Reduce Health Care Expenditures Research Articles

Cost-Effectiveness of a Sublingual Bacterial Vaccine for the Prophylaxis of Recurrent Urinary Tract Infections

Introduction: Recurrent urinary tract infections (rUTIs) affect 5–10% of women, resulting in an enormous healthcare and society burden. Uromune® is a polybacterial sublingual vaccine with an excellent clinical benefit in rUTI prophylaxis. This study assesses the impact of sublingual vaccination on healthcare resource use and expenditures associated with this pathology. Methods: A quasi-experimental, pretest-posttest, single center study including women with rUTI and vaccinated with Uromune® in real-life clinical practice was performed. Variables were the need of healthcare resources, collected prospectively during two follow-up years, and the rUTI-associated expenditure, calculated using the micro-costing methodology; these were compared before and after vaccination. Results: A total of 166 women {mean (standard deviation [SD]) urinary tract infection episodes/year 6.19 (2.15)} were included. After vaccination, annual consultations with a primary care physician (PCP) (43.9%), emergency room visits (71.8%), urinary analysis (90.0%), and ultrasound exams (35.6%) decreased compared to pre-vaccination (all p < 0.001). Per patient consumption in antibiotics, PCP consultations, emergency room visits, and complementary exams significantly decreased (all p < 0.02), resulting in a reduction in healthcare expenditure per patient/year from mean (SD) 1,001.1 (655.0) to 497.1 (444.4) EUR. Conclusion: Sublingual bacterial vaccination with Uromune® decreased healthcare resource use and associated expenditure in women with rUTI, representing an optimal strategy to reduce rUTI-associated healthcare and economic burden.

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual.

Suicide rates have been steadily increasing in both the U.S. general population and military, with significant psychological and economic consequences. The purpose of the current study was to examine the economic costs and cost-benefit of the suicide-focused Collaborative Assessment and Management of Suicidality (CAMS) intervention versus enhanced treatment as usual (ETAU) in an active duty military sample using data from a recent randomized controlled trial of CAMS versus ETAU. The full intent-to-treat sample included 148 participants (mean age 26.8 years ± 5.9 SD years, 80% male, 53% White). Using a micro-costing approach, the cost of each condition was calculated at the individual level from a healthcare system perspective. Benefits were estimated at the individual level as cost savings in past-year healthcare expenditures based on direct care reimbursement rates. Cost-benefit was examined in the form of cost-benefit ratios and net benefit. Total costs, benefits, cost-benefit ratios, and net benefit were calculated and analyzed using general linear mixed modeling on multiply imputed datasets. Results indicated that treatment costs did not differ significantly between conditions; however, CAMS was found to produce significantly greater benefit in the form of decreased healthcare expenditures at 6-month follow-up. CAMS also demonstrated significantly greater cost-benefit ratios (i.e., benefit per dollar spent on treatment) and net-benefit (i.e., total benefit less the cost of treatment) at 12-month follow-up. The current study suggests that beyond its clinical effectiveness, CAMS may also convey potential economic advantages over usual care for the treatment of suicidal active duty service members. Our findings demonstrate cost savings in the form of reduced healthcare expenditures, which theoretically represent resources that can be reallocated toward other healthcare system needs, and thus lend support toward the overall value of CAMS.

Employee Perspectives on Onsite Health Clinics in Semiconductor Company in South Korea.

(1) Background: Onsite clinics are increasingly common features of corporate health promotion programs. These clinics allow employers to offer convenient care to employees at their workplaces, which can lead to reduced healthcare expenditure and improved productivity. The objective of this study was to build basic data by qualitatively exploring employees’ experiences and perspectives on onsite clinics in a semiconductor company, as one part of the project to examine and improve the health management system of a large semiconductor company in Korea. (2) Methods: This study adopted the methodology of “Consolidated Criteria for Reporting Qualitative Research” (COREQ-32 checklist). Semi-structured interviews were conducted for this study over a two-month period. For data analysis, a codebook was developed and the constant comparative method was used. (3) Results: Most employees perceived convenience and a sense of belonging as the benefits of onsite clinics, while barriers to the use of onsite clinics included a lack of communication, concerns about confidentiality, and a provider-centered system. Promotion of onsite clinic services and affiliated physicians, employee-centered service provisions, and trust-building in healthcare information privacy were considered necessary to strengthen the role of onsite clinics as a primary care provider in the workplace. (4) Conclusions: The results of this qualitative study help us to gain a better understanding of employees’ perspectives on the onsite clinic’s service and roles.

Access to health care and mental health—Evidence from the ACA preexisting conditions provision

This study evaluates the impact of the Affordable Care Act (ACA) preexisting conditions provision on mental health. The 2014 policy ensured individuals with preexisting health conditions the right to obtain insurance coverage. Using longitudinal data from the Panel Study of Income Dynamics between 2007 and 2017 and estimating difference-in-differences models, our study provides evidence that the policy reduced severe mental distress by 1.44 percentage points (baseline mean: 8.09%) among individuals with preexisting physical health conditions. Exploiting pre-ACA, state-level variation in policies providing insurance coverage options to people with preexisting conditions, we find that this improvement in mental well-being is highly associated with the presence of high-risk pools before 2014, which provided individuals with prior health conditions access to coverage. Specifically, we show that our main results are driven by individuals with preexisting health conditions living in the 16 states that did not have high-risk pools. Furthermore, gender-specific analysis shows that the reduction in mental distress is primarily observable among women. When examining potential mechanisms, our analysis provides evidence that increases in insurance coverage, reductions in healthcare expenditures, and improvements in physical health can explain the positive effects of the provision on mental well-being.

Telerehabilitation of acute musculoskeletal multi-disorders: prospective, single-arm, interventional study

BackgroundAcute musculoskeletal (MSK) pain is very common and associated with impaired productivity and high economic burden. Access to timely and personalized, evidence-based care is key to improve outcomes while reducing healthcare expenditure. Digital interventions can facilitate access and ensure care scalability.ObjectivePresent the feasibility and results of a fully remote digital care program (DCP) for acute MSK conditions affecting several body areas.MethodsInterventional single-arm study of individuals applying for digital care programs for acute MSK pain. Primary outcome was the mean change between baseline and end-of-program in self-reported Numerical Pain Rating Scale (NPRS) score and secondary outcomes were change in analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI-GH) and engagement.ResultsThree hundred forty-three patients started the program, of which 300 (87.5%) completed the program. Latent growth curve analysis (LGCA) revealed that changes in NPRS between baseline and end-of-program were both statistically (p < 0.001) and clinically significant: 64.3% reduction (mean − 2.9 points). Marked improvements were also noted in all secondary outcomes: 82% reduction in medication intake, 63% reduction in surgery intent, 40% in fear-avoidance beliefs, 54% in anxiety, 58% in depression and 79% recovery in overall productivity. All outcomes had steeper improvements in the first 4 weeks, which paralleled higher engagement in this period (3.6 vs 3.2 overall weekly sessions, p < 0.001). Mean patient satisfaction score was 8.7/10 (SD 1.26).Strengths and limitationsThis is the first longitudinal study demonstrating the feasibility of a DCP for patients with acute MSK conditions involving several body areas. Major strengths of this study are the large sample size, the wide range of MSK conditions studied, the breadth of outcomes measured, and the very high retention rate and adherence level. The major limitation regards to the absence of a control group.ConclusionsWe observed very high completion and engagement rates, as well as clinically relevant changes in all health-related outcomes and productivity recovery. We believe this DCP holds great potential in the delivery of effective and scalable MSK care.Trial registrationNCT, NCT04092946. Registered 17/09/2019;

ANALYSIS OF PATTERNS OF THE FINANCIAL SUPPORT OF THE HEALTH CARE SYSTEM IN UKRAINE UNDER DECENTRALIZATION REFORM AND THE COVID-19 PANDEMIC

In Ukraine, the coronavirus disease (COVID-19) pandemic partially overlapped in time with such critically important transformational processes as the second stage of the financial decentralization reform and the integration stage of the health care system reform. In this regard, the study of the main peculiarities of the change in the model of financial support of the health care system in Ukraine in these conditions, as well as the determination of which of these processes had the greatest impact on the volatility of the health care public expenditures, becomes relevant. The research involves the implementation of two stages - bibliometric analysis and statistical analysis. According to the results of the bibliometric analysis of Scopus publications concerning financial support of the health care system and COVID-19, six contextual clusters of scientific research were identified, focused on determining the impact of health care expenditures on the effectiveness of anti-coronavirus measures, age, gender, social and medical prerequisites and consequences of the spread of the COVID-19, relationship between the cost of medical services and outpatient treatment, socioeconomic, financial-economic and institutional prerequisites for ensuring the quality of the health care system and its resistance to shocks caused by the pandemic, key determinants, tools and measures to combat the spread of COVID-19. As part of the second block of bibliometric analysis, aimed at identifying the relationship between health care expenditures and decentralization reforms, five contextual clusters are identified, which are focused on the study of approaches and models to optimize health care expenditures taking into account socio-demographic factors and decentralization reform priorities, fiscal, economic and ecological determinants and factors of public health, age and geographical prerequisites that determine the peculiarities of the formation of the health care financing system, the influence of micro-financial and managerial prerequisites for financial assurance of the quality of the health care system I, effectiveness of insurance medicine. According to the results of the statistical analysis, it is established that during the period of active implementation of the financial decentralization reform (2015-2018), the share of health care expenditures in the State Budget of Ukraine was relatively stable and fluctuated within 2%, while in 2019 the share of this group of expenditures has been increased to the level of almost 3.6%. At the same time, there was a reduction in health care expenditures in the expenditures of local budgets of Ukraine: during 2015-2019, their share gradually decreased by 3-5% annually, and in 2020-2021, the reduction amounted to almost 33% and 45% to the level the previous year respectively. The specific weight of this group of expenditures in the Consolidated Budget of Ukraine is relatively stable (9–11.1%). In general, according to the results of the analysis, it can be noted that the reform of financial decentralization did not lead to a significant transformation of the structure of spending powers, while the medical reform and the COVID-19 pandemic caused a redistribution of the expenditure burden in the field of health care from the local to the state budget, although the specific weight of these expenses in the structure of the Consolidated Budget of Ukraine did not increase significantly even during the pandemic period.

Japanese anesthesiologists' knowledge of the cost of medicines and their attitudes toward cost containment: a cross-sectional survey.

Objectives: This study surveyed Japanese anesthesiologists’ knowledge of the cost of medicine and their attitudes toward cost containment to determine how these factors may affect their choice of medication and provide insight into reducing healthcare expenditures.Materials and Methods: In this cross-sectional study, Japanese anesthesiologists’ knowledge of medicine prices and their attitudes toward cost containment were surveyed to identify barriers in lowering the cost of anesthesia. The proportion of participants who correctly guessed the cost of the five most frequently used types of drugs within 25% of the actual price was determined, and their attitudes regarding drug prices and barriers to achieving cost containment were analyzed.Results: In total, responses to 60 questionnaires were analyzed. The proportion of participants correctly guessing the price within 25% of the actual price for each of the five drug categories, including neuromuscular blocking agents, inhaled anesthetics, intravenous anesthetics, opioids, and neuromuscular blockade reversal agents, was 30% (n=18), 18.3% (n=11), 6.67% (n=4), 30.0% (n=18), and 63.3% (n=38), respectively. Participants believed they had adequate access to information on prices, that the cost of a product influenced their decisions regarding product use, and that more information about cost might change their use of the drugs but did not believe that they had adequate knowledge about product prices.Conclusion: The proportion of participants with acceptable price estimates is small. Educating anesthesiologists about the cost of anesthetic agents may be required to encourage cost-containing behaviors. This study is the first survey to assess Japanese anesthologists’ knowledge of the cost of medicines.

Why Not Home?: A Study of the Impact of an Effort to Reduce Postacute Expenditures.

Accountable Care Organizations (ACOs) aiming to reduce healthcare expenditure adopt strategies targeting costly postacute service utilization, asking "why not home?" as a part of the hospital discharge planning paradigm. This study examined the impact of an interventional approach to implement evidence-based interventions to improve transitions of care to the least restrictive next site of care on the rate of skilled nursing facility (SNF) admissions per 1,000, SNF length of stay (LOS), and total SNF cost. The impact of the interventional approach for an ACO-attributed Medicare population, analyzing Medicare Shared Savings Plan Part A and Part B beneficiary claims data, was examined. A pre-/postintervention analysis was conducted, for dates of service 12 months pre- and postintervention for patients admitted to any hospital within the integrated health care system. The outcome variables were defined as SNF admission rate, SNF LOS, cost of care (total SNF cost, SNF cost per admission), and hospital LOS prior to SNF discharge. There was early evidence of the effectiveness of the multifaceted interventions that involved the delivery of interprofessional team member education focused on the tenets of value-based care and discharging patients to the least restrictive setting, as appropriate. In the normalized data review, it was noted that the rate of SNF discharges per 1,000 patients changed from 73 per 1,000 patients in the preintervention period to 70 per 1,000 patients in the postintervention period. The total SNF cost in the postintervention period only increased by 3%, with a difference of $616,014, despite the 10% increase in the total ACO-attributed patient population during the same period. The results of this study imply that a multifaceted intervention with aims to shift the transitional care planning paradigm toward discharging to the least restrictive next site of care is an effective strategy for ACOs with aspirations to improve the utilization and expenditure in the postacute setting. The analyses suggest that providing education to interprofessional team members that reinforces the tenets of value-based care and the importance of asking, "why not home?" for every hospitalized patient, and leveraging technology-based insights positively impact discharge rates to SNF and other ACO outcomes.

Disparity on Online Patient-Provider Communication and Implications for a Post-COVID Era

Older adults living with HIV/AIDS (OALWHA) in rural areas of the U.S. are a highly marginalized community. Intersectional stigma related to age, HIV status, geography, sexual orientation, gender identity, and race oftentimes create a complex lived experience for this population group. While there is a significant need for qualitative research that highlights the intersecting stigmas experienced by OALWHA in rural areas, recruitment challenges exist. Fear of being outed in their rural communities, due to their HIV status and LGBTQ+ identities, makes many OALWHA reluctant to participate in research. However, there is much resiliency in the population as well, especially during the COVID-19 pandemic. In fact, as research approaches have pivoted to phone/virtual data collection during the pandemic, this can help promote anonymity among this population group. This presentation will detail methodological considerations for recruitment, data collection, and analysis for qualitative research with OALWHA in rural areas of the U.S.

Minimally invasive microbiopsy for genetic profiling of melanocytic lesions: A case series

To the Editor: More than 90% of skin biopsies performed on lesions clinically suspicious for cutaneous melanoma are benign nevi.1 Novel tools are needed to improve diagnostic accuracy and to reduce health care expenditures related to screening. Here, we piloted the use of a micropunch biopsy (MPB) device, which allows submillimeter suture-free and painless sampling from skin lesions.2 Unlike adhesive tape stripping, which captures anucleate, nonviable cells from the superficial layers of the skin, MPB captures viable cells from the deeper tissue where cancers originate.

109. Develop and Implement a Novel Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children’s Hospital Located in an Adult-Centered Community Hospital in San Joaquin Valley, California

BackgroundA pediatric-specific antimicrobial stewardship program (Ped ASP) has been shown to optimize antimicrobial use, improve patient outcomes, and reduce healthcare expenditures in this population. Opportunities and challenges exist when developing a Ped ASP for a children’s hospital within an adult-centered medical center primarily due to mixed infrastructure. The objective of this study is to provide process and outcome data of a new Ped ASP in a non-freestanding children’s hospital within an adult-centered tertiary hospital.MethodsA pediatric infectious disease physician and four pediatric pharmacists designed a Ped ASP utilizing direct and indirect patient care activities to optimize pediatric antimicrobial use in 21 bed-pediatric services within a 685-bed, adult-centered medical center. Implemented in 2020, Ped ASP activities include thrice weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The Ped ASP team also developed policies, education, and other resources to further guide appropriate antimicrobial use, in collaboration with the adult team.ResultsPed ASP was initiated on general pediatric (PED) and pediatric intensive care (PICU) units. In 2020, a total of 286 charts were reviewed with 199 antibiotic interventions provided, including optimization of antimicrobial selection (23%), IV-to-PO conversion (15%), and antimicrobial dosage adjustment (13%). Annual average antibiotic length and days of therapy per 1000 patient-days were 241 and 290 respectively in PED, and 388 and 432 in PICU. The overall trend from 2020 to 2021 decreased in PED but increased in PICU (Fig. 1). The ratio of narrow to broad spectrum antibiotic use increased for both PED and PICU (Fig. 2). Simultaneously, a pediatric-specific antibiogram, extended-infusion protocol of beta-lactams, and neonatal sepsis treatment algorithm were developed and implemented. Antibiotic Days of Therapy per 1000 Patient Days Ratio of Narrow: Broad Spectrum Antibiotic UsageConclusionA Ped ASP was successfully developed in a non-freestanding children’s hospital. Continual metrics served as an important tool to identify areas for improvement. Future goals include expansion of Ped ASP to other service lines, enhanced ASP education and development of additional pediatric antimicrobial treatment pathways.Disclosures All Authors: No reported disclosures

Navigating the Evolving Landscape of the Dermatologic Workforce.

As dermatologists endeavor to meet growing patient demand, novel care models are transforming how the field is practiced. Physician extenders-which include physicians not board certified in dermatology, physician assistants, and nurse practitioners-can play a pivotal role in bridging health care disparities and reducing health care expenditures. Nevertheless, while the dermatologic workforce is adapting to evolving public needs, patient safety must remain the key priority when negotiating changes in scope of practice. Given that the current literature highlights concerning differences in diagnostic accuracy and procedural safety between different providers, further evidence is needed to help guide health care policies and care models.

Outcomes of Cytomegalovirus Monitoring in Autologous Transplantation: A Single Institution Experience

Introduction: Identification of patients seropositive for cytomegalovirus (CMV) prior to stem cell transplant (SCT) is a well-accepted practice across institutions designed to reduce a known cause of morbidity and mortality in this population, but the role of monitoring and preemptive approaches to CMV identification and treatment are controversial and not standardized in autologous transplantation. The preemptive approach necessitates the use of significant resources and requires persistent patient involvement. Patients undergoing autologous SCT are at a relatively low risk for CMV reactivation, especially those seronegative for CMV at the time of transplant. Here, we show that the necessity of routine monitoring of autologous transplant patients is of minimal clinical value.Methods: To determine the efficacy of the CMV monitoring protocol currently in place at our institution in detecting patients who would later develop CMV reactivation and disease following autologous SCT, we retrospectively analyzed the charts of 218 adult patients between 11/1/14 and 8/1/19 who underwent transplant at St. Louis University Hospital. No patients underwent CD34 selected stem cell infusions. The protocol stipulated the following: CMV IgG/IgM and CMV DNA PCR prior to preparative regimen followed by weekly CMV DNA PCR to day +30 . We correlated the predictive ability of positive results on any of these screening tests to identify whether patients would later develop quantifiable CMV DNA PCR positivity, clinical manifestations of CMV disease, and/or require pharmacologic treatment for CMV.Results: Quantifiable pre-BMT DNA PCR was positive in only 0.46% of patients, and 97.79% of patients were DNA PCR negative prior to transplant. CMV IgG was positive in 56.4% patients, and only 22.1% of patients in this group went on to develop a quantifiable post-transplant PCR. Of the remaining 43.6% of patients initially testing negative for CMV IgG, no patients went on to develop a quantifiably positive post-transplant PCR. Regardless of seropositivity, only 0.08% of the 1,191 PCRs performed during the study period were found to be quantifiable. Further, no patients in our cohort developed CMV disease or required CMV treatment during the monitoring period. This trend persisted despite stratification by age, diagnosis, transplant number, and preparative regimen.Conclusion: When clinically-significant CMV is defined by cases requiring treatment or the development of end-organ disease, no screening tests performed elicited clinical action. Laboratory-based CMV surveillance, based on our data, has minimal diagnostic implications and represents an overly-stringent practice in a set of patients already utilizing a substantial share of healthcare resources. We believe that pre-transplant screening for CMV IgM serology and CMV DNA PCR can be safely eliminated in the autologous SCT population at our institution while CMV IgG still plays a role in determining candidacy for CMV-negative blood products. We also propose the elimination of serial post-transplant monitoring with DNA PCR in patients without clinical signs, symptoms, or pathologic findings suggestive of CMV disease. We have changed the protocol to test for CMV PCR only if there are clinical scenarios that indicate a utility, such as prolonged fever post-transplant, unexplained cytopenias, or unexplained pneumonitis, colitis, or hepatitis. By extension, other centers should consider determining the necessity of CMV screening in their autologous transplant population given the potential resource conservation and reduction in healthcare expenditures. DisclosuresFesler: abbvie: Consultancy, Speakers Bureau; incyte: Consultancy, Speakers Bureau; sanofi: Speakers Bureau; morphosys: Speakers Bureau; epizyme: Consultancy; jazz: Consultancy; Skipta: Consultancy; Best Doctors: Consultancy; Aptitude Health: Consultancy; Care Dx: Consultancy; Opinionsite: Consultancy. Goldenberg: Seattle Genetics: Membership on an entity's Board of Directors or advisory committees.

Breaking the cycle: A public-private partnership to combat the American opioid epidemic

There has been an increased focus on the opioid epidemic in the United States, yet policy-based interventions such as prescription limits, restrictions on doctor shopping, and notification programs for high-volume prescribers have had no significant impact. In this paper, the authors explore a novel public health policy: a joint public-private partnership between the federal government and hospitals to establish long-term treatment centers for patients admitted to the emergency department after an overdose. These centers would provide medication for opioid use disorder, give individuals the necessary support for recovery, and reduce healthcare expenditures. Similar longitudinal strategies may be used in other areas of public health.

Is urban green space associated with lower mental healthcare expenditure?

IntroductionWhile the evidence of mental health benefits from investing in green space accumulates, claims of reduced healthcare expenditure are rarely supported by evidence from analyses of actual healthcare data. Additionally, the question of ‘who pays?’ has been ignored. We addressed these gaps using person-level data in three Australian cities. Methods55,339 participants with a mean follow-up time of 4.97 years in the Sax Institute's 45 and Up Study (wave 2, collected 2012–2015) were linked to fee-for-service records of antidepressant prescriptions and talking therapy subsidised by the Australian Government (including data on per unit fee, state subsidy, and individual co-payment). Total green space, tree canopy and open grass within 1.6 km road network distances were linked to each participant. Multilevel logistic, negative binomial, and generalised linear models with gamma distribution adjusted for demographic and socioeconomic confounders were used to assess association between each green space variable and prescribing/referral and costs of antidepressants and talking therapy. ResultsPrescription of at least one course of antidepressants occurred for 20.01% (n = 11,071). Referral for at least one session of talking therapy occurred in 8.95% (n = 4954). 13,482 participants (24.4%) had either a prescription or a referral. A 10% increase in green space was associated with higher levels of antidepressant prescribing (e.g. incident rate ratio (IRR) = 1.06, 95%CI = 1.04–1.08). Tree canopy was not associated with antidepressant prescribing or referrals for talking therapy. Open grass was associated with higher odds (OR = 1.17, 95%CI = 1.13–1.20) and counts (IRR = 1.05, 95%CI = 1.02–1.08) of antidepressant prescriptions. Open grass was also associated with lower odds (OR = 0.87, 95%CI = 0.82–0.92) and counts (IRR = 0.93, 95%CI = 0.90–0.96) of talking therapy referrals. Open grass was associated with higher total and mean per-person levels of expenditure on antidepressant prescriptions. ConclusionAlthough green space supports mental health, these unexpected results provide pause for reflection on whether greening strategies will always result in purported reductions in mental healthcare expenditure.

1235 A Multi-Site Review of Second Hip Fractures Across 6 Dublin Teaching Hospitals

Abstract Introduction Hip fractures are a common presentation to Irish hospitals with 3,701 hip fractures recorded by 16 hospitals in the Irish Hip Fracture Database (IHFD) in 2019. Second hip fractures (HF2) make up a significant proportion of hip fractures and represent an opportunity to prevent subsequent fragility fracture. Method Hip fracture datasheets from 2019 in six Dublin hospitals were analysed. Results 1,284 hip fractures in total were recorded in 2019 in these six hospitals. 112 of these were second hip fractures (8.72%). 24.1% of patients had a HF2 in year 1 post their first hip fracture (HF1). 14.3% of patients had a HF2 in Year 2, 8% in Year 3, 8.9% in Year 4 and 6.3% in Year 5. 17.9% of patients had an HF2 at an unknown time in relation to their HF1. 57.6% of all patients with any hip fracture were started on bone protection medications (BPMs) during their admission. 18.9% continued a pre-admission prescription. 7% of all patients were previously assessed and determined not to require BPM. 6.9% of patients were awaiting outpatient department (OPD) assessment for bone protection. 8.6% had no assessment for bone protection conducted. Of all patients with an HF2, 48.2% were started on BPMs on admission with their HF2. 33% continued BPMs started pre-admission. Discussion In 2019, approximately 1 in 10 hip fractures were second hip fractures. Evidence suggests that fracture liaison services represent a viable, economic means of preventing second hip fractures to improve patient outcomes and reduce healthcare expenditure.

Remote Patient Monitoring and Incentives to Support Smoking Cessation Among Pregnant and Postpartum Medicaid Members: Three Randomized Controlled Pilot Studies.

BackgroundSmoking rates among low-income individuals, including those eligible for Medicaid, have not shown the same decrease that is observed among high-income individuals. The rate of smoking among pregnant women enrolled in Medicaid is almost twice that among privately insured women, which leads to significant disparities in birth outcomes and a disproportionate cost burden placed on Medicaid. Several states have identified maternal smoking as a key target for improving birth outcomes and reducing health care expenditures; however, efficacious, cost-effective, and feasible cessation programs have been elusive.ObjectiveThis study aims to examine the feasibility, acceptability, and effectiveness of a smartwatch-enabled, incentive-based smoking cessation program for Medicaid-eligible pregnant smokers.MethodsPilot 1 included a randomized pilot study of smartwatch-enabled remote monitoring versus no remote monitoring for 12 weeks. Those in the intervention group also received the SmokeBeat program. Pilot 2 included a randomized pilot study of pay-to-wear versus pay-to-quit for 4 weeks. Those in a pay-to-wear program could earn daily incentives for wearing the smartwatch, whereas those in pay-to-quit program could earn daily incentives if they wore the smartwatch and abstained from smoking. Pilot 3, similar to pilot 2, had higher incentives and a duration of 3 weeks.ResultsFor pilot 1 (N=27), self-reported cigarettes per week among the intervention group declined by 15.1 (SD 27) cigarettes over the study; a similar reduction was observed in the control group with a decrease of 17.2 (SD 19) cigarettes. For pilot 2 (N=8), self-reported cigarettes per week among the pay-to-wear group decreased by 43 cigarettes (SD 12.6); a similar reduction was seen in the pay-to-quit group, with an average of 31 (SD 45.6) fewer cigarettes smoked per week. For pilot 3 (N=4), one participant in the pay-to-quit group abstained from smoking for the full study duration and received full incentives.ConclusionsDecreases in smoking were observed in both the control and intervention groups during all pilots. The use of the SmokeBeat program did not significantly improve cessation. The SmokeBeat program, remote cotinine testing, and remote delivery of financial incentives were considered feasible and acceptable. Implementation challenges remain for providing evidence-based cessation incentives to low-income pregnant smokers. The feasibility and acceptability of the SmokeBeat program were moderately high. Moreover, the feasibility and acceptability of remote cotinine testing and the remotely delivered contingent financial incentives were successful.Trial RegistrationClinicalTrials.gov NCT03209557; https://clinicaltrials.gov/ct2/show/NCT03209557.

Objective medication adherence and persistence in people with multiple sclerosis: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Medication adherence is critical for the realization of pharmacotherapy benefits and reduced healthcare expenditure. Studies have shown up to 60% of people with Multiple sclerosis (MS) experience suboptimal medication adherence, which is associated with poorer health outcomes and subsequent discontinuation. The current systematic review reported on objectively measured adherence and discontinuation rates for self-administered oral and injectable disease-modifying therapies (DMTs). OBJECTIVES: To identify whether, in people with MS, the introduction of oral DMTs has improved medication adherence when compared with injectable DMTs. The secondary aim was to report synthesized objectively measured medication adherence and persistence rates for both oral and injectable DMTs in MS across varying study durations. METHODS: Literature searches were conducted through PubMed, Web of Science, Scopus, and PsycINFO. Inclusion criteria were limited to English, peer-reviewed, objective, self-administered DMT articles, published between July 1993 to December 2019. Publications reporting combined intravenous and self-administered DMT data, or that did not account for DMT switching in discontinuation rates, were excluded. Data were synthesized into observation lengths ranging from less than 8 months to greater than 36 months. Meta-analysis and meta-regression were undertaken on both oral and injectable 12-month adherence and discontinuation data. RESULTS: In total, 61 articles were included; 46 articles examined adherence and 26 examined discontinuation. Twelve-month adherence ranged between 53.0% to 89.2% for oral (N = 7) and 47.0% to 77.4% for injectable DMTs (N = 7). Results from the meta-analysis and meta-regression show significantly higher pooled mean medication possession ratio (MPR) adherence for oral DMTs (91.0%) when compared to injectable DMTs (77.0%) over 12 months (β = -0.146; 95% CI: -0.263 to -0.029). Results indicate major asymmetry across studies (LFK index: -5.18), proposing the presence of significant publication bias. Mean discontinuation over 12 months was between 10.5% to 33.3% for oral (N = 7) and 15.2% to 50.8% for injectable DMTs (N = 10), with meta-analysis results indicating the presence of significant heterogeneity (I2 Injectable: 99.5%; I2 Oral: 93.1%) between studies included in each subgroup. However, no appreciable difference in mean discontinuation rates across groups (Injectable: 27%; 95% Cl: 19.0%-34.0%; Oral: 24%; 95% CI: 17.0%-31.0%) was found. CONCLUSIONS: Medication adherence for oral DMTs suggests a significant improvement compared to adherence for injectable DMTs. No significant difference in discontinuation rates between oral and injectable DMTs was found. Oral DMT adherence and persistence studies are limited, given their relatively recent introduction. Suboptimal medication adherence and discontinuation issues remain present for both oral and injectable DMTs. Future studies would benefit from improved consistency in methodology, such as comparable adherence and persistence definitions. DISCLOSURES: The authors did not receive any funding for this study. Mardan and Hussain have nothing to disclose. Grech reports grants from Merck Pharmaceutical, outside the submitted work. Allan reports grants received from Merck Pharmaceutical outside the submitted work. Allan holds advisory board and consulting positions with Merck and advisory board positions for Bristol Myers Squibb and Novartis, for which Monash Institute of Neurological Diseases receives consulting fees.

Long-term costs and cost-effectiveness of adjunctive corticosteroids for patients with septic shock in New Zealand

ObjectiveThe aim of the study was to determine whether adjunctive hydrocortisone reduced healthcare expenditure and was cost-effective compared with placebo in New Zealand patients in the Adjunctive Glucocorticoid Therapy in Patients with Septic Shock (ADRENAL) trial. DesignThis is a health economic analysis using data linkage to New Zealand Ministry of Health databases to determine resource use, costs, and cost-effectiveness for a 24-month period. SettingThe study was conducted in New Zealand. Participants and interventionPatients with septic shock were randomised to receive a 7-day continuous infusion of 200 mg of hydrocortisone or placebo in the ADRENAL trial. Main outcome measuresHealthcare expenditure was associated with all hospital admissions, emergency department presentations, outpatient visits, and pharmacy expenditure. Effectiveness outcomes included mortality at 6 months and 24 months and quality of life at 6 months. Cost-effectiveness outcomes were assessed with reference to quality-adjusted life years gained at 6 months and life years gained at 24 months. ResultsOf 3800 patients in the ADRENAL trial, 419 (11.0%) were eligible, and 405 (96.7% of those eligible) were included. The mean total costs per patient over 24 months were $143,627 ± 100,890 and $143,772 ± 97,117 for the hydrocortisone and placebo groups, respectively (p = 0.99). Intensive care unit costs for the index admission were $50,492 and $62,288 per patient for the hydrocortisone and placebo groups, respectively (p = 0.09). The mean number of quality-adjusted life years gained at 6 months and mean number of life years gained at 24 months was not significantly different by treatment group, and the probability of hydrocortisone being cost-effective was 55% at 24 months. ConclusionsIn New Zealand, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes compared with placebo in patients with septic shock.

A Community Partnership to House and Care for Complex Patients

Summary Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than do people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA beneficiaries gaining access to permanent supportive housing in a setting that allowed CCA and Hearth to monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. The authors' experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and that permanent supportive housing may contribute to meaningful reductions in health care expenditures.