Eric T. Roberts

Cost-Effectiveness of Coronary Artery Calcium Testing for Coronary Heart and Cardiovascular Disease Risk Prediction to Guide Statin Allocation: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background The Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated. Objective To model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines. Methods We developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a “treat all” strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas. Results We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use. Conclusion Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients risks of CVD.

The Quality Of Care Delivered To Patients Within The Same Hospital Varies By Insurance Type

In attempting to explain why hospitals vary in the quality of care delivered to patients, a considerable body of health policy research points to differences in hospital characteristics such as ownership, safety-net status, and geographic location as the most important contributing factors. This article examines the extent to which a patients type or lack of insurance may also play a role in determining the quality of care received at any given hospital. We compared within-hospital quality, as measured by risk-adjusted mortality rates, for patients according to their insurance status. We examined the Agency for Healthcare Research and Qualitys innovative Inpatient Quality Indicators and pooled 2006-08 State Inpatient Database records from eleven states. We found that privately insured patients had lower risk-adjusted mortality rates than did Medicare enrollees for twelve out of fifteen quality measures examined. To a lesser extent, privately insured patients also had lower risk-adjusted mortality rates than those in other payer groups. Medicare patients appeared particularly vulnerable to receiving inferior care. These findings suggest that to help reduce care disparities, public payers and hospitals should measure care quality for different insurance groups and monitor differences in treatment practices within hospitals.

Cost-Effectiveness of a new Rotavirus Vaccination Program in Pakistan: a Decision Tree Model

BACKGROUNDnRotavirus gastroenteritis places a significant health and economic burden on Pakistan. To determine the public health impact of a national rotavirus vaccination program, we performed a cost-effectiveness study from the perspective of the health care system.nnnMETHODSnA decision tree model was developed to assess the cost-effectiveness of a national vaccination program in Pakistan. Disease and cost burden with the program were compared to the current state. Disease parameters, vaccine-related costs, and medical treatment costs were based on published epidemiological and economic data, which were specific to Pakistan when possible. An annual birth cohort of children was followed for 5 years to model the public health impact of vaccination on health-related events and costs. The cost-effectiveness was assessed and quantified in cost (2012 US

The effect of emergency department copayments for Medicaid beneficiaries following the Deficit Reduction Act of 2005.

) per disability-adjusted life-year (DALY) averted and cost per death averted. Sensitivity analyses were performed to assess the robustness of the incremental cost-effectiveness ratios (ICERs).nnnRESULTSnThe base case results showed vaccination prevented 1.2 million cases of rotavirus gastroenteritis, 93,000 outpatient visits, 43,000 hospitalizations, and 6700 deaths by 5 years of age for an annual birth cohort scaled from 6% current coverage to DPT3 levels (85%). The medical cost savings would be US

The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities

1.4 million from hospitalizations and US

Market Share Matters: Evidence Of Insurer And Provider Bargaining Over Prices

200,000 from outpatient visit costs. The vaccination program would cost US

High-Price And Low-Price Physician Practices Do Not Differ Significantly On Care Quality Or Efficiency

35 million at a vaccine price of US

Does Churning in Medicaid Affect Health Care Use

5.00. The ICER was US

Patient sharing and quality of care measuring outcomes of care coordination using claims data

149.50 per DALY averted or US

Community Characteristics and Mortality: The Relative Strength of Association of Different Community Characteristics

4972 per death averted. Sensitivity analyses showed changes in case-fatality ratio, vaccine efficacy, and vaccine cost exerted the greatest influence on the ICER.nnnCONCLUSIONSnAcross a range of sensitivity analyses, a national rotavirus vaccination program was predicted to decrease health and economic burden due to rotavirus gastroenteritis in Pakistan by ~40%. Vaccination was highly cost-effective in this context. As discussions of implementing the intervention intensify, future studies should address affordability, efficiency, and equity of vaccination introduction.