Vladislav Berdunov

The Identification of Seniors at Risk (ISAR) score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Background: tools are required to identify high-risk older people in acute emergency settings so that appropriate services can be directed towards them. Objective: to evaluate whether the Identification of Seniors At Risk (ISAR) predicts the clinical outcomes and health and social services costs of older people discharged from acute medical units. Design: an observational cohort study using receiver–operator curve analysis to compare baseline ISAR to an adverse clinical outcome at 90 days (where an adverse outcome was any of death, institutionalisation, hospital readmission, increased dependency in activities of daily living (decrease of 2 or more points on the Barthel ADL Index), reduced mental well-being (increase of 2 or more points on the 12-point General Health Questionnaire) or reduced quality of life (reduction in the EuroQol-5D) and high health and social services costs over 90 days estimated from routine electronic service records. Setting: two acute medical units in the East Midlands, UK. Participants: a total of 667 patients aged ≥70 discharged from acute medical units. Results: an adverse outcome at 90 days was observed in 76% of participants. The ISAR was poor at predicting adverse outcomes (AUC: 0.60, 95% CI: 0.54–0.65) and fair for health and social care costs (AUC: 0.70, 95% CI: 0.59–0.81). Conclusions: adverse outcomes are common in older people discharged from acute medical units in the UK; the poor predictive ability of the ISAR in older people discharged from acute medical units makes it unsuitable as a sole tool in clinical decision-making.

Identifying patient-level health and social care costs for older adults discharged from acute medical units in England

BACKGROUND acute medical units allow for those who need admission to be correctly identified, and for those who could be managed in ambulatory settings to be discharged. However, re-admission rates for older people following discharge from acute medical units are high and may be associated with substantial health and social care costs. OBJECTIVE identifying patient-level health and social care costs for older people discharged from acute medical units in England. DESIGN a prospective cohort study of health and social care resource use. SETTING an acute medical unit in Nottingham, England. PARTICIPANTS four hundred and fifty-six people aged over 70 who were discharged from an acute medical unit within 72 h of admission. METHODS hospitalisation and social care data were collected for 3 months post-recruitment. In Nottingham, further approvals were gained to obtain data from general practices, ambulance services, intermediate care and mental healthcare. Resource use was combined with national unit costs. RESULTS costs from all sectors were available for 250 participants. The mean (95% CI, median, range) total cost was £1926 (1579-2383, 659, 0-23,612). Contribution was: secondary care (76.1%), primary care (10.9%), ambulance service (0.7%), intermediate care (0.2%), mental healthcare (2.1%) and social care (10.0%). The costliest 10% of participants accounted for 50% of the cost. CONCLUSIONS this study highlights the costs accrued by older people discharged from acute medical units (AMUs): they are mainly (76%) in secondary care and half of all costs were incurred by a minority of participants (10%).

Cost-Effectiveness of a Specialist Geriatric Medical Intervention for Frail Older People Discharged from Acute Medical Units: Economic Evaluation in a Two-Centre Randomised Controlled Trial (AMIGOS).

Background Poor outcomes and high resource-use are observed for frail older people discharged from acute medical units. A specialist geriatric medical intervention, to facilitate Comprehensive Geriatric Assessment, was developed to reduce the incidence of adverse outcomes and associated high resource-use in this group in the post-discharge period. Objective To examine the costs and cost-effectiveness of a specialist geriatric medical intervention for frail older people in the 90 days following discharge from an acute medical unit, compared with standard care. Methods Economic evaluation was conducted alongside a two-centre randomised controlled trial (AMIGOS). 433 patients (aged 70 or over) at risk of future health problems, discharged from acute medical units within 72 hours of attending hospital, were recruited in two general hospitals in Nottingham and Leicester, UK. Participants were randomised to the intervention, comprising geriatrician assessment in acute units and further specialist management, or to control where patients received no additional intervention over and above standard care. Primary outcome was incremental cost per quality adjusted life year (QALY) gained. Results We undertook cost-effectiveness analysis for 417 patients (intervention: 205). The difference in mean adjusted QALYs gained between groups at 3 months was -0.001 (95% confidence interval [CI]: -0.009, 0.007). Total adjusted secondary and social care costs, including direct costs of the intervention, at 3 months were £4412 (€5624,

Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial).

6878) and £4110 (€5239,

Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility study

6408) for the intervention and standard care groups, the incremental cost was £302 (95% CI: 193, 410) [€385,

Introduction to Statistics and Modeling Methods Applied in Health Economics

471]. The intervention was dominated by standard care with probability of 62%, and with 0% probability of cost-effectiveness (at £20,000/QALY threshold). Conclusions The specialist geriatric medical intervention for frail older people discharged from acute medical unit was not cost-effective. Further research on designing effective and cost-effective specialist service for frail older people discharged from acute medical units is needed. Trial Registration ISRCTN registry ISRCTN21800480 http://www.isrctn.com/ISRCTN21800480

NHS Outcomes Framework 2012–13

Background One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months. Objective To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care. Methods Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%). Results The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded. Conclusions The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation. Trial Registration ClinicalTrials.gov NCT01136148

Earlier Detection And Treatment of Non-Alcoholic Fatty Liver Disease: An Economic Evaluation to Appraise An Innovative Diagnostic Pathway to Detect And Intervene Where There Are Known Risk Factors

Objectives To assess the long-term cost-effectiveness of a risk stratification pathway, compared with standard care, for detecting non-alcoholic fatty liver disease (NAFLD) in primary care. Setting Primary care general practices in England. Participants Adults who have been identified in primary care to have a risk factor for developing NAFLD, that is, type 2 diabetes without a history of excessive alcohol use. Intervention A community-based pathway, which uses transient elastography and hepatologists to stratify patients at risk of NAFLD, has been implemented and demonstrated to be feasible (NCT02037867). Earlier identification could mean earlier treatments, referral to specialist and enrolment into surveillance programmes. Design The impact of earlier detection and treatment with the risk stratification pathway on progression to later stages of liver disease was examined using decision modelling with Markov chains to estimate lifetime health and economic effects of the two comparators. Data sources Data from a prospective cross-sectional feasibility study indicating risk stratification pathway and standard care diagnostic accuracies were combined with a Markov model that comprised the following states: no/mild liver disease, significant liver disease, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplant and death. The model data were chosen from up-to-date UK sources, published literature and an expert panel. Outcome measure An incremental cost-effectiveness ratio (ICER) indicating cost per quality-adjusted life year (QALY) of the risk stratification pathway compared with standard care was estimated. Results The risk stratification pathway was more effective than standard care and costs £2138 per QALY gained. The ICER was most sensitive to estimates of the rate of fibrosis progression and the effect of treatment on reducing this, and ranged from −£1895 to £7032/QALY. The risk stratification pathway demonstrated an 85% probability of cost-effectiveness at the UK willingness-to-pay threshold of £20 000/QALY. Conclusions Implementation of a community-based risk stratification pathway is likely to be cost-effective. Trial registration number NCT02037867, ClinicalTrials.gov.

Cost-Effectiveness Analysis Of Alternative Strategies Of Monitoring For Amiodarone-Related Thyroid Toxicity In Uk Primary Care.

The increasing complexity of health economics methodology has raised the need for technical methods to systematically use patient-level data and characterize uncertainty around the decision problem for decision makers. This chapter provides an introduction to these methods, focusing on trial-based statistical techniques and economic modeling methods for the purpose of health economic analysis. This chapter describes some differences between the more commonly used frequentist approach for clinical analysis and the developing use of Bayesian methods for health economic analysis. Statistical methods described include the use of power calculations, hypothesis testing, and regression analysis, and their relevance for economic analysis. More advanced statistical methods are also introduced, such as the area under the curve method for assessing incremental benefit, controlling for missing data and baseline characteristics, and using mapping algorithms for eliciting preference-based tariff scores when a preference-based measure has not been collected within a study. The second part of the chapter focuses on modeling methods designed to synthesize data from multiple sources when the economic analysis needs to go beyond a single source of primary data or for a longer time horizon. Multiple types of economic models are described, including decision trees, state transition models (including Markov chain models), microsimulation, and discrete event simulation. The chapter breaks down key elements of model design and offers recommendations on possible sources of data that may be used to derive parameter estimates. The conclusion of the chapter includes recommendations for appropriately reporting results of the statistical and modeling analyses carried out as part of an economic evaluation.