drug acquisition costs were obtained from publicly available sources and medical resource utilization was based on a survey of Canadian clinicians. The time horizon was 10 years. Results of the incremental analysis were calculated sequentially. Results: In the base case lenvatinib was associated with cost savings of CAD$4,640 and CAD$120,095 and a QALY difference of 0.15 and -0.28 vs sorafenib and atezo+bev, respectively. The base case deterministic analysis resulted in lenvatinib being dominant over sorafenib and cost-effective vs. atezo+bev (sequential ICER for atezo+bev was CAD$425,754 per QALY). Results of the probabilistic sensitivity analysis (PSA) were consistent with the base case findings with lenvatinib being the optimal treatment strategy in >99% of iterations. Conclusions: Results of this analysis demonstrate that lenvatinib represents the optimal use of healthcare resources as a first-line treatment for uHCC in Canada.

Most Important Factors for Deciding Rehabilitation Provision for Severe Stroke Survivors Post Hospital Discharge: A Study Protocol for a Best-Worst Scaling Experiment.

Efficient decision-making is crucial to ensure adequate rehabilitation with optimal use of healthcare resources. Establishing the factors associated with making decisions concerning rehabilitation provision is important to guide clinical staff towards person-centred decisions for rehabilitation after severe stroke. In this study we conduct a best–worst scaling (BWS) experiment to identify the most important factors and their relative weight of importance for deciding the type of ongoing rehabilitation services a person with severe stroke might receive post hospital discharge. Fractional, efficient designs are applied regarding the survey design. Key multidisciplinary staff regularly involved in making decisions for rehabilitation in a stroke unit will be recruited to participate in an online BWS survey. Hierarchical Bayes estimation will be used as the main analysis method, with the best–worst count analysis as a secondary analysis. The survey is currently being piloted prior to commencing the process of data collection. Results are expected by the end of September 2021. The research will add to the current literature on clinical decision-making in stroke rehabilitation. Findings will quantify the preferences of factors among key multi-disciplinary clinicians working in stroke units in the UK, involved in decision-making concerning rehabilitation after stroke.

Real-world treatment and health care resource use among severe asthma patients in Japan.

There are limited studies on healthcare resource use (HCRU) among adult asthma patients in Japan using real-world evidence, and analysis on acute treatment and associated costs stratified by disease severity is further limited. This study aimed to characterize the disease burden of severe asthma patients in Japan in terms of HCRU and comorbid medical conditions, with particular interest in oral corticosteroid (OCS) dependency. This retrospective cohort study of asthma patients used data from a claims database of diagnosis procedure combination hospitals in Japan. The severe asthma cohort included patients treated with OCS for more than 180 days in one year before the index date, with at least one asthma diagnosis claim. Comorbidity and drug use in the look-back period, HCRU, assumed OCS-related adverse events, and asthma exacerbations in the follow-up period were analyzed. Costs associated with the treatment of severe asthma were approximately twice that of mild/moderate asthma, and the annual median cost of patients hospitalized due to asthma reached ¥448,000 (USD $4073). Annual asthma exacerbation rate was higher in the severe asthma cohort than in the mild/moderate cohort. Patients with longer OCS use in the previous year had higher risks of secondary adrenal insufficiency, osteoporosis, and pneumonia in the following year. OCS use among asthma patients in Japan incurred greater medical and economic burden. Better understanding of the disease characteristics including the severity of asthma and appropriate management of disease burden will lead to more optimal use of healthcare resources in Japan.

Transanal minimally invasive surgery (TAMIS) versus endoscopic submucosal dissection (ESD) for resection of non-pedunculated rectal lesions (TRIASSIC study): study protocol of a European multicenter randomised controlled trial

BackgroundIn the recent years two innovative approaches have become available for minimally invasive en bloc resections of large non-pedunculated rectal lesions (polyps and early cancers). One is Transanal Minimally Invasive Surgery (TAMIS), the other is Endoscopic Submucosal Dissection (ESD). Both techniques are standard of care, but a direct randomised comparison is lacking. The choice between either of these procedures is dependent on local expertise or availability rather than evidence-based. The European Society for Endoscopy has recommended that a comparison between ESD and local surgical resection is needed to guide decision making for the optimal approach for the removal of large rectal lesions in Western countries. The aim of this study is to directly compare both procedures in a randomised setting with regard to effectiveness, safety and perceived patient burden.MethodsMulticenter randomised trial in 15 hospitals in the Netherlands. Patients with non-pedunculated lesions > 2 cm, where the bulk of the lesion is below 15 cm from the anal verge, will be randomised between either a TAMIS or an ESD procedure. Lesions judged to be deeply invasive by an expert panel will be excluded. The primary endpoint is the cumulative local recurrence rate at follow-up rectoscopy at 12 months. Secondary endpoints are: 1) Radical (R0-) resection rate; 2) Perceived burden and quality of life; 3) Cost effectiveness at 12 months; 4) Surgical referral rate at 12 months; 5) Complication rate; 6) Local recurrence rate at 6 months. For this non-inferiority trial, the total sample size of 198 is based on an expected local recurrence rate of 3% in the ESD group, 6% in the TAMIS group and considering a difference of less than 6% to be non-inferior.DiscussionThis is the first European randomised controlled trial comparing the effectiveness and safety of TAMIS and ESD for the en bloc resection of large non-pedunculated rectal lesions. This is important as the detection rate of these adenomas is expected to further increase with the introduction of colorectal screening programs throughout Europe. This study will therefore support an optimal use of healthcare resources in the future.Trial registrationNetherlands Trial Register, NL7083, 06 July 2018.

Willingness of patients to use unused medication returned to the pharmacy by another patient: a cross-sectional survey

ObjectivesRedispensing by pharmacies of medication unused by another patient could contribute to optimal use of healthcare resources. This study aimed to assess patient willingness to use medication returned by another...

Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis.

SummaryBackgroundThe high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources.ObjectivesTo gain insight in to the healthcare utilization of people with AK in a population‐based cohort, and the management of AK in a primary and secondary care setting.MethodsA retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow‐up of patients with AK in the Netherlands. Data sources consisted of a population‐based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System).ResultsIn the population‐based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin‐screening visit had no previous AK‐related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41–56%). Topical agents were the second most used treatment by dermatologists (13–21%) but were rarely applied in primary care (2%). During the first AK‐related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low‐ and high‐risk patients, which is inconsistent with the Dutch general practitioner guidelines for ‘suspicious skin lesions’ from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow‐up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years.Conclusions AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow‐up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor.The high prevalence of AK requires optimal use of healthcare resources.Nevertheless, (population based) AK healthcare utilization and management data are very rare. What does this study add? Although AK‐related care already consumes substantial resources, about 70% of the AK population has never received care.Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow‐up schedules were applied.This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care.

Evaluation of Health Literacy in Veteran Affairs Outpatient Population: A Focus on Patient Self-Perceived Health Status

Health literacy is of great importance for clinicians to maximize patient involvement and in the effective delivery of healthcare services. Health literacy driven health communication strategies may encourage appropriate and optimal use of healthcare resources and medications. We evaluated health literacy level in veterans with unique population demographics and focused on patient self-perceived health status (SPHS). Veterans (N=194) were enrolled in this cross-sectional study. Only 40% had poor or inadequate health literacy level. Older individuals displayed poorer health literacy level. 57.2% of the patients had good/above SPHS. Patients with good or above SPHS had 1.7 times higher (OR: 1.68, 95% CI=0.79-3.54) compared to patients with below good SPHS. Veterans with hospitalization were 11% less likely (OR=0.89) to report good or adequate health literacy level compared to those not hospitalized. Veterans with good or adequate health literacy level perceived their health status to be better than veterans with poor or inadequate health literacy. Using plain and simple language by providers while counseling patients about their disease and medications, might have a positive ripple effect on the current patient-centered care delivery. Clinicians could use a tailored approach to improve communication with patients.

An Automatic Health Monitoring System for Patients Suffering From Voice Complications in Smart Cities

Current evolutions in the Internet of Things and cloud computing make it believable to build smart cities and homes. Smart cities provide smart technologies to residents for the improved and healthier life, where smart healthcare systems cannot be ignored due to rapidly growing elderly people around the world. Smart healthcare systems can be cost-effective and helpful in the optimal use of healthcare resources. The voice is a primary source of communication and any complication in the production of voice affects the personal as well as professional life of a person. Early screening of voice through an automatic voice disorder detection system may save life of a person. In this paper, an automatic voice disorder detection system to monitor the resident of all age group and professional backgrounds is implemented. The proposed system detects the voice disorder by determining the source signal from the speech through the linear prediction analysis. The analysis calculates the features from normal and disordered subjects. Based on these features, the spectrum is computed, which provided distribution of energy in normal and voice disordered subjects to differentiate between them. It is found that lower frequencies from 1 to 1562 Hz contributes significantly in the detection of voice disorders. The system is developed by using sustained vowel and running speech so that it can be deployed in a real world. The obtained accuracy for the detection of voice disorder with the sustained vowel is 99.94% ± 0.1, and that is for running speech is 99.75% ± 0.8.

"Tailoring" Hematopoietic Progenitor Cell Collection: Impact of a Data-Driven Prediction Algorithm for Blood Volume Processing in Large Volume Leukapheresis

Background:The predominant source of hematopoietic progenitor cells (HPCs) for hematopoietic stem cell transplantation (HSCT) is peripheral blood (PB). HPCs are collected for HSCT using large volume leukapheresis (LVL) that typically involves processing >4 blood volumes to ensure adequate yield of HPCs. LVL is time-intensive, causes volume overload and hypocalcemia, and in small children, requires prolonged sedation. The purpose of this quality improvement project was to assess whether a collection efficiency-based, data-driven prediction algorithm for HPC collection can meaningfully decease the volume of blood processed in well-mobilized patients.MethodsWe evaluated the CD34+ cellular collection efficiency 2 (CE2; see below) in 240 consecutive adult autologous (A-auto), 59 adult allogeneic (A-allo), and 23 pediatric autologous (P-auto) collections ("training set"). In the training set, mean (1SD) CD34+ CE2s in A-auto, A-allo and P-auto collections were 47% (16%), 51% (14%), and 59% (32%), respectively (Fig. 1).CD34 Collection Efficiency 2 (CE2) was calculated as below:CD34+ CE2= CD34+ yield/[BVP x Precollection PB CD34 count]Blood Volume to be processed (BVP) was calculated as below:BVP= CD34+ cell target/ [CD34+ CE2 x Precollection PB CD34+ count]In order to have a high level of confidence that the targeted dose of CD34+ cells will be collected with implementation of the prediction formula, the CD34+ CE2 was set at the 3rd percentile (30%) in the A-auto group, and lowest attained CD34+ CE2 in the A-allo (30%) and P-auto groups (25%) for the A-auto, A-allo and P-auto prediction formulae, respectively. These CD34+ CE2s were used to calculate the BVP in a large cohort of consecutive patients from Froedtert Memorial Lutheran Hospital and the Children's Hospital Wisconsin which included 461 A-Auto, 90 A-Allo and 16 P-Auto collections over a period of 16 months (2/2015- 5/2016). Data was collected from both prediction-driven truncated and standard non-truncated LVLs and comparisons were made with regards to blood volume processed, duration of LVL, financial impact and time to neutrophil and platelet engraftment.ResultsAfter implementation of the BVP prediction formula, 91 truncations were performed in 42 (9%), 41 (46%) and 8 (50%) of 461 A-auto, 90 A-allo and 16 P-auto collections, respectively, representing an overall truncation rate of 16% (Fig. 2). Of the 91 total procedures truncated, 4 procedures (all A-Auto) failed to reach the CD34+ collection target, however, cell yields were extremely close to targets and were not deemed to be prediction failures (Table 1). In truncated LVL procedures, reduction in volume of blood processed was 34% overall, with average decreased processing of 31%, 36% and 46% (of 4 blood volumes) in A-auto, A-allo and P-auto collections, respectively (Fig. 3). The average time for a randomly selected group of 20 standard 4BV collections was 4 hr 49 mins. A 34% truncation in BVP would result in the procedure concluding 1 hr 38 mins earlier and this prediction formula based intervention is predicted to save on average $132 per patient ($35/hr Nursing time; $25/hr Cell Processing technologist time, and 35% overhead) and total savings of $12,039 over 91 truncated procedures during the 16 month period assessed. Median neutrophil and platelet engraftment were not significantly different in autologous HSCT patients with truncated vs. non-truncated procedures (10 days each for neutrophil engraftment, and 20 days vs. 19 days in truncated vs. non-truncated procedures for platelet engraftment).ConclusionThe use of a data-driven HPC prediction algorithm resulted in the truncation of 16% of all LVL procedures. The volume of truncation was significant in most cases and did not adversely impact the ability to collect the desired number of stem cells and resulted in comparable neutrophil and platelet engraftment time. This approach may be particularly important in mitigating risks of LVL in populations with higher concern for adverse events such as children, and patients with poor tolerance for LVL-induced volume overload. Finally, in our experience, this approach has resulted in enhancing patient satisfaction associated with shorter procedures and promotes optimal use of healthcare resources by limiting costs. [Display omitted] DisclosuresPadmanabhan:Bloodcenter of Wisconsin: Patents & Royalties: A patent application has been filed on a Method of detecting platelet activating antibodies that cause heparin-induced thrombocytopenia/thrombosis; PCT/US14/62591; Terumo BCT: Consultancy, Honoraria; Schlesinger & Associates: Consultancy, Honoraria; LEK Consulting: Consultancy, Honoraria; Mallinckrodt Pharmaceuticals: Consultancy, Honoraria; Fenwal (Fresenius Kabi): Research Funding.

Renal safety with pamidronate (PAM) 1-hour infusion for metastatic breast cancer (MBC) and multiple myeloma (MM): A multi-centre, population-based analysis

6042 Background: ASCO guidelines recommend PAM be infused over 2 hours to avoid renal deterioration (RD). BCCA recommends 1-hr PAM infusions based on safety from two case series, one randomized controlled trial (RCT) (ASCO 1999 abstract 2223) and one retrospective analysis (ASCO 2002 abstract 208). Longer PAM infusions can affect the optimal use of healthcare resources. Methods: Prevalence of RD (≥ 2 times baseline serum creatinine [SCr)]) with 1-hr PAM infusions between Jan 2000-Dec 2002 from the BCCA registry and systemic therapy drug database was compared to that with 2-hr PAM infusions in RCTs. A cost-minimization analysis comparing the 1- and 2-hr PAM infusions and the 15-minute infusion of zoledronic acid (ZA) was performed with a sensitivity analysis that varied the opportunity cost of time in the treatment room. Results: RD occurred in 10.4% of 144 patients: 15.5% (13/87) in MM, 3.5% (2/57) in MBC. There is no evidence that this differs from the 10% reported in RCTs (one-tailed binomial test, p=0.4741). Increase in SCr was not normally distributed: median increase = 14% in MM and 13% in MBC patients, respectively. The respective costs/dose (drug/labour/supplies) of PAM and ZA are $325 and $610CDN. Cost neutrality occurs if the opportunity cost of chair time is $6.33/min for PAM 1-hr vs ZA and $2.71/min for PAM 2-hr vs ZA. If a median $4/min is used, the respective costs of PAM 1-hr, 2-hr, and ZA infusions become: $685, $790, and $925. Conclusions: Prevalence of RD with 1-hr PAM infusions from a population database was not different than that with 2-hr PAM infusions in RCTs. Our findings further support the safety of 1-hr PAM infusions. PAM via 1-hr infusion is less expensive than ZA. No significant financial relationships to disclose.

Renal safety with pamidronate (PAM) 1-hour infusion for metastatic breast cancer (MBC) and multiple myeloma (MM): A multi-centre, population-based analysis

6042 Background: ASCO guidelines recommend PAM be infused over 2 hours to avoid renal deterioration (RD). BCCA recommends 1-hr PAM infusions based on safety from two case series, one randomized controlled trial (RCT) (ASCO 1999 abstract 2223) and one retrospective analysis (ASCO 2002 abstract 208). Longer PAM infusions can affect the optimal use of healthcare resources. Methods: Prevalence of RD (≥ 2 times baseline serum creatinine [SCr)]) with 1-hr PAM infusions between Jan 2000-Dec 2002 from the BCCA registry and systemic therapy drug database was compared to that with 2-hr PAM infusions in RCTs. A cost-minimization analysis comparing the 1- and 2-hr PAM infusions and the 15-minute infusion of zoledronic acid (ZA) was performed with a sensitivity analysis that varied the opportunity cost of time in the treatment room. Results: RD occurred in 10.4% of 144 patients: 15.5% (13/87) in MM, 3.5% (2/57) in MBC. There is no evidence that this differs from the 10% reported in RCTs (one-tailed binomial test, p=0.4741). Increase in SCr was not normally distributed: median increase = 14% in MM and 13% in MBC patients, respectively. The respective costs/dose (drug/labour/supplies) of PAM and ZA are $325 and $610CDN. Cost neutrality occurs if the opportunity cost of chair time is $6.33/min for PAM 1-hr vs ZA and $2.71/min for PAM 2-hr vs ZA. If a median $4/min is used, the respective costs of PAM 1-hr, 2-hr, and ZA infusions become: $685, $790, and $925. Conclusions: Prevalence of RD with 1-hr PAM infusions from a population database was not different than that with 2-hr PAM infusions in RCTs. Our findings further support the safety of 1-hr PAM infusions. PAM via 1-hr infusion is less expensive than ZA. No significant financial relationships to disclose.