Supporting community-dwelling older people with cognitive impairment to stay at home: A modelled cost analysis.

OBJECTIVE: To model the potential financial implications of Australian programs supporting cognitively impaired community-dwelling older people. METHODS: Markov cohort models of (a) an observational study of a residential dyadic training program for carers and people with dementia (GTSAH) and (b) a frailty intervention (FIT) in a cognitively impaired subgroup. Direct health and social welfare costs accrued over 5 years (2018 $AUD prices) were captured. GTSAH costs $3755, FIT costs $1834, and permanent residential aged care (P-RAC) costs $237 per day. RESULTS: Modelling predicted costs break even in approximately 5 months for GTSAH and 7 months for FIT, after which these interventions saved funds. The primary driver of savings was the P-RAC cost (discounted at 5%/annum), at $121 030 for GTSAH vs $231 193 for standard care; and $47 857 with FIT vs $111 359 for standard care. CONCLUSIONS: Programs supporting cognitively impaired community-dwelling older people could be financially beneficial; further evaluation and implementation would be a worthwhile investment.

Simulation of health care and related costs in people with dementia in Australia.

Objectives The aim of this study was to develop a validated model to predict current and future Australian costs for people with dementia to help guide decision makers allocate scarce resources in the presence of capacity constraints. Methods A hybrid discrete event simulation was developed to predict costs borne in Australia for people with dementia from 2015 to 2050. The costs captured included community-based care, permanent and respite residential aged care, hospitalisation, transitional care, pharmaceuticals, aged care assessments, out of hospital medical services and other programs. Results The costs borne for people with dementia in Australia are predicted to increase from A$11.8 billion in 2015 to A$33.6 billion in 2050 at 2013-14 prices, ceteris paribus. If real per capita health and social expenditure increased by 1.0% annually, these costs are predicted to increase by around A$14.2 billion to a total of around A$47.8 billion by 2050. Conclusions This simulation provides useful estimates of the potential future costs that will be borne for people with dementia and allows the exploration of the effects of capacity constraints on these costs. The model demonstrates that the level of real annual per capita growth in health and social expenditure has significant implications for the future sustainability of dementia care in Australia. What is known about the topic? With the aging of the Australian population, the number of people living with dementia is predicted to rise markedly in the next four decades. As the number of people living with dementia increases, so too will the financial burden these debilitating and degenerative diseases place on private and public resources. These increases are likely to challenge the efficiency and sustainability of many health systems in the developed world. What does this paper add? This research provides a validated model to predict current and future Australian costs for people with dementia to help guide decision makers allocate scarce resources in the presence of capacity constraints (i.e. where the supply of resources does not meet demand). The model predicts an increase in costs for people with dementia from A$11.8 billion in 2015 to A$33.6 billion in 2050 at 2013-14 prices. If real per capita health and social expenditure increased by 1.0% annually, these costs are predicted to increase by around A$14.2 billion to a total of around A$47.8 billion by 2050. What are the implications for practitioners? This simulation provides useful estimates of the potential future costs that will be borne for people with dementia and allows the exploration of the effects of capacity constraints on these costs. The model demonstrates that the level of real annual per capita growth in health and social expenditure has significant implications for the future sustainability of dementia care in Australia.

A simulation of dementia epidemiology and resource use in Australia.

OBJECTIVES: The number of people in the developed world who have dementia is predicted to rise markedly. This study presents a validated predictive model to assist decision-makers to determine this population's future resource requirements and target scarce health and welfare resources appropriately. METHODS: A novel individual patient discrete event simulation was developed to estimate the future prevalence of dementia and related health and welfare resource use in Australia. RESULTS: When compared to other published results, the simulation generated valid estimates of dementia prevalence and resource use. The analysis predicted 298,000, 387,000 and 928,000 persons in Australia will have dementia in 2011, 2020 and 2050, respectively. Health and welfare resource use increased markedly over the simulated time-horizon and was affected by capacity constraints. CONCLUSIONS: This simulation provides useful estimates of future demands on dementia-related services allowing the exploration of the effects of capacity constraints. Implications for public health: The model demonstrates that under-resourcing of residential aged care may lead to inappropriate and inefficient use of hospital resources. To avoid these capacity constraints it is predicted that the number of aged care beds for persons with dementia will need to increase more than threefold from 2011 to 2050.

Markov modeling and discrete event simulation in health care: a systematic comparison.

OBJECTIVES: The aim of this study was to assess if the use of Markov modeling (MM) or discrete event simulation (DES) for cost-effectiveness analysis (CEA) may alter healthcare resource allocation decisions. METHODS: A systematic literature search and review of empirical and non-empirical studies comparing MM and DES techniques used in the CEA of healthcare technologies was conducted. RESULTS: Twenty-two pertinent publications were identified. Two publications compared MM and DES models empirically, one presented a conceptual DES and MM, two described a DES consensus guideline, and seventeen drew comparisons between MM and DES through the authors' experience. The primary advantages described for DES over MM were the ability to model queuing for limited resources, capture individual patient histories, accommodate complexity and uncertainty, represent time flexibly, model competing risks, and accommodate multiple events simultaneously. The disadvantages of DES over MM were the potential for model overspecification, increased data requirements, specialized expensive software, and increased model development, validation, and computational time. CONCLUSIONS: Where individual patient history is an important driver of future events an individual patient simulation technique like DES may be preferred over MM. Where supply shortages, subsequent queuing, and diversion of patients through other pathways in the healthcare system are likely to be drivers of cost-effectiveness, DES modeling methods may provide decision makers with more accurate information on which to base resource allocation decisions. Where these are not major features of the cost-effectiveness question, MM remains an efficient, easily validated, parsimonious, and accurate method of determining the cost-effectiveness of new healthcare interventions.

Histology as a treatment effect modifier in advanced non-small cell lung cancer: a systematic review of the evidence.

BACKGROUND AND OBJECTIVE: We conducted a systematic review of prospective, randomized, controlled trials (RCT) to examine whether histology had a treatment modifying effect (TME) on the efficacy outcomes of chemotherapeutic agents in patients with advanced (stage IIIB-IV) non-small cell lung cancer (NSCLC). METHODS: Potentially pertinent publications were reviewed in full to determine if there was any TME by histology for overall survival (OS), progression-free survival (PFS) or treatment response rate (TRR). RESULTS: Data from three pemetrexed RCT, comparing (i) pemetrexed versus docetaxel, (ii) pemetrexed and cisplatin versus gemcitabine and cisplatin, and (iii) pemetrexed versus placebo, showed a statistically significant TME by histology for OS and PFS. One trial comparing pemetrexed and carboplatin versus gemcitabine and carboplatin found no significant associations between histology and OS. The results of this systematic review indicate that pemetrexed appears to have the most consistent treatment-by-histology interaction effect on the efficacy outcomes of chemotherapeutic agents in patients with advanced or metastatic NSCLC. Patients with non-squamous histology gain the greatest benefit from treatment with pemetrexed. Conversely, patients with squamous cell disease appeared to experience poorer OS when pemetrexed was compared with other active treatments, and similar OS when compared with placebo. Reproducible patterns of TME effect by histology with other chemotherapeutic agents are less clear. CONCLUSIONS: We consider that the historical approach to treating all NSCLC patients with the same chemotherapy regimen is now no longer acceptable.

Relationship between rheumatoid arthritis disease severity, health-related utility, and resource use in Australian patients: A cross-sectional, multicenter study.

OBJECTIVES: This research explores the relationship between rheumatoid arthritis (RA) severity measures, clinical characteristics, and patient preference-based health-related quality of life (ie, utility) in Australian RA patients. A secondary objective was to investigate the relationship between a range of disease severity measures, clinical characteristics, and the cost of RA-related resource use. METHODS: This was a cross-sectional, multicenter study of consecutive patients with RA aged > or =18 years attending routine clinical appointments. Patients completed a questionnaire comprising general demographic, resource use, and disease-specific questions; the RA-specific Health Assessment Questionnaire (HAQ); and 2 multiattribute preference-based quality-of-life (utility) instruments, the Health Utilities Index Mark 3 (HUI3) and the EuroQol 5 Dimensions (EQ-5D). A second questionnaire was completed by the patient's rheumatologist, with questions on key clinical data pertinent to RA, including the number and location of tender joints and swollen joints, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, current and previous treatments, and details of important comorbid conditions. Data on RA-specific resource use were also collected, including health-professional visits (eg, general practitioner, specialist, nurse, occupational therapist, paid caregivers), hospital admissions, surgery, and RA-associated home modifications. Spearman nonparametric correlation, simple linear, multiple, and stepwise regression analyses were used to explore the relationship between utility scores (HUI3 and EQ-5D) and variables including HAQ, RA-related resource use, and key demographic, physical, and biochemical measures. RESULTS: A total of 170 patients were recruited from 4 centers in Australia. Consistent with the epidemiology of RA, the ratio of women to men was approximately 3:1 (126 vs 44, respectively). Male and female patients were of similar age (mean [SD], 59.2 [12.9] and 58.9 [12.2] years, respectively). Time since diagnosis of RA was significantly shorter for men than for women (mean difference, -4.52 years; 95% CI, -8.65 to -0.38; P = 0.03). Of all the disease severity measures and clinical characteristics investigated, patients' HAQ scores predicted their utility most closely (for HUI3, R(2) = 0.626, P < 0.001; for EQ-5D, R(2) = 0.403, P < 0.001). The Disease Activity Score 28 severity index provided the next best relationship with a patient's utility; however, its explanatory power was poor (for HUI3, R(2) = 0.085, P < 0.001; for EQ-5D, R(2) = 0.042, P = 0.008). ESR, CRP, and, RA-affected joint counts had negligible explanatory power for patient utility. In analyses of the relationship between a range of key variables and the direct costs associated with RA, the HAQ score explained 22% of the variability in log costs (P < 0.001). CONCLUSION: This study found that of all the disease severity measures and clinical characteristics investigated, patients' HAQ scores predicted their utility most closely.

Using recombinant human thyroid-stimulating hormone for the diagnosis of recurrent thyroid cancer.

BACKGROUND: Recombinant human thyroid-stimulating hormone (rhTSH) has been suggested as a diagnostic agent in the diagnosis of recurrent thyroid cancer, instead of the current practice of thyroid hormone (THT) withdrawal. METHODS: An evidenced-based literature review was used as the basis for a cost-utility, decision-analytic model. Outcome measures were safety, efficacy (diagnostic performance and quality of life) and cost effectiveness of rhTSH. RESULTS: The literature search identified six comparative studies of rhTSH versus THT withdrawal. The most common adverse events associated with the use of rhTSH were headache (3.5-11.1%) and nausea (7.7-17%). When used as a diagnostic agent, the unadjusted sensitivity and specificity for rhTSH were 87% and 95%, respectively. Thus the use of rhTSH instead of THT withdrawal would result in a reduction in diagnostic accuracy, with 11% of patients' disease status being misclassified. Use of rhTSH resulted in a higher quality of life in the period prior to diagnostic testing than THT withdrawal (P < 0.001). When the impact of diagnostic performance, patient compliance to follow-up and modified quality of life were modelled over a 5 year time-frame, the incremental cost per QALY of rhTSH relative to THT withdrawal was $51 344.42. CONCLUSIONS: The use of rhTSH as a diagnostic agent appears to be safe but less diagnostically accurate and less cost-effective (on whole of healthcare cost basis) when used in the follow-up of patients with thyroid cancer who have had a previous negative radioiodine scan after thyroid hormone withdrawal.