Estimating the Impact of Switching from a Lower to Higher Valent Pneumococcal Conjugate Vaccine in Colombia, Finland, and The Netherlands: A Cost-Effectiveness Analysis.

INTRODUCTION: Widespread use of ten-valent (Synflorix™, GSK) or 13-valent (Prevenar 13™; Pfizer) conjugate vaccination programs has effectively reduced invasive pneumococcal disease (IPD) globally. However, IPD caused by serotypes not contained within the respective vaccines continues to increase, notably serotypes 3, 6A, and 19A in countries using lower-valent vaccines. Our objective was to estimate the clinical and economic benefit of replacing PCV10 with PCV13 in Colombia, Finland, and The Netherlands. METHODS: Country-specific databases, supplemented with published and unpublished data, informed the historical incidence of pneumococcal disease as well as direct and indirect medical costs. A decision-analytic forecasting model was applied, and both costs and outcomes were discounted. The observed invasive pneumococcal disease (IPD) trends from each country were used to forecast the future number of IPD cases given a PCV13 or PCV10 program. RESULTS: Over a 5-year time horizon, a switch to a PCV13 program was estimated to reduce overall IPD among 0-2 year olds by an incremental - 37.6% in Colombia, - 32.9% in Finland, and - 26% in The Netherlands, respectively, over PCV10. Adults > 65 years experienced a comparable incremental decrease in overall IPD in Colombia (- 32.2%), Finland (- 15%), and The Netherlands (- 3.7%). Serotypes 3, 6A, and 19A drove the incremental decrease in disease for PCV13 over PCV10 in both age groups. A PCV13 program was dominant in Colombia and Finland and cost-effective in The Netherlands at 1 × GDP per capita (€34,054/QALY). CONCLUSION: In Colombia, Finland, and The Netherlands, countries with diverse epidemiologic and population distributions, switching from a PCV10 to PCV13 program would significantly reduce the burden of IPD in all three countries in as few as 5 years.

Exploring the costs of a 13-valent pneumococcal conjugate vaccination program for home care patients.

OBJECTIVE: The city of Joensuu in Finland vaccinated 409 elderly home care patients with the 13-valent pneumococcal conjugate vaccine (PCV13) in autumn 2012. All home care patients were also eligible for a seasonal influenza vaccine. The objective of this retrospective real-world data cohort study was to evaluate whether the immunization intervention with PCV13 for home care patients was cost saving from the payer's (municipality's) perspective in terms of a return on investment (ROI). METHODS: This was a retrospective observational registry study. We used registry data from the regional Mediatri patient information system covering all North Karelian municipalities, including individual-level data for all health and social care service utilization, diagnoses and procedures. Home care patients and their use of services were followed for 2 years. Cost comparisons were based on two specifications: (1) pneumonia-related health care costs; and (2) total health care costs. We compared patients who had received both influenza and PCV13 vaccinations to patients only vaccinated against influenza. RESULT: The pneumonia-related costs in the PCV13-vaccinated group were 434 EUR lower and the total health care costs 3800 EUR lower per person, compared to the non-PCV13-vaccinated group (bootstrapped 95% CIs -1682-527 EUR and -8233-621 EUR, respectively). PCV13 vaccination was associated with a return on investment of 7 EUR per 1 EUR spent during the 2 year follow-up period when pneumonia-related costs were used as baseline. Probability of the positive return on investment was .715. CONCLUSION: The results suggest that vaccinating home care patients could potentially be cost saving from the health care and service producer's perspectives. The uncertainty from the decision-making perspective was due to the large variation in individual costs.

Characteristics of first-time varenicline users - A cross-sectional study in Finnish quitters.

BACKGROUND: Varenicline is an efficacious medicine for smoking cessation (SC) but little is known about the characteristics of varenicline users. This study examined the characteristics of first-time (naïve) varenicline users in Finland and compared those who had previously used SC pharmacotherapy to those who were trying SC pharmacotherapy for the first time. METHODS: A cross-sectional survey was conducted in Finnish community pharmacies between February 2014 and January 2015. Pharmacy customers purchasing a varenicline starter package for the first time ever were asked to complete a questionnaire or to participate in a structured interview conducted by the pharmacist (identical questions). The questionnaire included questions about demographic characteristics, smoking habits, previous cessation attempts and factors associated with varenicline use. RESULTS: Altogether 98 people completed the survey. The majority were daily smokers (96%, n = 94), with a history of over 10 years of regular smoking (94%, n = 92), and a strong/very strong nicotine dependence (67%, n = 66). Half of the participants (54%, n = 53) were trying a SC pharmacotherapy for the first time. Demographic characteristics and smoking habits were similar between first-time and previous users of SC medications (p > 0.05). Health centers (42%, n = 41) and occupational health care clinics (37%, n = 36) were the most common sources of varenicline prescriptions. The majority of participants received the prescription for varenicline after mentioning their desire for quitting to a physician (70%, n = 69). CONCLUSIONS: Considering the relatively large proportion of SC naïve medicine users among new users of varenicline, smokers who have previously been reluctant to quit smoking, to use other pharmacological SC interventions, or perhaps unaware of these options may be interested in attempting cessation with varenicline. Most participants made the initiative to discuss their smoking with the physician, which led to varenicline prescribing. This suggests that physicians may not satisfactorily recognize their patients' nicotine dependence and desire to quit, and they should more actively support patients' smoking cessation.

Re-treatment with varenicline is a cost-effective aid for smoking cessation.

OBJECTIVE: One quit attempt with varenicline has been found to be a cost-effective smoking cessation intervention. The purpose of this study was to analyze varenicline's cost-effectiveness in patients who relapse during or after the first treatment. A comparison was made between re-treatment schema with varenicline and re-treatment schema with bupropion, NRT and unaided cessation, and treatment once with varenicline in a Finnish context. METHODS: The two-quit version of BENESCO Markov model was used to follow a cohort of smokers making up to two quit attempts over a lifetime. The abstinence rates of the interventions were derived from a Cochrane review. Gender- and age-specific data on the incidence and prevalence of five smoking-related diseases were included in the model. Quality-adjusted life-years, total expected costs, and the lifetime cumulative incidence of smoking-related morbidities and mortality were the primary outcomes evaluated. RESULTS: The study cohort comprised 116,533 smokers who were willing to make a quit attempt. In the lifetime simulation, re-treatment with varenicline yielded 6,150-20,250 extra quitters, depending on the comparator. Among these quitters it was possible to prevent 899-2,972 additional cases of smoking-related diseases, and 395-1,307 deaths attributable to smoking. Re-treatment with varenicline resulted in cost savings of up to 54.9 million Euros. Re-treatment with varenicline dominated all the other smoking cessation interventions used in the analysis. Sensitivity analysis supported the robustness of the base case results. LIMITATIONS: The analysis did not consider adverse events, and included only five major smoking-related diseases, which is a conservative approach, and probably leads to under-estimation of cost-effectiveness of cessation interventions. Furthermore, assumptions of constant relative risks for smoking-related diseases for each smoking status and the proxy values used as efficacy estimates of second quit attempts for other interventions than varenicline are limitations. CONCLUSIONS: A second quitting effort with varenicline is economically justifiable.

Cost-effectiveness of routine measuring of serum drug concentrations and anti-drug antibodies in treatment of rheumatoid arthritis patients with TNF-α blockers.

Monitoring of anti-drug antibodies (ADAbs) or serum concentrations of biologicals in treatment of rheumatoid arthritis could provide an explanation for a loss of efficacy and help in the choice of subsequent medication. Current clinical practices do not generally include such monitoring of tumor necrosis factor (TNF)-α blockers on a routine basis. The main aims of this study were to estimate the probabilities of optimal and nonoptimal treatment decisions if infliximab or adalimumab drug trough level (DL) and ADAbs are tested or not in rheumatoid arthritis, and to model cost-effectiveness of performing such monitoring on a routine basis. Data on DLs and ADAbs concentrations were obtained in Finland from clinically requested monitoring analyses of 486 and 1,137 samples from patients on adalimumab and infliximab, respectively. DL was within the target range in 42% of samples from adalimumab- and 50.4% of infliximab-treated patients. ADAbs were detected in approximately 20% and 13.5% of samples from adalimumab- and infliximab-treated patients, respectively. ADAbs were found in 52.3% and 41.3% of those with low adalimumab or infliximab DLs, respectively. The monitoring data were incorporated into probabilities for making the optimal treatment decision. Economic impact of clinical decision-making was modeled in a short-term (3-6 months) scenario with 100 hypothetical patients. In the model, the combined measurement of DLs and ADAbs was cost-saving compared to the nontesting scenario when the monitoring results affected the treatment decision in at least 2-5 of 100 patients, a proportion which is easily exceeded in real-life clinical practice. This study indicates that routine monitoring of drug level and ADAbs is cost-beneficial in clinical practice, thereby improving the decision-making process in using TNF-α blockers.

Economic impact of 13-valent pneumococcal conjugate vaccine in Finnish adults ≥50 years with underlying chronic medical conditions.

RATIONALE, AIMS AND OBJECTIVES: Invasive pneumococcal diseases (IPD) are associated with substantial burden in adults (≥50 years). Moreover, adults with vascular, metabolic or respiratory diseases have been shown to have a 3-6 times higher risk of IPD when compared with their healthy controls. These persons at higher risk are likely to benefit most from pneumococcal vaccinations. The 13-valent pneumococcal conjugate vaccine (PCV13) was recently introduced to prevent the 13 most prevalent serotypes causing invasive pneumococcal disease in adults. The objective of this study was to estimate the expected 5-year economic impact of targeted PCV13 vaccination compared with no vaccination in Finnish adults (≥50 years) at moderate or high risk for IPD. METHODS: A budget impact model was developed to predict the impact of PCV13 vaccination in terms of the costs and IPD events avoided for years 2012-2016. RESULTS: Approximately 35% of the 2.2 million Finns over 50 years of age can be considered to be at moderate or high risk for IPD because of underlying chronic medical conditions. Vaccination of these people with PCV13 could provide an estimated net budget savings of about €218 million compared with the current no-vaccination situation over the next 5 years. Among the risk groups considered, the largest absolute net savings (€66.2 million) could be expected to be obtained by vaccinating people with heart disease, due to its high prevalence in the target population. CONCLUSION: In Finland, the immunization with PCV13 vaccine, of adults (≥50 years) at moderate and high risk of IPD, is estimated to lead to substantial cost savings in the 5 years after vaccination.

[Cost-effectiveness alone is not sufficient as basis for prioritization]. / Kustannusvaikuttavuus ei yksin riitä priorisoinnin perustaksi.

Cost-effectiveness has been suggested as the sole ethical basis for prioritization systems. The methods of health economics per se may be beneficial in decision making situations of various types. The structure of Finnish healthcare system and value-based choices associated with the application of cost-effectiveness make, however, utilizability more difficult than thought. Analysis of cost- effectiveness is worth using, but criteria and methods of decision making of health economics cannot be harnessed as tools for technocratic decision-making. Value-based choices should be subjected to wide public debate.

Characterization of a compressive imaging system using laboratory and natural light scenes.

Compressive imagers acquire images, or other optical scene information, by a series of spatially filtered intensity measurements, where the total number of measurements required depends on the desired image quality. Compressive imaging (CI) offers a versatile approach to optical sensing which can improve size, weight, and performance (SWaP) for multispectral imaging or feature-based optical sensing. Here we report the first (to our knowledge) systematic performance comparison of a CI system to a conventional focal plane imager for binary, grayscale, and natural light (visible color and infrared) scenes. We generate 1024×1024 images from a range of measurements (0.1%-100%) acquired using digital (Hadamard), grayscale (discrete cosine transform), and random (Noiselet) CI basis sets. Comparing the outcome of the compressive images to conventionally acquired images, each made using 1% of full sampling, we conclude that the Hadamard Transform offered the best performance and yielded images with comparable aesthetic quality and slightly higher spatial resolution than conventionally acquired images.

Prototype development and field-test results of an adaptive multiresolution PANOPTES imaging architecture.

The design, development, and field-test results of a visible-band, folded, multiresolution, adaptive computational imaging system based on the Processing Arrays of Nyquist-limited Observations to Produce a Thin Electro-optic Sensor (PANOPTES) concept is presented. The architectural layout that enables this imager to be adaptive is described, and the control system that ensures reliable field-of-view steering for precision and accuracy in subpixel target registration is explained. A digital superresolution algorithm introduced to obtain high-resolution imagery from field tests conducted in both nighttime and daytime imaging conditions is discussed. The digital superresolution capability of this adaptive PANOPTES architecture is demonstrated via results in which resolution enhancement by a factor of 4 over the detector Nyquist limit is achieved.

Cost-effectiveness analysis of budesonide/formoterol maintenance and reliever therapy versus fixed combination treatments for asthma in Finland*.

BACKGROUND: Budesonide/formoterol maintenance and reliever therapy has shown its effectiveness as a treatment for moderate-to-severe asthma. OBJECTIVE: To explore the cost-effectiveness of budesonide/formoterol maintenance and reliever therapy as compared to fixed combination therapies (budesonide/formoterol and salmeterol/fluticasone) with terbutaline as needed in the treatment of asthma in Finland. METHODS: Patients without asthma exacerbations during a 6-month period were used as the effectiveness variable in the within-trial economic analysis. Finnish unit costs were applied to pooled resource use data, and multinomial cost-effectiveness plane and acceptability curves were formed based on bootstrapping. RESULTS: Use of budesonide/formoterol maintenance and reliever therapy significantly reduced the rate of severe asthma exacerbations as compared with a fixed dose of budesonide/formoterol or salmeterol/fluticasone and terbutaline as needed. Total costs over 6 months were 496 euros per patient for those who used the budesonide/formoterol maintenance and reliever therapy treatment model, which was 78-101 euros lower than the cost of fixed combinations of salmeterol/fluticasone or budesonide/formoterol with terbutaline as needed. The results indicate that the budesonide/formoterol maintenance and reliever therapy achieves a high probability (> 93%) of cost effectiveness irrespective of willingness to pay level. CONCLUSIONS: Budesonide/formoterol maintenance and reliever therapy may be considered in the treatment of moderate-to-severe asthma instead of conventional treatment with combination products in view of its good clinical efficacy and a high probability of cost-effectiveness in the Finnish setting. However, a cost-effectiveness analysis with a longer time horizon, more Finnish-specific data, and ICS + short/long-acting inhaled beta(2)-agonist as an additional comparator is still warranted.

Productivity and employees' organizational justice perceptions in long-term care for the elderly.

We examined the associations between productivity, employer characteristics, and context variables, and the organizational justice perceptions of 330 female employees in long-term institutional elderly people care. The productivity measure used was the proportion of the inpatient days to total costs. Employees working in high productivity units experienced higher procedural justice than those working in low productivity units. Hostile employees experienced both the procedures and management as less fair than non-hostile employees. Unit size and resident turnover were negatively and registered nurses percentage positively associated with procedural justice perceptions.

RUG-III for exploring the association between staffing levels and cost-efficiency in nursing facility care in Finland.

The current health policy of the Finnish government with regard to the production of health services strongly emphasizes productivity and efficiency. On the other hand, the staff generally demand better staffing for nursing facility care. This study incorporates the Resource Utilization Groups (RUG-III) in the calculation of the staffing levels and cost-efficiency and explores the association between cost-efficiency and staff levels in nursing facility care in Finland. The results indicate an improvement potential in case-mix-based staffing. Existing labor resources can be used more fairly and effectively while cost-efficiency differences can be diminished by applying the RUG-III for the allocation of the staff.

Patient- and ward-level determinants of nursing time in nursing facilities.

OBJECTIVES: To explore the patient- and ward-level determinants of wage-adjusted nursing time in long-term care wards for the elderly with a view to improving efficiency of the use of labour resources. METHODS: The wage-adjusted nursing time given to patients was obtained from a time measurement study. Patient characteristics were based on the Minimum Data Set 2.0 of the Resident Assessment Instrument for nursing homes. Ordinary least-squares regression analysis and multilevel modelling were used to disentangle the effect of patient- and ward-level factors on nursing time. RESULTS: A significant difference in wage-adjusted nursing time between wards was detected, which was partly explained by characteristics of patients in wards. The combination of patients' physical functioning and cognition and the Resource Utilization Groups RUG-III/22 resource use classification explained 20-25% of patients' nursing time over a 24-hour period. Variables related to the operational environment of the ward did not explain differences in wage-adjusted nursing time once the patient profile of the ward had been controlled for. The results also showed notable unmeasured patient and ward level effects, inefficiency and randomness in the allocation of nursing time. CONCLUSIONS: By improving the allocation and use of labour resources, the substantial variation in nursing time between wards could be diminished. Managers should allocate their staff primarily according to patients' resource needs.

The cost efficiency and clinical quality of institutional long-term care for the elderly.

This study applied the stochastic frontier cost function with inefficiency effects to estimate the association between quality of care and cost efficiency in institutional long-term care wards for the elderly in Finland. We used several clinical quality indicators for indicating adverse care processes and outcomes, based on the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS). Average cost inefficiency among the wards was 22%. We found an association between the clinical quality indicators and cost inefficiency. Higher prevalence of pressure ulcers was associated with higher costs, whereas the higher prevalence of use of depressants and hypnotics increased inefficiency.

The association between quality of care and technical efficiency in long-term care.

OBJECTIVE: To analyse the association between quality of care and technical (productive) efficiency in institutional long-term care wards for the elderly. SETTING: One hundred and fourteen public health centre hospitals and residential homes in Finland. STUDY DESIGN: Wards were divided into two categories according to their rank in the quality distribution, considering 41 quality variables separately. The technical efficiency scores of the good- and poor-quality groups were compared using cross-sectional data. METHODS: Data envelopment analysis was used for calculating technical efficiency. The Mann-Whitney test and correlation coefficients were used to explore the association between quality and efficiency. RESULTS: The wards where quality indicators indicated less pro-active (passive) nursing practice and more dependent patients-for instance, in terms of very high prevalence of bedfast residents or very high prevalence of daily physical restraints-performed more efficiently than the comparison group. CONCLUSION: The results suggest that an association may exist between technical efficiency and unwanted dimensions of quality. Hence, the efficiency and quality of care are essential aspects of management and performance measurement in elderly care.

Measuring the productive efficiency and clinical quality of institutional long-term care for the elderly.

The authors consider the association between productive efficiency and clinical quality in institutional long-term care for the elderly. Cross-sectional data were collected from 122 wards in health-centre hospitals and residential homes in Finland in 2001. Productive efficiency was measured in terms of technical efficiency, which was defined as the unit's distance from the (best practice) production frontier. The analysis employed stochastic production frontier estimation, where technical inefficiency in the production function was specified to be a function of ward characteristics and clinical quality of care. Several quality indicators based on the Resident Assessment Instrument, such as prevalence of pressure ulcers and depression with no treatment, were used in the analysis. The results did not reveal systematic association between technical efficiency and clinical quality of care. However, the prevalence of pressure ulcers, indicating poor quality of care was associated with technical efficiency, a fact which highlights the importance of including quality measures in the assessment of efficiency in long-term care.