Quality of life and cost consequence of delays in endovascular treatment for acute ischemic stroke in China.

BACKGROUND: Although endovascular therapy (EVT) improves clinical outcomes in patients with acute ischemic stroke, the time of EVT initiation significantly influences clinical outcomes and healthcare costs. This study evaluated the impact of EVT treatment delay on cost-effectiveness in China. METHODS: A model combining a short-term decision tree and long-term Markov health state transition matrix was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes and healthcare costs. Clinical outcomes and cost data were derived from clinical trials and literature. Incremental cost-effectiveness ratio and incremental net monetary benefits were simulated. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the model. The willingness-to-pay threshold per quality-adjusted life-year (QALY) was set to ¥71,000 ($10,281). RESULTS: EVT performed between 61 and 120 min after the stroke onset was most cost-effective comparing to other time windows to perform EVT among AIS patients in China, with an ICER of ¥16,409/QALY ($2376) for performing EVT at 61-120 min versus the time window of 301-360 min. Each hour delay in EVT resulted in an average loss of 0.45 QALYs and 165.02 healthy days, with an average net monetary loss of ¥15,105 ($2187). CONCLUSIONS: Earlier treatment of acute ischemic stroke patients with EVT in China increases lifetime QALYs and the economic value of care without any net increase in lifetime costs. Thus, healthcare policies should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration in China.

Cost-effectiveness analysis of ranibizumab for retinal vein occlusion patients in China from the societal perspective.

BACKGROUND: Clinical trials in China have demonstrated that ranibizumab can improve the clinical outcomes of branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). However, no economic evaluation of ranibizumab has been conducted among Chinese patient population. METHODS: To provide insights into the economic profile of ranibizumab among Chinese RVO population, a Markov state-transition model was used to predict the outcomes of ranibizumab comparing to laser photocoagulation and observational-only care from the societal perspective. This model simulated changes in patient visuality, quality-adjusted of life years (QALY), medical costs, and direct non-medical costs of individuals with visual impairment due to BRVO or CRVO in lifetime. The base-case analysis used an annual discount rate of 5% for costs and benefits following the China Guidelines for Pharmacoeconomic Evaluations. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model. RESULTS: The base-case incremental cost-effectiveness ratio (ICER) comparing ranibizumab to laser photocoagulation was ¥65,008/QALY among BRVO patients and was ¥65,815/QALY among CRVO patients, respectively. Comparing to the 2019 gross domestic product (GDP) per capita of ¥71,000, both two ICERs were far below the cost-effective threshold at three times of GDP per capita (¥213,000). The deterministic and probabilistic sensitivity analyses demonstrated the base-case results were robust in most of the simulation scenarios. CONCLUSION: The current Markov model demonstrated that ranibizumab may be cost-effective compared with laser photocoagulation to treat BRVO and cost-effective compared to observation-only care to treat CRVO in China from the societal perspective.

Burden of cardiovascular diseases associated with fine particulate matter in Beijing, China: an economic modelling study.

OBJECTIVE: To evaluate the economic and humanistic burden associated with cardiovascular diseases that were attributable to fine particulate matter (≤ 2.5 µg/m3 in aerodynamic diameter; PM2.5) in Beijing. METHODS: This study used a health economic modelling approach to compare the actual annual average PM2.5 concentration with the PM2.5 concentration limit (35 µg/m3) as defined by the Chinese Ambient Air Quality Standard in terms of cardiovascular disease outcomes in Beijing adult population. The outcomes included medical costs, quality-adjusted life-years (QALYs) and net monetary loss (NML). Beijing annual average PM2.5 concentration was around 105 µg/m3 during 2013-2015. Therefore, we estimated the differences in cardiovascular outcomes of Beijing adults between exposure to the PM2.5 concentration of 105 µg/m3 and exposure to the concentration of 35 µg/m3. According to WHO estimates, the hazard ratios of coronary heart disease and stroke associated with the increase of PM2.5 concentration from 35 to 105 µg/m3 were 1.15 and 1.29, respectively. RESULTS: The total 1-year excess medical costs of cardiovascular diseases associated with PM2.5 pollution in Beijing was US$147.9 million and the total 1-year QALY loss was 92 574 in 2015, amounting to an NML of US$2281.8 million. The expected lifetime incremental costs for a male Beijing adult and a female Beijing adult were US$237 and US$163, the corresponding QALY loss was 0.14 and 0.12, and the corresponding NML was US$3514 and US$2935. CONCLUSIONS: PM2.5-related cardiovascular diseases imposed high economic and QALY burden on Beijing society. Continuous and intensive investment on reducing PM2.5 concentration is warranted even when only cardiovascular benefits are considered.

Performance of unanchored matching-adjusted indirect comparison (MAIC) for the evidence synthesis of single-arm trials with time-to-event outcomes.

BACKGROUND: The objectives of the present study were to evaluate the performance of a time-to-event data reconstruction method, to assess the bias and efficiency of unanchored matching-adjusted indirect comparison (MAIC) methods for the analysis of time-to-event outcomes, and to propose an approach to adjust the bias of unanchored MAIC when omitted confounders across trials may exist. METHODS: To evaluate the methods using a Monte Carlo approach, a thousand repetitions of simulated data sets were generated for two single-arm trials. In each repetition, researchers were assumed to have access to individual-level patient data (IPD) for one of the trials and the published Kaplan-Meier curve of another. First, we compared the raw data and the reconstructed IPD using Cox regressions to determine the performance of the data reconstruction method. Then, we evaluated alternative unanchored MAIC strategies with varying completeness of covariates for matching in terms of bias, efficiency, and confidence interval coverage. Finally, we proposed a bias factor-adjusted approach to gauge the true effects when unanchored MAIC estimates might be biased due to omitted variables. RESULTS: Reconstructed data sufficiently represented raw data in the sense that the difference between the raw and reconstructed data was not statistically significant over the one thousand repetitions. Also, the bias of unanchored MAIC estimates ranged from minimal to substantial as the set of covariates became less complete. More, the confidence interval estimates of unanchored MAIC were suboptimal even using the complete set of covariates. Finally, the bias factor-adjusted method we proposed substantially reduced omitted variable bias. CONCLUSIONS: Unanchored MAIC should be used to analyze time-to-event outcomes with caution. The bias factor may be used to gauge the true treatment effect.

Lifetime quality of life and cost consequences of delays in endovascular treatment for acute ischaemic stroke: a cost-effectiveness analysis from a Singapore healthcare perspective.

OBJECTIVES: Endovascular therapy (EVT) significantly improves clinical outcomes in patients with acute ischaemic stroke (AIS), while the time of EVT initiation after stroke onset influences both patient clinical outcomes and healthcare costs. This study determined the impact of EVT treatment delay on cost effectiveness of EVT in the Singapore healthcare setting. DESIGN: A short-term decision tree and long-term Markov health state transition model was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes (modified Rankin Scale scores), short-term costs and long-term modelled (lifetime) costs; all of which were used in calculating an incremental cost-effectiveness ratio of EVT vs non-EVT treatment. Clinical outcomes and cost data were derived from clinical trials, literature, expert opinion, electronic medical records and community-based surveys from Singapore. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the model. The willingness to pay for per quality-adjusted life-year (QALY) was set to Singapore $50 000 (US$36 500). SETTING: Singapore healthcare perspective. PARTICIPANTS: The model included patients with AIS in Singapore. INTERVENTIONS: EVT performed within 6 hours of stroke onset. OUTCOME MEASURES: The model estimated incremental cost-effectiveness ratios (ICERs) and net monetary benefits (NMB) for EVT versus non-EVT treatment, varied by time from symptom onset to time of treatment. RESULTS: EVT performed between 61 min and 120 min after the stroke onset was most cost-effective time window to perform EVT in the Singapore population, with an ICER of Singapore $7197 per QALY (US$5254) for performing EVT at 61-120 min versus 121-180 min. The resulting incremental NMB associated with receipt of EVT at the earlier time point is Singapore $39 827 (US$29 074) per patient at the willingness-to-pay threshold of Singapore $50 000. Each hour delay in EVT resulted in an average loss of 0.54 QALYs and 195.35 healthy days, with an average net monetary loss of Singapore $26 255 (US$19 166). CONCLUSIONS: From the Singapore healthcare perspective, although EVT is more expensive than alternative treatments in the short term, the lifetime ICER is below the willingness-to-pay threshold. Thus, healthcare policies and procedures should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration.

Association Between Supplemental Private Health Insurance and Burden of Out-of-Pocket Healthcare Expenditure in China: A Novel Approach to Estimate Two-Part Model with Random Effects Using Panel Data.

INTRODUCTION: Private health insurance (PHI) is an important supplement to the basic health insurance schemes in the Chinese healthcare system. However, there is an absence of evidence on whether the strategy of engaging PHI to reduce burden is effective in China. As such, we aimed to investigate the association between supplemental PHI and the out-of-pocket (OOP) burden of household healthcare expenditure in China. METHODS: We conducted a panel data analysis using data from three waves of China Health and Retirement Longitudinal Study (CHARLS). Specifically, a two-part model (TPM) with a first-stage probit and second-stage generalized linear model (GLM) framework was used to analyze the data. To account for individual-level random effects in both stages and their correlation in the TPM analysis, we proposed a generalized structural equation modeling (GSEM) approach to implement the estimation. The proposed approach allowed us to simultaneously analyze the association of PHI with the probability of having any healthcare and the OOP burden conditional on having any healthcare expenditure. RESULTS: Using the GSEM estimates, we found that supplemental PHI was significantly associated with a higher probability (4.29 percentage points) of having any OOP healthcare expenditure but a lower OOP burden conditional on having any expenditure (-2.37 percentage points). Overall, supplemental PHI was insignificantly associated with a lower OOP burden (-1.05 percentage points). DISCUSSION: Our findings suggested that supplemental PHI in China may be able to effectively improve access to healthcare while keeping the OOP healthcare expenditure burden flat. Also, GSEM is a feasible method to estimate random-effect TPMs.

Cost-Effectiveness Analysis of Four Common Diagnostic Methods for Clostridioides difficile Infection.

BACKGROUND: No studies have evaluated the cost-effectiveness of single and two-step different diagnostic test strategies for Clostridioides difficile infection (CDI), including direct and indirect costs. OBJECTIVE: To evaluate the cost-effectiveness of commonly available diagnostic tests for CDI including nucleic acid amplification testing (NAAT) alone, glutamate dehydrogenase followed by enzyme immunoassay for toxin (GDH/EIA), GDH then NAAT (GDH/NAAT), and NAAT then EIA (NAAT/EIA). DESIGN: Decision tree model from the US societal perspective with inputs derived from the literature. Willingness-to-pay threshold was set at $150,000 per quality-adjusted life year (QALY) gained. To assess the impact of uncertainty in model inputs on the findings, we performed one-way and probabilistic sensitivity analyses. PARTICIPANTS: We conducted the analysis to represent a population aged 65 years old with diarrhea who received a CDI diagnostic test. MAIN MEASURES: Incremental cost-effectiveness ratios (ICER) and incremental net monetary benefits (INMB). KEY RESULTS: NAAT alone was the most cost-effective approach overall; GDH/NAAT was the most cost-effective two-step option. NAAT alone led to the highest QALYs gained, at an incremental cost of $54,547 (vs. GDH/NAAT), $55,410 (vs. GDH/EIA), and $50,231 (vs. NAAT/EIA) per QALY gained. NAAT/EIA was not cost-effective compared to any other strategy. GDH/NAAT resulted in a higher QALY compared to GDH/EIA, at an incremental cost of $96,841 per QALY gained. Variability in the likelihood of comorbidities, CDI probability, and age at disease onset did not substantially change the results. One-way sensitivity analyses showed that results were most sensitive to likelihood of recurrence, followed by CDI mortality rate and probability of severe CDI. Probabilistic sensitivity analyses explored known uncertainties in the base case and confirmed the robustness of the results. CONCLUSIONS: NAAT alone and GDH/NAAT (among the two-step options) were the most cost-effective diagnostic test approaches for CDI.

Impact of supplementary private health insurance on hospitalization and physical examination in China.

Private health insurance (PHI) is considered an important supplement to the basic social health insurance schemes in the Chinese healthcare system. However, whether the strategy of engaging PHI as supplementary coverage is effective cannot be determined without knowing the impact of supplementary PHI on healthcare access and utilization, the evidence on which is currently absent in China. Therefore, we aimed to investigate the effects of supplementary PHI on hospitalization and physical examination to provide such evidence in the Chinese setting. We conducted a cross-sectional analysis using data from the 2015 wave of China Health and Retirement Longitudinal Study (CHARLS). Using probit models and bivariate probit models with instrumental variables (IVs), we evaluated the effects of supplementary PHI on the utilization of hospitalization and physical examination. Our analyses provided evidence that supplementary PHI increased the probability of physical examination but decreased that of hospitalization. Our findings suggest that supplementary PHI in China may effectively promote the use of high-value preventive care, thereby reducing subsequent utilization of expensive medical services. The present study provided preliminary evidence that the China healthcare system can benefit from engaging PHI as supplements to SHI.

Risk selection into supplemental private health insurance in China.

BACKGROUND: Information on risk selection is important for the regulation and development of supplemental private health insurance (PHI). The research on risk selection into supplemental PHI has been documented in several developed countries where the regulation of the PHI markets was relatively mature. However, evidence on this important aspect of the supplemental PHI market in China is still absent in the literature. The private insurers in China were not prohibited from discrimination against pre-existing conditions and did not guarantee ongoing enrolment. Therefore, the direction and degree of risk selection could not be inferred using the evidence from the other countries. To provide evidence on risk selection into supplemental PHI in China, we conducted a cross-sectional analysis using data from the 2015 wave of China Health and Retirement Longitudinal Study (CHARLS). RESULTS: Using probit models, we found that individuals having better self-reported general health were more likely to enrol in PHI in China, suggesting advantageous selection. This result was confirmed by an alternative analysis using an instrumental variable. We also adjusted the realized occurrence of hospitalization by excluding potential moral hazard effect and showed that the adjusted hospitalization risk was negatively associated with PHI enrolment, which also indicated advantageous selection. CONCLUSIONS: The findings suggested potential over-insurance of healthier individuals or under-insurance of less healthy individuals. The regulation of the PHI market in China should aim to address the inefficiency. The current study could also contribute to the information base for policymakers in countries where the PHI markets similarly lack strong regulation.

Cost-effectiveness and value-based prices of the 9-valent human papillomavirus vaccine for the prevention of cervical cancer in China: an economic modelling analysis.

OBJECTIVES: To evaluate the cost-effectiveness of the 9-valent human papillomavirus (HPV) vaccine for the prevention of cervical cancer in China. DESIGN: Health economic modelling using the Papillomavirus Rapid Interface for Modelling and Economics (PRIME) model populated with China-specific data. SETTING: Individual cervical cancer prevention in China using the 9-valent HPV vaccine from the perspective of private sector purchasers in relation to receiving other HPV vaccines and not receiving vaccination for 16-year-old girls in China who had not been previously infected with HPV. PARTICIPANTS: Not applicable. INTERVENTIONS: Vaccination using the 9-valent, the quadrivalent and the bivalent vaccines. PRIMARY OUTCOME MEASURE: Incremental costs per disability-adjusted life year (DALY) prevented. RESULTS: In the base case, the incremental costs per DALY prevented were, respectively, US$35 000 and US$50 455 compared with the quadrivalent and the bivalent vaccines, both of which were above the cost-effective threshold of US$25 920/DALY prevented. To be cost-effective in these comparisons, the 9-valent vaccine should be priced at $550 and $450 for the full doses, respectively. To be highly cost-effective, the price thresholds were $435 and $335. The incremental costs per DALY prevented in relation to no vaccination was US$23 012, making the 9-valent vaccine marginally cost-effective. The results were robust in most one-way sensitivity analyses including changing vaccination age to 13 and 26 years. CONCLUSIONS: At the current price, the 9-valent HPV vaccine is not cost-effective compared with the quadrivalent and the bivalent vaccines for young girls in China who had not been previously infected with HPV. Policymakers and clinicians should keep potential vaccine recipients informed about the economic profile of the 9-valent vaccine and carefully consider expanding its use in China at the current price.

Economic Evaluation of the 2016 Chinese Guideline and Alternative Risk Thresholds of Initiating Statin Therapy for the Management of Atherosclerotic Cardiovascular Disease.

OBJECTIVE: The 2016 Chinese guidelines for the management of dyslipidemia recommended mixed rules that centered around a 10% 10-year risk threshold to initiate statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). The present study aimed to evaluate the cost-effectiveness of the guideline statin-initiation strategy and alternative strategies. METHODS: A decision analytic model using discrete event simulation with event probabilities based on a validated ASCVD risk prediction tool for Chinese was constructed. Risk factor inputs were from the dataset of a nationally representative survey of middle-aged and elderly Chinese. Data of statin treatment effectiveness were from a published meta-analysis. Other key input data were identified from the literature or relevant databases. The strategies we evaluated were the guideline strategy, a 15% 10-year risk threshold strategy and a 20% 10-year risk threshold strategy. After excluding any extended dominance strategies, the incremental costs per quality-adjusted life year (QALY) gained of each strategy was calculated. RESULTS: The 20% 10-year risk threshold strategy was an extended dominance option. The incremental costs per QALY gained from the 15% 10-year risk threshold strategy compared with no treatment and the guideline strategy compared with the 15% 10-year risk threshold strategy were CN¥69,309 and CN¥154,944, respectively. The results were robust in most sensitivity analyses. CONCLUSIONS: The guideline strategy and the 15% 10-year risk threshold strategy are optimal when using the three times and the two times the gross domestic product per capita willingness-to-pay standards, respectively.

Factors related to the comparative effectiveness of clozapine in patients with schizophrenia.

AIM: To examine the factors related to the comparative effectiveness of clozapine. PATIENTS & METHODS: US insurance claims databases were used to identify schizophrenia patients. To examine the factors modifying the comparative effectiveness of clozapine in relation to other second-generation antipsychotics, a series of variables were interacted with a clozapine indicator in regressions. RESULTS: The impacts of clozapine on both persistence and adherence were significantly modified by prior hospitalization, prior epilepsy diagnosis and prior use of antianginal agents. The relative risks of heavy inpatient services use and heavy emergency department services use were also modified by several factors. CONCLUSION: Several factors can be used to identify patients who are more likely to benefit from clozapine than other second-generation antipsychotics.

Super enhancer inhibitors suppress MYC driven transcriptional amplification and tumor progression in osteosarcoma.

Osteosarcoma is the most common primary bone sarcoma that mostly occurs in young adults. The causes of osteosarcoma are heterogeneous and still not fully understood. Identification of novel, important oncogenic factors in osteosarcoma and development of better, effective therapeutic approaches are in urgent need for better treatment of osteosarcoma patients. In this study, we uncovered that the oncogene MYC is significantly upregulated in metastastic osteosarcoma samples. In addition, high MYC expression is associated with poor survival of osteosarcoma patients. Analysis of MYC targets in osteosarcoma revealed that most of the osteosarcoma super enhancer genes are bound by MYC. Treatment of osteosarcoma cells with super enhancer inhibitors THZ1 and JQ1 effectively suppresses the proliferation, migration, and invasion of osteosarcoma cells. Mechanistically, THZ1 treatment suppresses a large group of super enhancer containing MYC target genes including CDK6 and TGFB2. These findings revealed that the MYC-driven super enhancer signaling is crucial for the osteosarcoma tumorigenesis and targeting the MYC/super enhancer axis represents as a promising therapeutic strategy for treatment of osteosarcoma patients.

Reduction of healthcare costs through a transitions-of-care program.

PURPOSE: Results of an evaluation of the impact of a pharmacy-based transitional care program on healthcare costs in a population of high-risk patients are reported. METHODS: A nonrandomized, observational cohort study was conducted to compare cost outcomes in a group of patients discharged from a single hospital who were referred to an ambulatory care pharmacy-based transitions-of-care (TOC) program and a control group of patients discharged from neighboring hospitals who received usual care; all patients were members of the same managed Medicaid plan. The intervention and control groups were matched by number of hospitalizations during the 180 days preceding the index admission and by index admission length of stay. In the intervention group, all matched patients referred for TOC services (including those who did not qualify for services, could not be contacted, or declined services) were included in an intent-to-treat analysis. Thirty- and 180-day inpatient, outpatient, prescription, emergency room, and total costs were analyzed by ordinary least-squares and generalized linear model regressions, with selected costs further analyzed using two-part regression models. RESULTS: Among 830 patients referred to the TOC program, total healthcare costs at 180 days after discharge were an average of $2,139 lower than costs in the control group, yielding estimated savings of nearly $1.8 million for the managed care plan. CONCLUSION: Compared with usual postdischarge care, use of TOC services was associated with a significant reduction in 180-day total healthcare costs.

Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program.

BACKGROUND: Postdischarge medication management services have been shown to reduce the incidence of medication-related problems during the transition from inpatient to outpatient care. A pharmacist-run transition of care (TOC) program has been developed to reduce the unplanned readmissions of a high-risk managed Medicaid population after hospitalization. OBJECTIVE: To estimate the budget impact of adding an outpatient pharmacy-based TOC program to a medical benefit from the payer perspective. METHODS: A budget impact analysis was conducted using a decision-tree model developed in Microsoft Excel. The effect on inpatient and total health care costs from the payer perspective was estimated for the 2-year period following initial hospital discharge. Inputs were based on a total plan population of 240,000 lives, with a high-risk population of 7.5%, of whom 37% were hospitalized and potentially qualified for TOC services, resulting in an eligible population of 6,660 patients. The TOC program was assumed to initially cover 30% of the eligible population, with expansion to 60% over the 2 years. We previously reported that this program reduced the risk of readmission by 32% within 6 months and saved the health plan $2,139 per patient referred to the program, inclusive of program cost, compared with patients receiving usual discharge care. Sensitivity analyses were performed to test the impact of uncertainty of model inputs on the results, with the cost of TOC services ranging from $99 to $2,000 per patient referred. RESULTS: The model showed that the TOC program was cost saving at over $3 per member per month in the first 6 months, which translates to over $25 million in total health care cost savings over 2 years. These results were primarily driven by the estimated reduction in inpatient costs associated with the program, which were estimated at $20 million over the 2 years. Sensitivity analyses illustrated that within all the reasonable ranges of model input parameters, including the upper limit of TOC services set to $2,000 per patient referred, the TOC program resulted in cost savings to the health plan. CONCLUSIONS: The TOC program resulted in potential cost savings of over $25 million to the managed Medicaid plan over a period of 2 years, corresponding to over $4 per member per month. DISCLOSURES: Funding for this study was contributed by the Komoto Family Foundation, which provided fellowships to Ni and McCombs during the time of this study. Colayco is employed by Synergy Pharmacy Solutions and by the Komoto Family Foundation. Hashimoto and Komoto are employed by Synergy Pharmacy Solutions. Gowda and Wearda report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Ni, Colayco, and McCombs, along with the other authors. Hashimoto, Komoto, and Wearda took the lead in data collection, assisted by Ni, Colayco, and Gowda. Data interpretation was performed by Ni, Colayco, and McCombs, along with the other authors. The manuscript was written by Ni and Colayco and revised by Gowda and McCombs, along with the other authors.

Impact of a pharmacy-based transitional care program on hospital readmissions.

OBJECTIVES: Avoidable readmissions of patients discharged from hospitals are a major concern. This study evaluates the impact of pharmacist-provided postdischarge services on hospital readmissions for members of a US managed Medicaid health plan. STUDY DESIGN: Prospective cohort study. METHODS: Synergy Pharmacy Solutions (SPS) initiated a transition of care (TOC) service for high-risk members of the Kern Health Systems (KHS) managed Medicaid plan. Over 1100 patients were referred to SPS between April 2013 and March 2015. KHS classified hospitalized members as high risk for readmission based on prior healthcare utilization, a health risk assessment questionnaire, and the use of the Johns Hopkins predictive modeler. This study compares SPS TOC recipients with a matched sample of KHS members discharged from nonintervention hospitals. Thirty-day and 180-day readmissions and time-to-readmission were defined as outcomes. Logistic regression and Cox model were estimated, controlling for demographics, diagnostic and drug profiles, and prior hospital utilization. RESULTS: KHS identified 1763 high-risk discharges from nonintervention hospitals, of which 1005 and 669 were matched to 830 and 558 selected SPS patients in 30-day and 180-day populations, respectively. The SPS postdischarge intervention reduced the risk of readmission within 30 days by 28% (odds ratio [OR], 0.720; 95% confidence interval [CI], 0.526-0.985) and within 180 days by 31.9% (OR, 0.681; 95% CI, 0.507-0.914). The estimated effect of the SPS intervention from the Cox model was a reduction in risk of 25% (hazard ratio, 0.749; 95% CI, 0.566-0.992). CONCLUSIONS: A community pharmacy-based postdischarge TOC program can significantly reduce readmission rates at 30 and 180 days compared with usual discharge care.

Expected lifetime numbers, risks, and burden of osteoporotic fractures for 50-year old Chinese women: a discrete event simulation incorporating FRAX.

This work was undertaken to provide an estimation of expected lifetime numbers, risks, and burden of fractures for 50-year-old Chinese women. A discrete event simulation model was developed to simulate the lifetime fractures of 50-year-old Chinese women at average risk of osteoporotic fracture. Main events in the model included hip fracture, clinical vertebral fracture, wrist fracture, humerus fracture, and other fracture. Fracture risks were calculated using the FRAX® tool. Simulations of 50-year-old Chinese women without fracture risks were also carried out as a comparison to determine the burden of fractures. A 50-year-old Chinese woman at average risk of fracture is expected to experience 0.135 (95 % CI: 0.134-0.137) hip fractures, 0.120 (95 % CI: 0.119-0.122) clinical vertebral fractures, 0.095 (95 % CI: 0.094-0.096) wrist fractures, 0.079 (95 % CI: 0.078-0.080) humerus fractures, and 0.407 (95 % CI: 0.404-0.410) other fractures over the remainder of her life. The residual lifetime risk of any fracture, hip fracture, clinical vertebral fracture, wrist fracture, humerus fracture, and other fracture for a 50-year-old Chinese woman is 37.36, 11.77, 10.47, 8.61, 7.30, and 27.80 %, respectively. The fracture-attributable excess quality-adjusted life year (QALY) loss and lifetime costs are estimated at 0.11 QALYs (95 % CI: 0.00-0.22 QALYs) and US $714.61 (95 % CI: US $709.20-720.02), totaling a net monetary benefit loss of US $1,104.43 (95 % CI: US $904.09-1,304.78). Chinese women 50 years of age are at high risk of osteoporotic fracture, and the expected economic and quality-of-life burden attributable to osteoporotic fractures among Chinese women is substantial.

Estimating the Impact of Adherence to and Persistence with Atypical Antipsychotic Therapy on Health Care Costs and Risk of Hospitalization.

STUDY OBJECTIVE: To estimate the impact of adherence to and persistence with atypical antipsychotics on health care costs and risk of hospitalization by controlling potential sources of endogeneity. DESIGN: Retrospective cohort study using medical and pharmacy claims data. DATA SOURCE: Humana health care insurance database. PATIENTS: A total of 32,374 patients with a diagnosis of schizophrenia or bipolar disorder and who had a prescription for noninjectable atypical antipsychotics (aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone), after a washout period of at least 180 days during which there was no use of any atypical antipsychotics, between January 2007 and June 2013. MEASUREMENTS AND MAIN RESULTS: The effects of adherence (proportion of days covered by all atypical antipsychotic prescription fills) to and persistence (time from initiation to discontinuation of therapy) with atypical antipsychotics on outcomes (all-cause total health care costs, medication costs, medical services costs, and inpatient admissions) were examined. To exclude potential bias due to mutual causality between drug use patterns and health care utilization, the effects of adherence and persistence measured in the first year on outcomes measured in the second year were investigated. Instrumental variable regressions using reimbursement rate and mail order as instrumental variables were conducted to correct potential endogeneity due to omitted variable bias. Being adherent decreased total costs by $19,497 (p<0.05), increased medication costs by $8194 (p<0.001), decreased medical services costs by $27,664 (p<0.001), and reduced hospitalization risk by 27% (p<0.001). Being persistent decreased individual total costs by $23,927 (p<0.05), increased medication costs by $10,278 (p<0.001), and decreased medical services costs by $34,178 (p<0.001). We could not identify a significant association between persistence and the risk of hospitalization. CONCLUSION: Good adherence to and persistence with atypical antipsychotics led to lower total costs than poor adherence and persistence. Thus efforts should be made to improve adherence and persistence in patients taking atypical antipsychotics.

Health Care Utilization and Treatment Persistence Associated with Oral Paliperidone and Lurasidone in Schizophrenia Treatment.

BACKGROUND: Oral paliperidone and lurasidone are new second-generation antipsychotics (SGAs). Empirical evidence on the comparative costs and persistence of these 2 agents are absent in the literature. OBJECTIVE: To assess health care use and persistence associated with the 2 new agents oral paliperidone and lurasidone and other SGAs. METHODS: Schizophrenia patients who initiated SGA therapy were identified in the January 2007-June 2013 claims databases of a large managed care organization. Multivariate regressions using aripiprazole as the comparator were conducted. Ordinary least squares regressions were used to estimate the total medical and pharmacy costs associated with each drug. Poisson regressions were conducted to evaluate the frequency of hospitalizations and emergency department (ED) visits associated with each drug. A censored regression model was used to evaluate the comparative persistence. Sensitivity analyses using generalized linear models, two-part models, hurdle models, and instrumental variable regressions were also performed.   RESULTS: Compared with aripiprazole, paliperidone was not associated with significantly different total costs, yet lurasidone was associated with lower total costs (-$7,052; 95% CI = -$9,221, -$4,882). Lurasidone was also associated with significantly lower medical services costs (-$5,025; 95% CI = -$7,096, -$2,955), drug costs (-$2,026; 95% CI = -$2,695, -$1,357), hospital costs (-$3,026; 95% CI = -$4,731, -$1,321), outpatient costs (-$1,999; 95% CI = -$2,536, -$1,463), and ED costs (-$2,284; 95% CI = -$3,069, -$1,499), whereas paliperidone did not have significant effects on any types of costs. Paliperidone users had fewer ED visits (-0.25; 95% CI = -0.42, -0.08), while lurasidone users had fewer hospitalizations (-5.98; 95% CI = -6.61, -5.35) and fewer ED visits (-2.51; 95% CI = -2.92, -2.10). Both paliperidone and lurasidone were associated with lower levels of treatment persistence. CONCLUSIONS: Paliperidone does not associate with lower total costs compared with commonly used SGAs, whereas lurasidone is associated with lower total health costs. Thus, high access fees of lurasidone are not necessarily a major concern in prescription.

[Phosphorus adsorption characteristics of soils and sediments surrounding Dishui Lake in Shanghai].

Soils and sediments of different origins were collected, which included the cropland soils surrounding Dishui Lake, the sediments from rivers, the sediments of wetland and the sediments in Dishui Lake. These samples were used for the experiment of phosphorus isothermal adsorption. The results of this experiment were analyzed and fitted. It shows that, the adsorption-desorption equilibrium mass concentration (EPC(0) value) of the sediments in Dishui Lake (0.11-0.63 mg x L(-1)) is higher than that of the soils and sediments from other sources, which indicates that it is easier to release phosphorus to overlying water. Both the Langmuir model and Freundlich model have a high fitting degree to the isothermal adsorption of phosphorus. The maximum adsorption capacity (Q(m)) calculated by Langmuir model demonstrate that the adsorption capacity of soils and sediments from different sources follows the order: sediments from rivers (1 003.05-2977.65 mg x kg(-1)) > sediments in Dishui Lake (669.77-1 717.94 mg x kg(-1)) > sediments of wetland (368.60-1 145.51 mg x kg(-1)) > cropland soils(441.36-702.30 mg x kg(-). It shows that the adsorption capacity of cropland soils is the weakest. Cropland soils can be a source of phosphorus in Dishui Lake when extra fertilizer is used.