Health care costs make up nearly a fifth of U.S. gross domestic product, but health care is a peculiar thing to buy and sell. Both a scarce resource and a basic need, it involves physical and ...emotional vulnerability and at the same time it operates as big business. Patients have little choice but to trust those who provide them care, but even those providers confront a great deal of medical uncertainty about the services they offer.Selling Our Soulslooks at the contradictions inherent in one particular health care market-hospital care. Based on extensive interviews and observations across the three hospitals of one California city, the book explores the tensions embedded in the market for hospital care, how different hospitals manage these tensions, the historical trajectories driving disparities in contemporary hospital practice, and the perils and possibilities of various models of care.
As Adam Reich shows, the book's three featured hospitals could not be more different in background or contemporary practice. PubliCare was founded in the late nineteenth century as an almshouse in order to address the needs of the destitute. HolyCare was founded by an order of nuns in the mid-twentieth century, offering spiritual comfort to the paying patient. And GroupCare was founded in the late twentieth century to rationalize and economize care for middle-class patients and their employers. Reich explains how these legacies play out today in terms of the hospitals' different responses to similar market pressures, and the varieties of care that result.
Selling Our Soulsis an in-depth investigation into how hospital organizations and the people who work in them make sense of and respond to the modern health care market.
Background
We sought to determine the cost‐effectiveness of noninvasive fetal RhD blood group genotyping in nonalloimmunized and alloimmunized pregnancies in Canada.
Study design and methods
We ...developed two probabilistic state‐transition (Markov) microsimulation models to compare fetal genotyping followed by targeted management versus usual care (i.e., universal Rh immunoglobulin RhIG prophylaxis in nonalloimmunized RhD‐negative pregnancies, or universal intensive monitoring in alloimmunized pregnancies). The reference case considered a healthcare payer perspective and a 10‐year time horizon. Sensitivity analysis examined assumptions related to test cost, paternal screening, subsequent pregnancies, other alloantibodies (e.g., K, Rh c/C/E), societal perspective, and lifetime horizon.
Results
Fetal genotyping in nonalloimmunized pregnancies (at per‐sample test cost of C$247/US$311) was associated with a slightly higher probability of maternal alloimmunization (22 vs. 21 per 10,000) and a reduced number of RhIG injections (1.427 vs. 1.795) than usual care. It was more expensive (C$154/US$194, 95% Credible Interval CrI: C$139/US$175‐C$169/US$213) and had little impact on QALYs (0.0007, 95%CrI: −0.01–0.01). These results were sensitive to the test cost (threshold achieved at C$88/US$111), and inclusion of paternal screening. Fetal genotyping in alloimmunized pregnancies (at test cost of C$328/US$413) was less expensive (‐C$6280/US$7903, 95% CrI: ‐C$6325/US$7959 to ‐C$6229/US$7838) and more effective (0.19 QALYs, 95% CrI 0.17–0.20) than usual care. These cost savings remained robust in sensitivity analyses.
Discussion
Noninvasive fetal RhD genotyping saves resources and represents good value for the management of alloimmunized pregnancies. If the cost of genotyping is substantially decreased, the targeted intervention can become a viable option for nonalloimmunized pregnancies.
Aim
To estimate the cost‐effectiveness of dapagliflozin added to standard therapy, vs. standard therapy only, in patients with heart failure (HF) with reduced ejection fraction (HFrEF), from the ...perspective of UK, German, and Spanish payers.
Methods and results
A lifetime Markov model was built to estimate outcomes in patients with HFrEF. Health states were defined by Kansas City Cardiomyopathy Questionnaire total symptom score, type 2 diabetes and worsening HF events. The incidence of worsening HF and all‐cause mortality was estimated using negative binomial regression models and parametric survival analysis, respectively. Direct healthcare costs (2019 British pounds/Euro) and patient‐reported outcomes (EQ‐5D) were sourced from the existing literature and the Dapagliflozin And Prevention of Adverse‐outcomes in Heart Failure trial (DAPA‐HF), respectively; the median duration of follow‐up in DAPA‐HF was 18.2 months (range: 0–27.8). Future costs and effects were discounted at 3.0% for the Spanish and German analyses and 3.5% for the UK analysis. In the UK setting, treatment with dapagliflozin was estimated to increase life‐years and quality‐adjusted life‐years (QALYs) from 5.62 to 6.20 (+0.58) and 4.13 to 4.61 (+0.48), respectively, and reduce lifetime hospitalizations for HF (925 and 820 events per 1000 patients for placebo and dapagliflozin, respectively). Similar results were obtained for Germany and Spain. The incremental cost‐effectiveness ratios were £5822, €5379 and €9406/QALY in the UK, Germany and Spain, respectively. In probabilistic sensitivity analyses, more than 90% of simulations were cost‐effective at a willingness‐to‐pay threshold of £20 000/QALY in UK and €20 000/QALY in Germany and Spain.
Conclusion
Dapagliflozin is likely to be a cost‐effective treatment for HFrEF in the UK, German and Spanish healthcare systems.
Severe asthma imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity, co‐morbidities, complexity in care pathways and ...differences between national or regional healthcare systems. Better understanding of the mechanisms has enabled a stratified approach to the management of severe asthma, supporting the use of targeted treatments with biologicals. However, there are still many issues that require further clarification. These include selection of a certain biological (as they all target overlapping disease phenotypes), the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home‐based) and its cost‐effectiveness. The EAACI Guidelines on the use of biologicals in severe asthma follow the GRADE approach in formulating recommendations for each biological and each outcome. In addition, a management algorithm for the use of biologicals in the clinic is proposed, together with future approaches and research priorities.
Background
In a global, phase III, open‐label, noninferiority trial (REFLECT), lenvatinib demonstrated noninferiority to sorafenib in overall survival and a statistically significant increase in ...progression‐free survival in patients with unresectable hepatocellular carcinoma (HCC). Recently, lenvatinib became the first agent in more than 10 years to receive approval as first‐line therapy for unresectable HCC, along with the previously approved sorafenib. The objective of this study was to determine the comparative cost‐effectiveness of lenvatinib and sorafenib as a first‐line therapy of unresectable HCC.
Materials and Methods
A state‐transition model of unresectable HCC was developed in the form of a cost–utility analysis. The model time horizon was 5 years; the efficacy of the model was informed by the REFLECT trial, and costs and utilities were obtained from published literature. Probabilistic sensitivity analyses and subgroup analyses were performed to test the robustness of the model.
Results
Lenvatinib dominated sorafenib in the base case analysis. A probabilistic sensitivity analysis indicated that lenvatinib remains a cost‐saving measure in 64.87% of the simulations. However, if the cost of sorafenib was reduced by 57%, lenvatinib would no longer be the dominant strategy.
Conclusion
Lenvatinib offered a similar clinical effectiveness at a lower cost than sorafenib, suggesting that lenvatinib would be a cost‐saving alternative in treating unresectable HCC. However, lenvatinib may fail to remain cost‐saving if a significantly cheaper generic sorafenib becomes available.
Implications for Practice
This analysis suggests an actionable clinical policy that will achieve cost saving. This cost–utility analysis showed that lenvatinib had a similar clinical effectiveness at a lower cost than sorafenib, indicating that lenvatinib may be a cost‐saving measure in patients with unresectable HCC, in which $23,719 could be saved per patient. The introduction of a new therapeutic option for the first time in 10 years in Canada provides an important opportunity for clinicians, researchers, and health care decision‐makers to explore potential modifications in recommendations and practice guidelines.
This article focuses on the cost‐effectiveness of lenvatinib and sorafenib as a first‐line therapy for unresectable hepatocellular carcinoma.
Background
Colonoscopy is the most widely used colorectal cancer (CRC) screening test in the United States. Through the detection and removal of potentially precancerous polyps, it can prevent CRC. ...However, CRC screening remains low among adults who are recommended for screening. The New Hampshire Colorectal Cancer Screening Program implemented a patient navigation (PN) intervention to increase colonoscopy screening among low‐income patients in health centers in New Hampshire. In the current study, the authors examined the cost‐effectiveness of this intervention.
Methods
A decision tree model was constructed using Markov state transitions to calculate the costs and effectiveness associated with PN. Costs were calculated for the implementation of PN in a statewide public health program and in endoscopy centers. The main study outcome was colonoscopy screening completion. The main decision variable was the incremental cost‐effectiveness ratio associated with the PN intervention compared with usual care.
Results
The average cost per screening with PN was $1089 (95% confidence interval, $1075‐$1103) compared with $894 with usual care (95% confidence interval, $886‐$908). Among patients who were navigated, approximately 96.2% completed colonoscopy screening compared with 69.3% of those receiving usual care (odds ratio, 11.2; P <. 001). The incremental cost‐effectiveness ratio indicated that 1 additional screening completion cost approximately $725 in a public health program and $548 in an endoscopy center with PN compared with usual care, both of which are less than the average Medicare reimbursement of $737 for a colonoscopy procedure.
Conclusions
PN was found to be cost‐effective in increasing colonoscopy screening among low‐income adults in the New Hampshire Colorectal Cancer Screening Program, even at the threshold of current Medicare reimbursement rates for colonoscopy. The results of the current study support the implementation of PN in statewide public health programs and endoscopy centers.
Patient navigation is a cost‐effective intervention for increasing colonoscopy screening among low‐income adults, even at the threshold of current Medicare reimbursement rates for colonoscopy. The results of the current study support the implementation of patient navigation in statewide public health programs and local endoscopy centers.
Laryngotracheal stenosis (LTS) is resource-intensive disease. The cost-effectiveness of LTS treatments has not been adequately explored. We aimed to conduct a cost-effectiveness analysis comparing ...open reconstruction (cricotracheal/tracheal resection CTR/TR) with endoscopic dilation in the treatment of LTS.
Retrospective cohort.
Tertiary referral center (2013-2017).
Thirty-four LTS patients were recruited. Annual costs were derived from the Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University. Cost-effectiveness analysis compared CTR/TR versus endoscopic dilation at a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) over 5- and 10-year time horizons. The incremental cost-effectiveness ratio (ICER) was calculated with deterministic analysis and tested for sensitivity with univariate and probabilistic sensitivity analysis.
Mean LTS costs were $4080.09 (SE, $569.29) annually for related health care visits. The major risk factor for increased cost was etiology of stenosis. As compared with idiopathic patients, patients with intubation-related stenosis had significantly higher annual costs ($5286.56 vs $2873.62, P = .03). The cost of CTR/TR was $8583.91 (SE, $2263.22). Over a 5-year time horizon, CTR/TR gained $896 per QALY over serial dilations and was cost-effective. Over a 10-year time horizon, CTR/TR dominated dilations with a lower cost and higher QALY.
The cost of treatment for LTS is significant. Patients with intubation-related stenosis have significantly higher annual costs than do idiopathic patients. CTR/TR contributes significantly to cost in LTS but is cost-effective versus endoscopic dilations for appropriately selected patients over a 5- and 10-year horizon.
Background
The present epidemic of dermatophytosis in India is marked by an increase in chronic, recurrent and disseminated cases. A combination of oral itraconazole and topical luliconazole is being ...increasingly utilised by dermatologists in India. The superiority of this combination is not supported by robust clinical trial data.
Objective
We conducted this randomised, open‐label, two arms, parallel assignment intervention trial between November 2022 and May 2023 to determine the superiority of topical 1% Luliconazole over bland emollient as adjuvant to systemic Itraconazole therapy in the management of dermatophytosis.
Method
In this study, 135 patients of either sex were randomised to two study cohorts. Major exclusions being concomitant medical illness, use of concomitant medication and substance abuse. Participants were randomly assigned to receive topical bland emollient, (Cohort I, n = 67) or topical luliconazole, (Cohort II, n = 68). Both cohorts received oral itraconazole 200 mg/day (100 mg BID) and levocetirizine 5 mg twice a day as a systemic regime. Clinical and mycological cure at the end of 6 weeks and clinical relapse among cure patients during 10‐week follow‐up were observed.
Results
The cure rates for Cohorts I and II at 6 weeks were 50 (74.62%) and 56 (82.35%), (p = .46), respectively. During the 4‐week follow‐up period, clinical relapses were observed in 16 (32%) of the 50 patients in Cohort I and 12 (21.43%) of the 56 patients in Cohort II (p = .18). Luliconazole cohort shows a significantly higher medical cost (p < .05).
Conclusion
Our study shows a similar cure rate and relapse rate for patients receiving topical Luliconazole versus topical bland emollient as an adjuvant to the systemic itraconazole regime.
Metal halide perovskites are emerging scintillator materials in X‐ray detection and imaging. However, the vulnerable structure of perovskites triggers unreliable performance when they are utilized in ...X‐ray detectors under cumulative dose irradiation. Herein, a self‐limited growth strategy is proposed to construct CsPbBr3 nanocrystals that are embedded in a transparent amorphous network structure, featuring X‐imaging with excellent resolution (≈16.8 lp mm−1), and fast decay time (τ = 27 ns). Interestingly, it is found that the performance degradation of the scintillator, caused by the damage from high‐dose X‐ray irradiation, can be fully recovered after a facile thermal treatment process. This indicates a superior recycling behavior of the explored perovskites scintillator for practical applications. The recoverability of the as‐explored scintillator is attributed to the low atom‐migration rate in the amorphous network with high‐viscosity (1 × 1014 cP). This result highlights the practical settlement of the promising perovskites for long‐term, cost‐effective scintillator devices.
A self‐limited growth strategy is proposed to construct CsPbBr3 nanocrystals, which features X‐imaging with excellent resolution (16.8 lp mm−1). More importantly, the blurred X‐ray images of the damaged perovskite NCs, due to irradiation at high dose rate, are well refreshed by a thermal treatment. This discovery broadens the research and application of the scintillators and opens a new chapter.
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