Comparing the Medicaid Prospective Drug Utilization Review Program Cost-Savings Methods Used by State Agencies in 2015 and 2016.

BACKGROUND: The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR process and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR involving ongoing, periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, and medically unnecessary care, and implement corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure the prescription drug cost-savings generated from its DUR programs annually, but it provides no methodology for doing so. An earlier article compared the methodologies used by states to measure cost-savings in their retrospective DUR program in fiscal years 2014 and 2015. OBJECTIVE: To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid prospective DUR program in federal fiscal years 2015 and 2016. METHODS: For each state, we downloaded from Medicaid's website the cost-savings methodologies included in the Medicaid DUR 2015 and 2016 reports. We then reviewed and synthesized the reports. Methods described by the states were classified into a unique group based on the methodology used, except for Arkansas and Connecticut, which were classified in more than 1 category for the same period. RESULTS: Currently, 3 different methodologies are being used by states. In 2015 and 2016, the most common methodology used (by 18 states) was the calculation of total claim rejections and subtracting claim resubmissions at the amount actually paid. The comparisons of DUR program cost-savings among states are unreliable, because the states lack a common methodology in the way they measure their performance. CONCLUSIONS: Considering the lack of methodologic consistency among states in measuring the savings in the Medicaid DUR program shown in this analysis, the federal government must lead an effort to define a unique methodology to measure cost-savings in its entire DUR program. This will help to improve the measure of savings among states and understand how this program is performing in that matter.

Accuracy, limitations and cost efficiency of eDNA-based community survey in tropical frogs.

Rapid environmental change in highly biodiverse tropical regions demands efficient biomonitoring programmes. While existing metrics of species diversity and community composition rely on encounter-based survey data, eDNA recently emerged as alternative approach. Costs and ecological value of eDNA-based methods have rarely been evaluated in tropical regions, where high species richness is accompanied by high functional diversity (e.g., the use of different microhabitats by different species and life stages). We first tested whether estimation of tropical frogs' community structure derived from eDNA data is compatible with expert field assessments. Next, we evaluated whether eDNA is a financially viable solution for biodiversity monitoring in tropical regions. We applied eDNA metabarcoding to investigate frog species occurrence in five ponds in the Chiquitano dry forest region in Bolivia and compared our data with a simultaneous visual and audio encounter survey (VAES). We found that taxon lists and community structure generated with eDNA and VAES correspond closely, and most deviations are attributable to different species' life histories. Cost efficiency of eDNA surveys was mostly influenced by the richness of local fauna and the number of surveyed sites: VAES may be less costly in low-diversity regions, but eDNA quickly becomes more cost-efficient in high-diversity regions with many sites sampled. The results highlight that eDNA is suitable for large-scale biodiversity surveys in high-diversity areas if life history is considered, and certain precautions in sampling, genetic analyses and data interpretation are taken. We anticipate that spatially extensive, standardized eDNA biodiversity surveys will quickly emerge in the future.

Latin American Clinical Epidemiology Network Series - Paper 4: Economic evaluation of Kangaroo Mother Care: cost utility analysis of results from a randomized controlled trial conducted in Bogotá.

BACKGROUND AND OBJECTIVE: Although kangaroo mother care (KMC) has been shown to be safe and effective in randomized controlled trials (RCTs), there are no published complete economic evaluations including the three components of the full intervention. METHODS: A cost utility analysis performed on the results of an RCT conducted in Bogotá, Colombia between 1993 and 1996. Hospital and ambulatory costs were estimated by microcosting in a sample of preterm infants from a University Hospital in Bogotá in 2011 and at a KMC clinic in the same period. Utility scores were assigned by experts by means of (1) direct ordering and scoring discrete health states and (2) constructing a multi-attribute utility function. Ninety-five percent confidence intervals (CIs) for the incremental cost-utility ratios (ICURs) were computed by the Fiellers theorem method. One-way sensitivity analysis on price estimates for valuing costs was performed. RESULTS: ICUR at 1 year of corrected age was $ -1,546 per extra quality-adjusted life year gained using the KMC method (95% CI $ -7,963 to $ 4,910). CONCLUSION: In Bogotá, the use of KMC is dominant: more effective and cost-saving. Although results from an economic analysis should not be extrapolated to different systems and communities, this dominant result suggests that KMC could be cost-effective in similar low and middle income countries settings.

A Comparison of 1-Year Treatment Costs in Patients with Type 2 Diabetes Following Initiation of Insulin Glargine or Insulin Detemir in Argentina.

OBJECTIVE: To estimate and compare type 2 diabetes mellitus treatment costs in insulin-naive patients following initiation of therapy with either insulin glargine (IG) or insulin detemir (ID) over 1-year time horizon from a payers' perspective in Argentina. METHODS: We used a pharmacoeconomic model based on a randomized trial comparing IG and ID (Rosenstock J, Davies M, Home PD, et al. A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia 2008;51:408-16) and Argentinean sources. Clinical, resource use, and cost data were combined to estimate direct medical costs (insulin, test strips, and needles) during the first year. Price per international unit of insulin is similar for IG and ID in the local market. Deterministic analysis was performed on insulin unit cost and probabilistic sensitivity analyses on clinical, resource use, and unit costs to evaluate contribution to variance on the difference in total annual treatment cost. RESULTS: Annual mean treatment cost (Argentinean pesos 2013) was AR $6229 for IG and AR $9257 for ID, showing 33% total cost reduction with IG (AR $3028; exchange rate US $1.00 = AR $5.30). Probabilistic sensitivity analysis showed that IG was cost saving in 88% of the simulations. The most influential parameter was the difference in insulin dose requirements. Threshold analysis showed that if the unit price of ID is reduced by 43%, ceteris paribus, the total annual costs per person for both insulin regimens would be the same. CONCLUSIONS: From a payer's perspective in Argentina, cost savings related to the use of IG represented one third of total treatment costs. Sensitivity analyses confirmed the robustness of these results.

Cost-effectiveness of integrated pest management compared with insecticidal spraying against the German cockroach in apartment buildings

This study assessed the cost and effectiveness of an integrated pest management (IPM) program using hydramethylnon gel baits compared with conventional spraying for controlling the German cockroach, Blattella germanica (L.) (Blattodea: Blattellidae), in two residential buildings in Yasuj, Iran. The IPM approach was based on educational programs using pamphlets, posters and lectures, sanitation using vacuuming and application of hydramethylnon gel baits. Conventional approach used cypermethrin (10 percent EC) on baseboard and cracks-and-crevices. Sticky traps were used as tools for monitoring cockroach population densities. The IPM approach reduced (943 percent) the rate of insecticide application compared to the conventional spray. Cockroach populations in the IPM treatment were significantly reduced from an average of 12.2 ± 3.01 cockroaches per unit before treatment to zero cockroach per unit by week four and thereafter. Cockroach populations in the conventional spray treatment were reduced from an average of 11.5 ± 4.43 cockroaches per unit before treatment to an average of 3.4 ± 0.99 cockroach per unit after 11 weeks of post treatment. The IPM treatment improved 100 percent of infested units compared to 78 percent for spray treatment to obtain a clean level of infestation (< 1cockroach per trap per unit). The results suggest that the intervention by IPM using hydramethylnon gel baits significantly reduced cockroach infestation compared to cypermethrin spray throughout the 11 weeks of post-treatment period. However, within the study period, the IPM system involving gel baits, educational program and sanitation was 363.2 percent more expensive than the conventional method.