Health Cost Savings Research Articles

Targeting housing mobility vouchers to help families with children.

Targeting housing mobility vouchers to help families with children.

Climate Change Mitigation: Assessing Strategies that Offer Potential Human Health Benefits

Climate change mitigation strategies, including efforts to reduce greenhouse gas emissions, are not specifically designed to improve human health but could potentially do so anyway.1,2 A review in this issue of EHP critically examines different models for estimating these so-called co-benefits and highlights improvements that could help assess which mitigation strategies are the most promising for both climate and human health.1 Mitigation strategies to reduce greenhouse gas emissions include shifting from fossil fuels to renewable energy sources, reducing energy use and waste, and improving transportation options.3 These strategies may also reduce air pollution, improve water quality, and promote physical activity.1,2,3 Characterizing the potential scope and scale of these health co-benefits can help policy makers prioritize mitigation actions against a backdrop of finite time and resources. Table 1 Examples of Mitigation Strategies and Selected Co-Benefits/Co-Harms (adapted from Remais et al.1) In constructing models to estimate co-benefits, experts must consider which health factors to include and how sensitive they are to mitigation actions. They must also consider key methodological issues such as sources of uncertainty and the possibility that some mitigation actions may be accompanied by low-probability events with highly adverse health impacts (e.g., a nuclear power plant disaster). These hypotheticals are challenging to characterize and quantify. Modelers also must interpret the results, for example, by using discount rates—complex calculations that convert anticipated future intervention costs, impacts on the climate, adverse health effects, and health cost savings, to their present-day value. “Discount rates are central to all decisions with long-term implications, and the co-benefits of mitigation activities have multiple costs and benefits distributed over time,” says lead author Justin Remais, an associate professor in environmental health at Emory University. “We need to consistently account for the relative value of near-term versus long-term benefits and costs.” But choosing an appropriate discount rate is challenging because it is based on a number of unknowns, including future generations’ wealth. The rate must also accommodate the social values of the current generation—for instance, how much people are willing to sacrifice their own comfort for an uncertain benefit to their descendents. Discount rates currently are not applied consistently across co-benefit models, something the authors recommend changing. They also suggest that policy makers be involved from the outset in developing models. Finally, they recommend that co-benefits modelers evaluate mitigation strategies on the basis of many criteria simultaneously, including not just health and climate impacts but also economic growth and political acceptability. “[This review] is a logical extension of the earlier range-finding papers published in The Lancet several years ago,2 featuring the health co-benefits idea and the related public health and economics arguments,” says Anthony McMichael, professor emeritus at the National Centre for Epidemiology and Population Health, Australian National University, who was not involved in the study. “The discounting issue is particularly important and will make a great difference to the estimated longer-term cost-benefits,” he says. McMichael also highlights inclusion of water impacts and potential health co-harms as welcome additions to models, although uncertainties continue to be a problematic, yet unavoidable issue. The need for rigorous co-benefits research and modeling is increasingly urgent because many significant mitigation policy decisions will be made worldwide in the next decade. “Policy makers need relevant, credible, and useful information regarding potential health impacts to inform these decisions,” Remais says. “Models that estimate the health co-benefits and co-harms of mitigation strategies can play a key role.”

Chronic Subdural Hematoma Management

To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients. Current management strategies of CSDHs remain widely controversial. Treatment options vary from medical therapy and bedside procedures to major operative techniques. We searched MEDLINE (PubMed and Ovid), EMBASE, CINAHL, Google scholar, and the Cochrane library from January 1970 through February 2013 for randomized and observational studies reporting one or more outcome following the management of symptomatic patients with CSDH. Independent reviewers evaluated the quality of studies and abstracted the data on the safety and efficacy of percutaneous bedside twist-drill drainage, single or multiple operating room burr holes, craniotomy, corticosteroids as a main or adjuvant therapy, use of drains, irrigation of the hematoma cavity, bed rest, and treatment of recurrences following CSDH management. Mortality, morbidity, cure, and recurrence rates were examined for each management option. Randomized, prospective, retrospective, and overall observational studies were analyzed separately. Pooled estimates, confidence intervals (CIs), and relative risks (RRs) were calculated for all outcomes using a random-effects model. A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized, and the remaining 234 were observational. We included our unpublished single center series of 834 patients. When comparing percutaneous bedside drainage to operating room burr hole evacuation, there was no significant difference in mortality (RR, 0.69; 95% CI, 0.46-1.05; P = 0.09), morbidity (RR, 0.45; 95% CI, 0.2-1.01; P = 0.05), cure (RR, 1.05; 95% CI, 0.98-1.11; P = 0.15), and recurrence rates (RR, 1; 95% CI, 0.66-1.52; P = 0.99). Higher morbidity was associated with the adjuvant use of corticosteroids (RR, 1.97; 95% CI, 1.54-2.45; P = 0.005), with no significant improvement in recurrence and cure rates. The use of drains following CSDH drainage resulted in a significant decrease in recurrences (RR, 0.46; 95% CI, 0.27-0.76; P = 0.002). Craniotomy was associated with higher complication rates if considered initially (RR, 1.39; 95% CI, 1.04-1.74; P = 0.01); however, craniotomy was superior to minimally invasive procedures in the management of recurrences (RR, 0.22; 95% CI, 0.05-0.85; P = 0.003). Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic.

Functional Foods, Health Benefits and Health Claims

The growing burden of health care cost remains a key policy issue. The potential effects on public health care costs of increasing the consumption of functional foods in diets through the ability to make new health claims is of major policy relevance. However, there are also multiple potential market failures associated with functional foods. This paper outlines a number of issues and market failures related to the consumption and production of healthier foods, including labelling of health claims. The paper also evaluates the potential magnitude of health-related cost savings by allowing new health claims, using the example of “soluble fibre from certain foods (barley and psyllium) and coronary heart disease” and “soy protein and coronary heart disease” health claims. The preliminary results suggest that an increased consumption of functional food due to new health claims could result in significant health cost savings. Despite this, the existence of production and consumption externalities could result in an inefficient outcome rather than the socially optimal level of consumption of foods with health benefits. Policy implications are discussed.

Evidence Matters Fall 2013

The feature article, “Aging in Place: Facilitating Choice and Independence,” reviews the trends underpinning the issue and looks at the federal, state, and local programs and policies for the elderly that are accommodating a shift away from institutional living and toward aging in place with supports. The Research Spotlight article, “Measuring the Costs and Savings of Aging in Place,” examines efforts to measure the potential health cost savings (as well as improvements in well-being) to families and the government when individuals are able to age in their homes with assistance, reinforcing the argument that housing matters. Finally, grassroots efforts to aid the elderly in their communities and provide practical solutions for the supportive services necessary to age in place are examined in the In Practice article, “Community-Centered Solutions for Aging at Home.” Readers may find that the issues involved in creating aging-friendly communities have much in common with the issues involved in building livable communities, such as the role that density and transit systems can play in providing access to neighborhood amenities.

Health Benefits of Reducing Sugar-Sweetened Beverage Intake in High Risk Populations of California: Results from the Cardiovascular Disease (CVD) Policy Model

BackgroundConsumption of sugar-sweetened beverage (SSB) has risen over the past two decades, with over 10 million Californians drinking one or more SSB per day. High SSB intake is associated with risk of type 2 diabetes, obesity, hypertension, and coronary heart disease (CHD). Reduction of SSB intake and the potential impact on health outcomes in California and among racial, ethnic, and low-income sub-groups has not been quantified.MethodsWe projected the impact of reduced SSB consumption on health outcomes among all Californians and California subpopulations from 2013 to 2022. We used the CVD Policy Model – CA, an established computer simulation of diabetes and heart disease adapted to California. We modeled a reduction in SSB intake by 10–20% as has been projected to result from proposed penny-per-ounce excise tax on SSB and modeled varying effects of this reduction on health parameters including body mass index, blood pressure, and diabetes risk. We projected avoided cases of diabetes and CHD, and associated health care cost savings in 2012 US dollars.ResultsOver the next decade, a 10–20% SSB consumption reduction is projected to result in a 1.8–3.4% decline in the new cases of diabetes and an additional drop of 0.5–1% in incident CHD cases and 0.5–0.9% in total myocardial infarctions. The greatest reductions are expected in African Americans, Mexican Americans, and those with limited income regardless of race and ethnicity. This reduction in SSB consumption is projected to yield $320–620 million in medical cost savings associated with diabetes cases averted and an additional savings of $14–27 million in diabetes-related CHD costs avoided.ConclusionsA reduction of SSB consumption could yield substantial population health benefits and cost savings for California. In particular, racial, ethnic, and low-income subgroups of California could reap the greatest health benefits.

Health benefits of adapting cleaner brick manufacturing technologies in Dhaka, Bangladesh

A total of 1,000 kilns producing 3.5 billion bricks and consuming 0.85 million tons of coal per year resulted in an estimated 2,200 to 4,000 premature deaths and 0.2 to 0.5 million asthma attacks per year in the Greater Dhaka region. In this paper, the emission reductions and health cost savings are presented for moving to cleaner brick manufacturing technologies for the districts of Gazipur, Savar, Dhamrai, Rupganj, Manikganj, Kaliganj, and Narayanganj. A summary of various technologies and feasibility of these technologies based on lessons learnt from the pilots is discussed. We explored three “what-if” scenarios through 2020 for better energy efficiency, lower coal consumption, and lower emission rates, under which the total health cost savings are estimated to range between USD12 million annually for short-term implementation and up to 55 million annually for long-term implementation. Between 2015 and 2020, the cumulative health cost savings could range between USD126 and 234 million, which clearly outweigh any cost of capital investment necessary for the technology change. An improvement in energy efficiency will result in USD1.8 to 3.0 million per year in coal savings, which will accrue to the kiln owners collectively, and these savings will pay back the capital investment within 3–4 years, in addition to the health cost savings for the city inhabitants. Hence, the entrepreneurs have all the social, environmental, and economic incentives to adopt cleaner technologies. A major gap at the regulatory level is in building awareness for the entrepreneurs and setting up an incentive structure to implement this transition, which is being addressed by an advisory committee by the Government of Bangladesh responsible for the revision of the Brick Burning Act of 1989 and related legislations.

UK population salt reduction: an experiment in public health

BackgroundThe UK has implemented a programme of voluntary salt reduction in collaboration with the food industry, which has resulted in a fall in salt intake in the population. We undertook a comprehensive analysis of the programme with the aim of providing a simple step-by-step guide for development and implementation of a national salt reduction programme that other countries could follow. MethodsWe identified several key components of the UK salt reduction programme by reviewing (1) the documents archived by Consensus Action on Salt and Health (CASH) on the UK salt reduction policy, (2) journal and press articles, and (3) relevant websites. The main elements of the UK programme include (1) setting up of an action group with strong leadership and scientific credibility; (2) establishing salt intake by measuring 24-h urinary sodium in a random sample of the population and identifying the major sources of salt by dietary record; (3) setting a salt intake target for the population and developing a salt-reduction strategy; (4) setting progressively lower voluntary salt targets for over 80 categories of food, with a clear timeframe for the industry to achieve these targets; (5) working and engaging with the food industry to encourage reformulation of food to contain less salt to meet these targets; (6) introducing clear labelling of salt content in food; (7) undertaking consumer awareness campaigns; (8) monitoring progress by (a) frequent surveys and media publicity of salt content in food, including naming and shaming, and (b) repeated 24-h urinary sodium measurement at 3–5-year intervals; and (9) applying pressure through media exposure with a potential threat of regulation by the Department of Health. FindingsThe outcome of the successful implementation of the UK salt reduction programme is shown in four areas. First, product surveys over the years showed substantial reductions in the salt content in food; for example, a 20% reduction in the salt content of bread from 2001 to 2011. Second, there was an increase in consumers' awareness of the dangers of salt and an increase in the number of individuals trying to cut down on salt, with a decrease in salt use at the table and a reduction in table and cooking salt sales. Third, the mean salt intake in the population as measured by 24-h urinary sodium fell from 9·5 g per day to 8·1 g per day (15% reduction; p<0·05) during the 7 years since the salt reduction programme began in 2003–04. Fourth, the reduction in salt intake achieved in the UK was estimated to prevent about 9000 cardiovascular deaths a year, saving the UK economy more than £1·5 billion per annum. A limitation of our study was the absence of a control group. InterpretationThe UK salt reduction programme reduced the salt intake of the whole population by gradual reformulation on a voluntary basis, reinforced by strong political pressure. Several countries are already following the UK's lead. The challenge now is to spread this policy out to all other countries around the world with appropriate local modifications. A reduction in salt intake worldwide would result in major public health improvements and cost savings. FundingNone.

Salt reduction in the United Kingdom: a successful experiment in public health

The United Kingdom has successfully implemented a salt reduction programme. We carried out a comprehensive analysis of the programme with an aim of providing a step-by-step guide of developing and implementing a national salt reduction strategy, which other countries could follow. The key components include (1) setting up an action group with strong leadership and scientific credibility; (2) determining salt intake by measuring 24-h urinary sodium, identifying the sources of salt by dietary record; (3) setting a target for population salt intake and developing a salt reduction strategy; (4) setting progressively lower salt targets for different categories of food, with a clear time frame for the industry to achieve; (5) working with the industry to reformulate food with less salt; (6) engaging and recruiting of ministerial support and potential threat of regulation by the Department of Health (DH); (7) clear nutritional labelling; (8) consumer awareness campaign; and (9) monitoring progress by (a) frequent surveys and media publicity of salt content in food, including naming and shaming, (b) repeated 24-h urinary sodium at 3-5 year intervals. Since the salt reduction programme started in 2003/2004, significant progress has been made as demonstrated by the reductions in salt content in many processed food and a 15% reduction in 24-h urinary sodium over 7 years (from 9.5 to 8.1 g per day, P<0.05). The UK salt reduction programme reduced the population's salt intake by gradual reformulation on a voluntary basis. Several countries are following the United Kingdom's lead. The challenge now is to engage other countries with appropriate local modifications. A reduction in salt intake worldwide will result in major public health improvements and cost savings.

Pressure care: prevention is better than a cure

418 British Journal of Healthcare Management 2013 Vol 19 No 9 © 2 01 3 M A H ea lth ca re L td components of a successful approach that can be adopted across all NHS trusts. Staff emphasised that highquality patient care is the overarching goal when reducing pressure care injuries. This can be achieved in several ways; prevention, innovation and collaboration. Pressure ulcer prevention is better than cure. Early intervention with proven, clinically effective equipment is absolutely vital as it can take only minutes for an at-risk patient to develop a pressure ulcer. Case studies have demonstrated that using innovative equipment for pressure area care can result in health service efficiencies, reduced incidence and cost savings into the hundreds of thousands of pounds for NHS trusts. Moving beyond prevention, innovation and collaboration have key roles to play in this area and it is time for suppliers to work more closely— and in a different way—with the NHS. Challenging economic times often inspire new ways of working, and there is a real opportunity for new types of industry partnership models designed to deliver tangible change. Creative thinking and procurement can enable trusts to benefit not only from cutting-edge pressure care technology, but also from the savings that can result from new ways of working. For example, ‘partnership design’ models, whereby suppliers and purchasers join together to design and sell products, is an effective way to generate revenue for NHS trusts. While this represents a radical departure from the traditional model, by combining suppliers’ technical know-how with clinical expertise, effective partnerships can improve patient care and build cost savings. The long-term outcome of developing more innovative partnerships will be that trusts can deliver the clinical outcomes necessary to effect real change; reducing the number of reported pressure injury cases, saving millions of pounds and freeing up beds. To achieve this, the NHS needs to explore new ways of working with suppliers. Carrying out an internal assessment of current methods and costs may encourage them to review alternative ways of managing pressure area care. Engaging those on the front line is crucial, and discussions with tissue viability nurses and other relevant staff members can help inform innovative strategies. With the NHS facing some of the biggest economic challenges in its 65-year history, embracing a fresh approach and new ways of working with its supplier base will be absolutely fundamental if we are to achieve the step change required to make it a sustainable service fit for future generations. BJHCM Graham Ewart, medical device specialist, argues that partnerships between the NHS and suppliers will become vital in easing the financial burden posed by pressure care to NHS trusts Pressure care: prevention is better than a cure

Cost-effectiveness of Bariatric Surgery

Bariatric surgery is probably more efficacious than medical or lifestyle intervention for long-term weight loss and remission of diabetes. The ability of bariatric surgery to reduce expenditures sufficiently to achieve cost savings remains hotly debated, and in 2 early studies, it appeared cost-saving over a relatively short period of time.1,2 More recent studies,3,4 including an analysis of 29 820 BlueCross BlueShield enrollees published in the June issue of JAMA Surgery,5 show no evidence of cost savings. These results are consistent with prior cost-effectiveness evaluations6,7 that demonstrated cost-effectiveness—but not cost savings—for bariatric procedures compared with usual medical care or intensive lifestyle interventions. Still, a critical policy question remains unanswered: does bariatric surgery need to be cost-effective (ie, more effective but more costly than usual care), or does it need to achieve the higher standard of cost savings (ie, more effective and less costly than usual care) to justify broader insurance coverage? Because bariatric surgery is so expensive, it is unlikely to achieve a cost-saving threshold for most eligible patients. Roux-en-Y gastric bypass (RYGB) costs $25 000 to $30 000 for the surgical admission (including the cost of the procedure and immediate preoperative, intraoperative, and postoperative services), and laparoscopic adjustable gastric banding (LAGB) costs $15 000 to $20 000.5 Annual health care costs for patients with a body mass index (BMI) of 35 or greater are $3000 to $10 000 per year.4,5 Even if total expenditures are reduced 50% after surgery, it may take up to 20 years to achieve cost neutrality. There is a need to identify whether certain bariatric procedures or patient subgroups have greater potential for health improvements and cost savings to inform insurance coverage decisions about bariatric procedures.

Who Pays for the Health Benefits of Exclusive Breastfeeding? An Analysis of Maternal Time Costs

The benefits of exclusive breastfeeding, including public health cost savings, are widely recognized, but breastfeeding requires maternal time investments. This study investigates the time taken to exclusively breastfeed at 6 months compared with not exclusively breastfeeding. Time use data were examined from an Australian survey of new mothers conducted during 2005-2006. Data from 139 mothers with infants age 6 months were analyzed using chi-square tests of independence to examine socioeconomic and demographic characteristics and 2-sided t tests to compare average weekly hours spent on milk feeding, feeding solids, preparing feeds, and the total of these. The comparison was of exclusively breastfeeding mothers with other mothers. We also compared exclusively breastfeeding with partially breastfeeding and formula feeding mothers using a 1-way between-groups analysis of variance (ANOVA). The exclusively breastfeeding (vs other) mothers spent 7 hours extra weekly on milk feeding their infants but 2 hours less feeding solids. These differences were statistically significant. ANOVA revealed significant differences between exclusively breastfeeding mothers, breastfeeding mothers who had introduced solids, and mothers who fed any formula, in time spent feeding milk, and solids, and preparing feeds. Exclusive breastfeeding is time intensive, which is economically costly to women. This may contribute to premature weaning for women who are time-stressed, lack household help from family, or cannot afford paid help. Gaining public health benefits of exclusive breastfeeding requires strategies to share maternal lactation costs more widely, such as additional help with housework or caring for children, enhanced leave, and workplace lactation breaks and suitable child care.

The economic impact of early intervention in psychosis services for children and adolescents

To develop and populate a plausible model of the impact of early intervention (EI) for children and adolescents with psychosis to estimate potential short-term health-related cost savings compared to generic Child and Adolescent Mental Health Services (CAMHS). A decision-tree-based model for EI in CAMHS was developed. The model was populated using data relating to the use of inpatient care and EI service activity for people aged under 18 from an area of North East England. Data were abstracted from the National Health Service clinical reporting systems for 2001-2008. Sensitivity analyses were performed to examine costs associated with the model under differing assumptions. EI delivered cost savings of £4814 per patient compared to care provided by generic CAMHS. Cost savings were predominantly a consequence of reduced length of hospital admissions for patients served by the EI team. The findings were robust to sensitivity analyses. These findings suggest that EI services for children and adolescents with psychosis provide potential direct health cost savings comparable to those observed for working-age adults.

Can and should value-based pricing be applied to molecular diagnostics?

Current pricing and reimbursement systems for diagnostics are not efficient. Prices for diagnostics are often driven by administrative practices and expected production cost. The purpose of the paper is to discuss how a value-based pricing framework being used to ensure efficient use and price of medicines could also be applied to diagnostics. Diagnostics not only facilitates health gain and cost savings, but also information to guide patients' decisions on interventions and their future 'behaviors'. For value assessment processes we recommend a two-part approach. Companion diagnostics introduced at the launch of the drug should be assessed through new drug assessment processes considering a broad range of value elements and a balanced analysis of diagnostic impacts. A separate diagnostic-dedicated committee using value-based pricing principles should review other diagnostics lying outside the companion diagnostics-and-drug 'at-launch' situation.

Bilateral total knee arthroplasty in a one-stage surgical procedure

Bilateral total knee arthroplasty (TKA) in a one-stage surgical procedure has the advantage of a single hospital stay, shorter rehabilitation, and reduced patient management costs. However, until now the use of this strategy has been limited by the fear of a higher rate of perioperative complications. The hypothesis of this study was that in selected patients, this management strategy would not result in any serious complications. This prospective 24-month pilot study was performed in a continuous series of patients without a control group. Inclusion criteria were bilateral non-infectious gonarthropathy, in patients classified as American Society of Anesthesiology (ASA)1 or2 and presenting with a preoperative hemoglobin level of at least 13g/dL. All patients underwent a pre- and postoperative evaluation using the International Knee Society (IKS) and Knee Injury and Osteoarthritis Score (KOOS) scores. Thirty patients were included in the study (25women, mean age 70.3years old [32 to 88years]; five ASA1 and 25 ASA2). All patients were followed-up and evaluated for a mean 18months (6 to 30months). Three deep vein thromboses, one cardiopulmonary accident and three confusional states were reported, but there were no perioperative deaths, pulmonary embolisms, nosocomial infections or revision procedures. At 18months follow-up the IKS score had improved from 98 (33-139) preoperatively to 169 (62-200) postoperatively. The five items of the KOOS score improved significantly. This preliminary series confirms that bilateral total knee replacement in a one-stage surgical procedure is a reliable alternative to a two-stage procedure in ASA1 and2 patients. Because of the savings in health costs with this strategy, public healthcare authorities should provide support by creating and sponsoring a specific group for further study. 4, prospective, no control group.

Optimizing Portfolios of Interventions for Type 2 Diabetes Prevention and Management

Type 2 Diabetes Mellitus (T2DM), the epidemic of the 21st century, accounts for 4.6 million deaths globally and for 11% of the global health expenditure. Several different public health, primary preventive, and secondary interventions promise better health outcomes and cost savings. This paper proposes a mathematical model for T2DM that comprehends the interactions of multiple interventions, the influence of those interventions on the costs, clinical indicators and utilities of disease states, as well as population dynamics. We use the model to optimize portfolios of interventions for awareness and disease management programs for various stages of T2DM, and give insights on the different ways interventions can be beneficial. For instance, our findings suggest that the main benefit of primary prevention (in the form of awareness interventions) may shift from averting new cases to increasing screening rates under different objectives. Among other policy points, we demonstrate that an intervention which is found to be costly under the classical net present value perspective can indeed be cost-saving in the future. Thus, accounting for long-run demographics and the interaction of interventions may be a useful extension to traditional cost-utility analyses.

Tromboprofilaxis durante inmovilización por lesión traumática no quirúrgica del miembro inferior. Un enfoque extrahospitalario

Thromboprophylaxis with low molecular weight heparin is efficient, effective and generates savings in health costs in hospitals. However, outside hospitals, there are situations of apparent risk of thrombosis, where there seems to be no such consensus. This occurs in traumatic lower limb injuries which are not undergoing surgery and need a period of immobilization. These are processes with multidisciplinary interventions (Emergency, Family Physicians and Traumatology), although during outpatient follow up it is not easy to find criteria for using thromboprophylaxis. We report a case of a pulmonary embolism, with unusual symptoms, in an ambulatory patient with a fractured fibula and metatarsal, who was being treated with Bemiparin. As we shall see, this is a rare complication, but it shows the importance of proper risk assessment of thromboembolic disease in these patients. We emphasize the accompanying tomographic images for their clarity and eloquence.

Targeted physiotherapy treatment for low back pain based on clinical risk can improve clinical and economic outcomes when compared with current best practice

Does a stratified primary care approach for patients with low back pain result in clinical and economic benefits when compared with current best practice? A randomised, controlled trial with stratification for three risk groups and a targeted treatment according to the risk profile. Group allocation was carried out by computer-generated block randomisation in a 2:1 ratio. Ten general practices in England. Men and women at least 18 years old with low back pain of any duration, with or without associated radiculopathy. Exclusion criteria were potentially serious disorders, serious illness or comorbidity, spinal surgery in the past 6 months, pregnancy, and receiving back treatments (except primary care). In the intervention group decisions about referral to risk group were made by use of the STarT Back Screening Tool. The 30-min assessment and initial treatment focused on promotion of appropriate levels of activity, including return to work, a pamphlet about local exercise venues and self-help groups, the Back Book, and a 15-min educational video Get Back Active. Low-risk patients were only given this clinic session. Medium-risk patients were referred for standardised physiotherapy to address symptoms and function. High-risk patients were referred for psychologically informed physiotherapy to address physical symptoms and function, and psychosocial obstacles to recovery. In the control group a 30-min physiotherapy assessment and initial treatment including advice and exercises was provided, with the option of onward referral to further physiotherapy, based on the physiotherapist's clinical judgement. The 12 months score of Roland and Morris Disability Questionnaire (RMDQ). Secondary measures were referral for further physiotherapy, back pain intensity, pain catastrophising, fear-avoidance beliefs, anxiety, depression, health-related quality of life, reduction of risk-subgroup, global change of pain, number of physiotherapy treatment sessions, adverse events, health-care resource use and costs over 12 months, number of days off work because of back pain, and satisfaction with care. Of 851 patients assigned to the intervention (n=568) and control groups (n=283) a total of 649 completed the 12 months follow-up. Adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4.7 [SD 5.9] vs 3.0 [5.9], between-group difference 1.8 [95% CI 1.6 to 2.6]) and at 12 months (4.3 [6.4] vs 3.3 [6.2], 1.1 [0.6 to 1.9]). At 12 months, stratified care was associated with a mean increase in generic health benefit (0.039 additional QALYs) and cost savings (£240.01 vs £274.40) compared with the control group. There were significant differences in favour of the intervention group in many of the secondary outcomes. A stratified management approach including a prognostic screening and treatment targeting, showed improved clinical and economic benefits when compared with current best practice.

Estimating health related costs and savings from balcony acoustic design for road traffic noise

A multi-faceted study is conducted with the objective of estimating the potential fiscal savings in annoyance and sleep disturbance related health costs due to providing improved building acoustic design standards. This study uses balcony acoustic treatments in response to road traffic noise as an example. The study area is the State of Queensland in Australia, where regional road traffic noise mapping data is used in conjunction with standard dose–response curves to estimate the population exposure levels. The background and the importance of using the selected road traffic noise indicators are discussed. In order to achieve the objective, correlations between the mapping indicator (LA10(18hour)) and the dose response curve indicators (Lden and Lnight) are established via analysis on a large database of road traffic noise measurement data. The existing noise exposure of the study area is used to estimate the fiscal reductions in health related costs through the application of simple estimations of costs per person per year per degree of annoyance or sleep disturbance. The results demonstrate that balcony acoustic treatments may provide a significant benefit towards reducing the health related costs of road traffic noise in a community.

Economic Evaluation of Genomic Test–Directed Chemotherapy for Early-Stage Lymph Node–Positive Breast Cancer

Multi-parameter genomic tests identify patients with early-stage breast cancer who are likely to derive little benefit from adjuvant chemotherapy. These tests can potentially spare patients the morbidity from unnecessary chemotherapy and reduce costs. However, the costs of the test must be balanced against the health benefits and cost savings produced. This economic evaluation compared genomic test-directed chemotherapy using the Oncotype DX 21-gene assay with chemotherapy for all eligible patients with lymph node-positive, estrogen receptor-positive early-stage breast cancer. We performed a cost-utility analysis using a state transition model to calculate expected costs and benefits over the lifetime of a cohort of women with estrogen receptor-positive lymph node-positive breast cancer from a UK perspective. Recurrence rates for Oncotype DX-selected risk groups were derived from parametric survival models fitted to data from the Southwest Oncology Group 8814 trial. The primary outcome was the incremental cost-effectiveness ratio, expressed as the cost (in 2011 GBP) per quality-adjusted life-year (QALY). Confidence in the incremental cost-effectiveness ratio was expressed as a probability of cost-effectiveness and was calculated using Monte Carlo simulation. Model parameters were varied deterministically and probabilistically in sensitivity analysis. Value of information analysis was used to rank priorities for further research. The incremental cost-effectiveness ratio for Oncotype DX-directed chemotherapy using a recurrence score cutoff of 18 was £5529 (US $8852) per QALY. The probability that test-directed chemotherapy is cost-effective was 0.61 at a willingness-to-pay threshold of £30 000 per QALY. Results were sensitive to the recurrence rate, long-term anthracycline-related cardiac toxicity, quality of life, test cost, and the time horizon. The highest priority for further research identified by value of information analysis is the recurrence rate in test-selected subgroups. There is substantial uncertainty regarding the cost-effectiveness of Oncotype DX-directed chemotherapy. It is particularly important that future research studies to inform cost-effectiveness-based decisions collect long-term outcome data.