Reduced Health Care Resource Utilization Research Articles

Clinical Implications

HomeHypertensionVol. 61, No. 2Clinical Implications Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBClinical Implications Originally published1 Feb 2013https://doi.org/10.1161/HYP.0b013e318284b8b8Hypertension. 2013;61:267Autoantibodies in Primary Aldosteronism (page 526)Primary aldosteronism (PA) is the most frequent endocrine cause of hypertension. The differential diagnosis between its 2 main subtypes, for example—aldosterone-producing adenoma and idiopathic hyperaldosteronism, is the key for selecting surgical or medical treatment, but challenging.In this study, we detected autoantibodies against the AT1 receptor (AT1AA) at a raised titer in serum of PA patients, and particularly in those with an aldosterone-producing adenoma as compared with those with idiopathic hyperaldosteronism or essential hypertension with similar blood pressure (BP) elevation. Of clinical relevance, the AT1AA titer provided a discrimination of aldosterone-producing adenoma from idiopathic hyperaldosteronism, thus suggesting that the AT1AA titer can help in selecting the PA patients to be submitted to adrenal vein sampling. The latter test, which is expensive, invasive, and not widely available, is recommended by the Endocrine Society Guidelines in all patients who are candidates for adrenalectomy.Finally, the mechanisms underlying PA have eluded identification thus far notwithstanding a long quest. As these AT1AA are suggested to play an agonistic effect, including stimulation of aldosterone secretion, their presence in aldosterone-producing adenoma patients could explain the persistent over-secretion of aldosterone in spite of the high BP, the suppression of the renin-angiotensin system and the hypokalemia, all factors that would be expected to blunt aldosterone secretion. Hence our data might shed a new light on the pathophysiology of PA.Download figureDownload PowerPointRenal Denervation and Sympathetic Activity (page title>Autoantibodies in Primary Aldosteronism (page 457)Catheter-based renal denervation has emerged as a novel treatment option for patients with resistant hypertension. The limited number of studies available thus far suggest that the procedure is safe and results in a significant and sustained BP reduction in the majority of treated patients with resistant hypertension. Although ablation of efferent renal nerves, as evident form a mean reduction in renal noradrenaline spillover of 47%, is likely to contribute to the BP lowering effects via alteration of renin release, renal blood flow, and tubular sodium retention, inhibition of central sympathetic outflow has also been documented by applying multiunit muscle sympathetic nerve activity recordings.Here, we examined whether renal denervation may differentially influence the sympathetic discharge pattern of single vasoconstrictor neurons in patients with resistant hypertension and found that all properties of single-unit muscle sympathetic nerve activity, including firing rates of individual vasoconstrictor fibers, firing probability, and multiple firing incidence of single units within a cardiac cycle, were substantially reduced. These findings indicate that renal denervation may restrain abnormal patterns of sympathetic nerve firing commonly evident in patients with resistant hypertension and exhibit renal signaling via afferent nerves projecting to certain brain stem nuclei as a likely contributor to the BP rise in resistant hypertension.Download figureDownload PowerPointCombination Therapy, CV Events, and BP Control (page Sympathetic Activity (page title>Autoantibodies in Primary Aldosteronism (page 309)Combination therapy is required to achieve current BP targets in ≈75% of hypertensive patients. Previous studies indicate that initial use of a combination accelerates the time course over which BP control is attained. However, the optimal time frame for achieving BP control in clinical practice has never been defined, and criteria for using initial combination therapy remain uncertain. In a retrospective, matched cohort study, the impact of initial versus delayed combination therapy on the risk of developing a cardiovascular (CV) event was assessed in a community practice setting. The mean baseline BP was ≈150/85 mm Hg, and two thirds had stage I hypertension. Initial combination treatment led to more rapid and more effective BP control and was associated with a 34% risk reduction for CV events or death relative to patients initiated on monotherapy and subsequently uptitrated to combination treatment by their practicing physicians. Fewer patients who experienced a CV event achieved target BP, and on-treatment BP parameters accounted for most of the difference in CV event rates.Initial combination therapy was also associated with a significant reduction in healthcare resource utilization. These results suggest that combination therapy should be initiated routinely in most patients likely to require multiple agents to reach goal BP, and that initial combination therapy is a superior treatment strategy for a large segment of the hypertensive population including many patients with mild hypertension.Download figureDownload PowerPoint Previous Back to top Next FiguresReferencesRelatedDetails February 2013Vol 61, Issue 2 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/HYP.0b013e318284b8b8 Originally publishedFebruary 1, 2013 PDF download Advertisement

Community-Based Palliative Care: The Natural Evolution for Palliative Care Delivery in the U.S.

Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care—those at home (including nursing homes) but not yet ready for hospice—unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).

Cost Comparison of Linezolid Versus Vancomycin for Treatment of Complicated Skin and Skin-Structure Infection Caused by Methicillin-ResistantStaphylococcus aureusin Quebec

In Canada, complicated skin and skin-structure infection (cSSSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is usually treated with antibiotics in hospital, with a follow-up course at home for stable patients. The cost implications of using intravenous and oral linezolid instead of intravenous vancomycin in Canadian clinical practice have not been examined. To evaluate the potential treatment cost impact for the Quebec health care system of linezolid versus vancomycin for MRSA-related cSSSI therapy, using a net impact analysis approach. Health care resource use associated with linezolid and vancomycin therapy was estimated for patients in Quebec, based on expert opinion. Costs were assigned to health care resources (antibiotics, medical supplies, laboratory testing and health care professional time) based on unit prices. The base-case analysis assumed 14 days of antibiotic treatment for both agents; five days in hospital followed by nine days at home. Therapy duration, length of inpatient treatment and discharge rates were varied in sensitivity analyses. Antibiotic costs were higher for linezolid than for vancomycin, for both inpatient ($874 versus $144, respectively) and outpatient therapy ($1,356 versus $1,242, respectively). Compared with vancomycin, lower costs for antibiotic preparation, administration and monitoring of linezolid offset drug acquisition costs. Total treatment costs were $3,850 for linezolid versus $5,189 for vancomycin. Results were sensitive to the number of treatment days spent at home and the discharge rate. Using linezolid instead of vancomycin to treat MRSA-related cSSSI, for hospital and home courses combined, may reduce health care resource utilization and costs in Quebec.

P-147 - A comparative cost-analysis of initiating pregabalin or SSRI/SNRI therapy in benzodiazepine resistant patients with generalized anxiety disorder

To compare healthcare costs from the perspective of the Spanish National Healthcare System (NHS) of initiating treatment with pregabalin or SSRI/SNRI as add-on therapies in patients with generalized anxiety disorder (GAD), who are resistant to benzodiazepine-based therapy (BR). BR patients with GAD (DSM-IV criteria) included in a prospective, multicentre, observational cohort study carried out in outpatients attending mental health centers, were selected in this post-hoc analysis. BR was defined as insufficient response with persistence of symptoms of anxiety (HAM-Anxiety scale≥ 16) after a 6-month course of BR (standard dose). Healthcare resource utilization (HRU) associated with GAD included drug treatments, medical visits, hospitalization and non-pharmacologic therapies which were collected twice (baseline and end-of-trial visits) during a 6-month period. Related costs were estimated in each visit and adjusted changes between visits compared using ANCOVA models. A total of 128 patients received pregabalin and 126 SSRI/SNRI. Compared with SSRI/SNRI, pregabalin was associated with significantly lower adjusted mean increment use of anxiolytics; 0.55 vs. 1.12, p < 0.001, and greater reduction in medical visits; −15.12 vs.−12.99, p = 0.029. Mean adjusted healthcare costs were significantly decreased in both medication cohorts; −€289: pregabalin (p = 0.003) and −€95 (p = 0.052) with SSRI/SNRI. Drug acquisition costs for SSRI/SNRI were lower than pregabalin, however adjusted healthcare cost reduction was numerically higher with pregabalin; −€289 versus −€194, p = 0.488. Initiating treatment with pregabalin was associated with significant reduction in HRU and total cost for GAD compared to SSRI/SNRI in BR patients in the Spanish NHS setting.

Comparative Net Cost Impact of the Utilization of Romiplostim and Intravenous Immunoglobulin for the Treatment of Patients with Immune Thrombocytopenia in Quebec,

Abstract 4211 Background:Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by increased platelet destruction and suboptimal platelet production, which results in low platelet counts and mild to severe bleeding. Bleeding events may range from petechiae and purpura to severe intracranial and gastrointestinal haemorrhage. Approximately 5% of adult ITP patients suffer from a fatal bleeding event. However, the risk of severe, fatal bleeding is significantly higher for patients who are unresponsive or intolerant to current therapies, over the age of 60 years, or refractory to splenectomy. The prevalence of diagnosed cases of chronic ITP in the overall population in Canada is reported to be 20.3 per 100,000; thus, it is estimated that there are about 160,000 people in Quebec with chronic ITP.Therapeutic management of ITP include the use of corticosteroids, immunosuppressive agents, and intravenous immunoglobulins (IVIg). IVIg is an expensive and occasionally scarce blood product. Surgical management includes splenectomy. Most recently, thrombopoietin (TPO) mimetic agents such as romiplostim and eltrombopag have been used to treat ITP.Romiplostim is indicated in Canada to increase the platelet levels in adult patients with chronic immune (idiopathic) thrombocytopenic purpura: •Who are non splenectomized and have had an inadequate response or are intolerant to corticosteroids and/or immunoglobulin; •Who are splenectomized and have had an inadequate response to splenectomy.Romiplostim does not have public reimbursement in the province of Quebec. Although the public drug program expert review acknowledged the benefit of romiplostim in substantially reducing the use of IVIg, the reviewers did not recognize the use of IVIg as a maintenance therapy. The objective of this study was to conduct a net cost analysis to determine if using romiplostim instead of IVIg can result in savings to the provincial health care budget in Quebec. Methods:A net cost impact model was developed to provide a detailed analysis of the cost implications of romiplostim utilization compared with IVIg, including the drug treatment costs, costs related to the preparation and administration of medications, monitoring costs, and indirect costs such as patients' time away from usual activities or work. Expert consultation with physicians, pharmacists and nurses in Quebec was used to define treatment algorithms including all health resource utilization required when using romiplostim and IVIg. Costs were assigned to direct (e.g., drugs, medical supplies, laboratory testing, healthcare professionals' time) and indirect (e.g., productivity) healthcare resources. Results:Based on the median weekly dose (3mcg/kg) observed in the pivotal romiplostim clinical trial in splenectomised patients, the annual cost of romiplostim per patient was $47,244. The annual per patient cost of IVIg was $114,548 based on an average dose suggested by a clinical expert (1g/kg every 4 weeks and average administration time of 3.5 hours). Lower costs for drug preparation and administration ($284 vs. $1355) and less time lost from work (valued at $447 vs. $2141) were attributed to romiplostim compared to IVIg. The time attributed to monitoring was the same for both romiplostim and IVIg ($115). The total average annual per patient costs including medication, drug administration, monitoring and lost productivity for romiplostim vs. IVIg were, respectively, $48,090 and $118,159. The use of romiplostim would save, on average, about $70,069 per patient per year. Conclusion:From a societal perspective, treating ITP patients with romiplostim can provide a lower cost alternative to IVIg for the overall provincial healthcare budget. Compared with IVIg, the use of romiplostim results in lower direct costs, reduced health care resource utilization and less indirect costs. As a precious commodity, blood products must be used wisely. As stated by the expert review committee in Quebec, IVIg should remain a last resort option to treat ITP. Romiplostim can allow for improved healthcare resource allocation by reserving IVIg for use in other areas of greater need while also providing cost savings. Romiplostim also potentially improves patients' quality of life by reducing the time required for drug infusion and avoids the risks associated with IV administration. Disclosures:Pettigrew:Amgen Canada Inc.: Consultancy. Deuson:Amgen: Employment, Equity Ownership. Garces:Amgen Canada: Employment, Equity Ownership.

Costs and Health Resources Utilization Following Switching to Pregabalin in Individuals with Gabapentin‐Refractory Neuropathic Pain: A post hoc Analysis

To analyze the changes in pain severity and associated costs resulting from resource utilization and reduced productivity in patients with gabapentin-refractory peripheral neuropathic pain who switched to pregabalin therapy in primary care settings in Spain. This is a post hoc analysis of a 12-week, multicentre, noninterventional cost-of-illness study. Patients were included in the study if they were over 18 years of age and had a diagnosis of chronic, treatment-refractory peripheral neuropathic pain. The analysis included all pregabalin-naïve patients who had previously shown an inadequate response to gabapentin and switched to pregabalin. Severity of pain before and after treatment with pregabalin, alone or as an add-on therapy, was assessed using the Short-Form McGill Pain Questionnaire (SF-MPQ) and its related visual analogue scale (VA). Healthcare resource utilization, productivity (including lost-workday equivalents [LWDE]), and related costs were assessed at baseline and after pregabalin treatment. A total of 174 patients switched to pregabalin had significant and clinically relevant reductions in pain severity (mean [SD] change on SF-MPQ VA scale, -31.9 [22.1]; P < 0.05 vs. baseline; effect size, 1.87). Reduction in pain was similar with both pregabalin monotherapy and add-on therapy. Significant reductions in healthcare resource utilization (concomitant drug use [in pregabalin add-on group], ancillary tests, and unscheduled medical visits) were observed at the end of trial. Additionally, there were substantial improvements in productivity, including a reduction in the number of LWDE following pregabalin treatment (-18.9 [26.0]; P < 0.0001). These changes correlated with substantial reductions in both direct (-652.9 ± 1622.4 €; P < 0.0001) and indirect healthcare costs (-851.6 [1259.6] €; P < 0.0001). The cost of care in patients with gabapentin-refractory peripheral neuropathic pain appeared to be significantly reduced after switching to pregabalin treatment, alone or in combination with other analgesic drugs, in a real-life setting.

Pentavalent Rotavirus Vaccine in Developing Countries: Safety and Health Care Resource Utilization

In the international, placebo-controlled, Rotavirus Efficacy and Safety Trial, the pentavalent rotavirus vaccine reduced the rate of rotavirus-attributable hospitalizations and emergency department visits by 95%. This study investigated the effect in Jamaica. The vaccine effect on rates of hospitalizations and emergency department visits in Jamaica was evaluated in both modified intention-to-treat and per-protocol analyses. Rates of serious adverse events, including intussusception, also were compared between groups. A total of 1804 Jamaican infants, 6 to 12 weeks of age at entry and primarily from low/middle-income families of African heritage, received ≥1 dose. During the first year after dose 1, there were 2 and 11 hospitalizations or emergency department visits attributable to rotavirus gastroenteritis involving any serotype among 831 evaluable vaccine recipients and 809 evaluable placebo recipients, respectively (rate reduction: 82.2% [95% confidence interval: 15.1%-98.0%]). In the per-protocol analysis, all 8 G1 to G4 rotavirus-attributable events that occurred ≥2 weeks after dose 3 were in the placebo group (rate reduction: 100% [95% confidence interval: 40.9%-100%]). Of the 1802 subjects included in the safety analyses, intussusception was confirmed for 1 vaccine recipient (115 days after the third dose) and 3 placebo recipients. One vaccine recipient and 3 placebo recipients died during the follow-up period, but none of the deaths was considered to be vaccine-related. In this posthoc subgroup analysis, the vaccine reduced health care resource utilization attributable to rotavirus gastroenteritis, without increased risk of intussusception or other serious adverse events, among infants in a resource-limited country.

Treatment of COPD: Relationships between daily dosing frequency, adherence, resource use, and costs

Medication adherence is important in managing COPD. This study analyzed real-world use of inhaled medications for COPD to characterize relationships between daily dosing frequency, adherence, healthcare resource utilization, and cost. This retrospective study used a large administrative claims database covering 8 million insured lives in the US from 1999 to 2006. Patients were stratified based on the recommended daily dosing frequency of their first COPD drug claim following COPD diagnosis. Adherence was measured using proportion of days covered (PDC) over 12 months following treatment initiation. Healthcare resource use included inpatient, outpatient, and emergency room visits. A multivariate regression model assessed the relationship between adherence and one-year healthcare resource use, controlling for demographics, comorbidities, and baseline resource use. Unit healthcare costs were obtained from the 2005 Medical Expenditure Panel Survey, adjusted to 2008 dollars. Based on a sample of 55,076 COPD patients, adherence was strongly correlated with dosing frequency. PDC was 43.3%, 37.0%, 30.2% and 23.0% for QD, BID, TID, and QID patient cohorts, respectively. Regression analysis showed that one-year adherence was correlated with healthcare resource utilization. For 1000 COPD patients, a 5% point increase in PDC reduced the annual number of inpatient visits (-2.5%) and emergency room visits (-1.8%) and slightly increased outpatient visits (+.2%); the net reduction in annual cost was approximately $300,000. COPD patients who initiated treatment with once-daily dosing had significantly higher adherence than other daily dosing frequencies. Better treatment adherence was found to yield reductions in healthcare resource utilization and cost.

Promotion of the mind through exercise (PROMoTE): a proof-of-concept randomized controlled trial of aerobic exercise training in older adults with vascular cognitive impairment

BackgroundSub-cortical vascular ischaemia is the second most common etiology contributing to cognitive impairment in older adults, and is frequently under-diagnosed and under-treated. Although evidence is mounting that exercise has benefits for cognitive function among seniors, very few randomized controlled trials of exercise have been conducted in populations at high-risk for progression to dementia. Aerobic-based exercise training may be of specific benefit in delaying the progression of cognitive decline among seniors with vascular cognitive impairment by reducing key vascular risk factors associated with metabolic syndrome. Thus, we aim to carry out a proof-of-concept single-blinded randomized controlled trial primarily designed to provide preliminary evidence of efficacy aerobic-based exercise training program on cognitive and everyday function among older adults with mild sub-cortical ischaemic vascular cognitive impairment.Methods/DesignA proof-of-concept single-blinded randomized trial comparing a six-month, thrice-weekly, aerobic-based exercise training group with usual care on cognitive and everyday function. Seventy older adults who meet the diagnostic criteria for sub-cortical ischaemic vascular cognitive impairment as outlined by Erkinjuntti and colleagues will be recruited from a memory clinic of a metropolitan hospital. The aerobic-based exercise training will last for 6 months. Participants will be followed for an additional six months after the cessation of exercise training.DiscussionThis research will be an important first step in quantifying the effect of an exercise intervention on cognitive and daily function among seniors with sub-cortical ischaemic vascular cognitive impairment, a recognized risk state for progression to dementia. Exercise has the potential to be an effective, inexpensive, and accessible intervention strategy with minimal adverse effects. Reducing the rate of cognitive decline among seniors with sub-cortical ischaemic vascular cognitive impairment could preserve independent functioning and health related quality of life in this population. This, in turn, could lead to reduced health care resource utilization costs and avoidance of early institutional care.Trial RegistrationClinicalTrials.gov Protocol Registration System: NCT01027858.

Patient-Reported Outcomes and Health-Care Resource Utilization in Patients with Psoriasis Treated with Etanercept: Continuous versus Interrupted Treatment

Objective The 24-week Etanercept Assessment of Safety and Effectiveness (EASE) study evaluated the effectiveness and tolerability of continuous versus interrupted etanercept treatment in patients with moderate to severe plaque psoriasis. The objective of this analysis was to assess patient-reported outcomes (PROs) and health-care resource utilization (HRU) data from the EASE study. Methods Patients received open-label etanercept 50 mg twice weekly for 12 weeks and then received either continued or interrupted (single round of discontinuation and re-treatment with etanercept) etanercept 50 mg once weekly for the second 12 weeks. PROs included the following: 1) the patient global assessments of psoriasis, joint pain, and itching scores; 2) the Dermatology Life Quality Index; 3) the Medical Outcomes Study Short Form 36 vitality domain; 4) the Beck Depression Inventory; 5) the European Quality-of-Life Group Feeling Thermometer; and 6) a patient satisfactionsurvey. HRU was evaluated using the Economic Implications of Psoriasis patient questionnaire. Results Continuous treatment with etanercept 50 mg twice weekly for 12 weeks followed by 50 mg once weekly for 12 weeks produced sustained and clinically important improvements in PROs and reductions in HRU. Reductions in some outcome measures after treatment discontinuation at week 12 were observed in the interrupted group; however, most changes did not revert to baseline levels, consistent with some residual clinical effect, and re-treatment produced improvements similar to week 12 levels. Conclusions Continuous etanercept treatment provided greater sustained improvements in PROs than interrupted therapy; however, interrupting etanercept therapy, if needed, has predictable and manageable effects.

Psoriatic arthritis patients treated with etanercept had reductions in healthcare resource utilization—Results from the experience diagnosing, understanding care, and treatment with enbrel (educate) trial

Psoriatic arthritis patients treated with etanercept had reductions in healthcare resource utilization—Results from the experience diagnosing, understanding care, and treatment with enbrel (educate) trial

Does supportive-expressive group therapy for metastatic breast cancer patients lower health care services resource utilization

6052 Background: Metastatic breast cancer is associated with psychological distress, which, in other diseases has been associated with higher health care resource utilization. We hypothesized that a psychosocial intervention in metastatic breast cancer will reduce health care resource utilization. Methods: Goodwin et al. reported results of a randomized controlled trial of supportive expressive group support in metastatic breast cancer (NEJM 2001;345:1719–1726). The intervention did not impact survival or quality of life (EORTC QLQ-C30) but it improved total mood disturbance (Profile of Mood States -POMS, range −32 to 200) and perception of pain (10 cm VAS). Resource utilization data were collected prospectively (data from 3 of the largest centers were used). Costing was done at 2 tertiary care U of Toronto hospitals in $2001 (Canadian) using the perspective of the health care system. A cost-minimization analysis was conducted as the primary analysis; secondarily, a cost-effectiveness analysis (CEA) was conducted for mood and perception of pain to identify costs associated with an improvement equal to 10% of the range of the scale (23.2 POMS, 1.0 cm pain VAS), an effect size considered clinically significant. Results: Average health care utilization costs for the intervention group were $25,537 +/- $21,059 and for the control group $22,461 +/- $18,686 (p = 0.43). A sensitivity analysis, of +/- 20% of hospitalization and chemotherapy costs (the two largest costs) resulted in no significant differences between groups. The CEA for POMS showed the intervention group incurred incremental costs of $6,205 per 23.2 points POMS improvement; the incremental cost per 1.0 cm VAS increase in perception of pain was $3076. Conclusions: Supportive-expressive group therapy in metastatic breast cancer does not lower health care resource utilization. Costs associated with clinically significant beneficial effects on mood and perception of pain were acceptable. No significant financial relationships to disclose.

Does supportive-expressive group therapy for metastatic breast cancer patients lower health care services resource utilization

6052 Background: Metastatic breast cancer is associated with psychological distress, which, in other diseases has been associated with higher health care resource utilization. We hypothesized that a psychosocial intervention in metastatic breast cancer will reduce health care resource utilization. Methods: Goodwin et al. reported results of a randomized controlled trial of supportive expressive group support in metastatic breast cancer (NEJM 2001;345:1719–1726). The intervention did not impact survival or quality of life (EORTC QLQ-C30) but it improved total mood disturbance (Profile of Mood States -POMS, range −32 to 200) and perception of pain (10 cm VAS). Resource utilization data were collected prospectively (data from 3 of the largest centers were used). Costing was done at 2 tertiary care U of Toronto hospitals in $2001 (Canadian) using the perspective of the health care system. A cost-minimization analysis was conducted as the primary analysis; secondarily, a cost-effectiveness analysis (CEA) was conducted for mood and perception of pain to identify costs associated with an improvement equal to 10% of the range of the scale (23.2 POMS, 1.0 cm pain VAS), an effect size considered clinically significant. Results: Average health care utilization costs for the intervention group were $25,537 +/- $21,059 and for the control group $22,461 +/- $18,686 (p = 0.43). A sensitivity analysis, of +/- 20% of hospitalization and chemotherapy costs (the two largest costs) resulted in no significant differences between groups. The CEA for POMS showed the intervention group incurred incremental costs of $6,205 per 23.2 points POMS improvement; the incremental cost per 1.0 cm VAS increase in perception of pain was $3076. Conclusions: Supportive-expressive group therapy in metastatic breast cancer does not lower health care resource utilization. Costs associated with clinically significant beneficial effects on mood and perception of pain were acceptable. No significant financial relationships to disclose.

Examination of resource use and clinical interventions associated with chronic kidney disease in a managed care population.

The management of chronic kidney disease (CKD) is multifaceted, including monitoring, early diagnosis, and treatment of comorbidities such as diabetes, hypoalbuminemia, and anemia, and initiating timely procedures in preparation for dialysis such as vascular access placement. Presumably, optimal care provided to patients during the predialysis phase will produce a significant impact on morbidity and mortality outcomes. A retrospective analysis was conducted to assess specific factors that may be associated with optimal quality of care for CKD patients during the predialysis phase. Health care resource utilization and the occurrence of interventions associated with optimal predialysis care were evaluated with claims data. Predialysis erythropoietin (EPO) therapy, nephrology referrals, and nutritional supplement administration were all examined during the 12 months prior to dialysis. Medical and pharmacy claims from a managed care database were analyzed for 1,936 incident dialysis patients. Of these, 48.7% did not have any interventions associated with optimal care. Only a minority of patients received prescription iron preparations (6.8%), vitamin D (4.0%), and phosphate binders (7.7%). A total of 20.8% patients had a vascular access placement, and 29.8% were in the care of a nephrologist during this same time period. Only 10.5% received predialysis EPO, yet more than 40% were diagnosed with anemia. Of the EPO users, however, 72.4% were also receiving other interventions to appropriately manage CKD. These claims-documented results suggest that the lack of EPO use in predialysis patients in a managed care plan may predict overall suboptimal treatment of these patients. There is an apparent need for the proactive management of CKD in a managed care plan to potentially redistribute or reduce health care resource utilization while improving patient outcomes.

The high cost of syncope: Cost implications of a new insertable loop recorder in the investigation of recurrent syncope

Background Patients with recurrent syncope frequently undergo extensive investigations that consume significant health care resources. Recent advances in long-term monitoring techniques have enhanced diagnostic yield in patients with infrequent symptoms. There is little information on the relative cost-effective profile of the investigative tools used in patients with syncope. Methods Two methods to determine health care costs in patients with syncope were used. In the first, health care resource utilization was determined in 24 patients with recurrent unexplained syncope and negative investigations who underwent insertion of the implantable loop recorder (ILR) during a pilot study of the feasibility of the device. The costs of investigations before, during, and after ILR implantation in each patient were calculated on the basis of median charges for an index investigation and a regression analysis of 1018 US Medicare hospital claims for syncope from 1993. Charges were converted to costs using a cost-to-charge ratio of 0.64. The second method was based on estimated costs per diagnosis and published diagnostic yields of 6 commonly applied tests in patients with syncope. A cohort simulation using theoretic models of 100 patients undergoing investigation for syncope was created to compare the diagnostic yield and cost per diagnosis of various diagnostic cascades. Results In the pilot study, the cost of investigation of syncope in the 2 years before ILR insertion was $7584 per patient. After the ILR was inserted, a diagnosis was obtained in 21 of 24 patients (diagnostic yield 88%). The cost of therapy was $2452, followed by a reduction in cost of care to $596 over 30 ± 10 months of follow-up. In the second method, the diagnostic yield of individual tests ranged from 3% for echocardiography to 88% for the ILR. The cost per diagnosis obtained ranged from $529 for the external loop recorder to $73,260 for electrophysiologic testing in patients without structural heart disease. An approach to syncope similar to that of the ILR pilot study resulted in a cost per diagnosis of $3193 and a diagnostic yield of 98%. Performance of echocardiography in half of the patients and electrophysiologic testing only in the presence of structural heart disease reduced the cost to $2494 and retained a diagnostic yield of 98%. Conclusions The cost of investigation of syncope is high. The ILR may reduce health care resource utilization by providing a diagnosis permitting definitive therapy. The cost per diagnosis profile of current diagnostic tests commonly used in patients with syncope is highly variable. A cost-effective approach to diagnosing this disorder can retain a high diagnostic yield with a reduction in resource utilization compared with a conventional approach. (Am Heart J 1999;137:870-7.)