RESUMEN
OBJECTIVE: To assess the impact of alternative methods of aggregating individual quality measures on Accountable Care Organization (ACO) overall scores. DATA SOURCE: 2014 quality scores for Medicare ACOs. STUDY DESIGN: We compare ACO overall scores derived using CMS' aggregation approach to those derived using alternative approaches to grouping and weighting measures. PRINCIPAL FINDINGS: Alternative grouping and weighting methods based on statistical criteria produced overall quality scores similar to those produced using CMS' approach (κ = 0.80 to 0.95). Scores derived from giving specific domains greater weight were less similar (κ = 0.51 to 0.93). CONCLUSIONS: How measures are grouped into domains and how these domains are weighted to generate overall scores can have important implications for ACO's shared savings payments.
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Organizaciones Responsables por la Atención/normas , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Mecanismo de Reembolso , Ahorro de Costo , Planes de Aranceles por Servicios , Humanos , Medicare/organización & administración , Modelos Estadísticos , Estados UnidosRESUMEN
BACKGROUND: Rivaroxaban is the first oral factor Xa inhibitor approved in the US to reduce the risk of stroke and blood clots among people with non-valvular atrial fibrillation, treat deep vein thrombosis (DVT), treat pulmonary embolism (PE), reduce the risk of recurrence of DVT and PE, and prevent DVT and PE after knee or hip replacement surgery. The objective of this study was to evaluate the costs from a hospital perspective of treating patients with rivaroxaban vs other anticoagulant agents across these five populations. METHODS: An economic model was developed using treatment regimens from the ROCKET-AF, EINSTEIN-DVT and PE, and RECORD1-3 randomized clinical trials. The distribution of hospital admissions used in the model across the different populations was derived from the 2010 Healthcare Cost and Utilization Project database. The model compared total costs of anticoagulant treatment, monitoring, inpatient stay, and administration for patients receiving rivaroxaban vs other anticoagulant agents. The length of inpatient stay (LOS) was determined from the literature. RESULTS: Across all populations, rivaroxaban was associated with an overall mean cost savings of $1520 per patient. The largest cost savings associated with rivaroxaban was observed in patients with DVT or PE ($6205 and $2742 per patient, respectively). The main driver of the cost savings resulted from the reduction in LOS associated with rivaroxaban, contributing to â¼90% of the total savings. Furthermore, the overall mean anticoagulant treatment cost was lower for rivaroxaban vs the reference groups. LIMITATIONS: The distribution of patients across indications used in the model may not be generalizable to all hospitals, where practice patterns may vary, and average LOS cost may not reflect the actual reimbursements that hospitals received. CONCLUSION: From a hospital perspective, the use of rivaroxaban may be associated with cost savings when compared to other anticoagulant treatments due to lower drug cost and shorter LOS associated with rivaroxaban.
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Pacientes Internos , Morfolinas/economía , Embolia Pulmonar/tratamiento farmacológico , Tiofenos/economía , Trombosis de la Vena/tratamiento farmacológico , Warfarina/economía , Administración Oral , Anticoagulantes/administración & dosificación , Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/economía , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/economía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/economía , Simulación por Computador , Ahorro de Costo/métodos , Ahorro de Costo/estadística & datos numéricos , Análisis Costo-Beneficio , Inhibidores del Factor Xa/administración & dosificación , Inhibidores del Factor Xa/economía , Inhibidores del Factor Xa/uso terapéutico , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Modelos Económicos , Morfolinas/administración & dosificación , Morfolinas/uso terapéutico , Embolia Pulmonar/economía , Embolia Pulmonar/prevención & control , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Rivaroxabán , Tiofenos/administración & dosificación , Tiofenos/uso terapéutico , Estados Unidos , Trombosis de la Vena/economía , Trombosis de la Vena/prevención & control , Warfarina/administración & dosificación , Warfarina/uso terapéuticoRESUMEN
The association of phytoplankton with bacteria is ubiquitous in nature and the bacteria that associate with different phytoplankton species are very diverse. The influence of these bacteria in the physiology and ecology of the host and the evolutionary forces that shape the relationship are still not understood. In this study, we used the Pseudo-nitzschia-microbiota association to determine (1) if algal species with distinct domoic acid (DA) production are selection factors that structures the bacterial community, (2) if host-specificity and co-adaptation govern the association, (3) the functional roles of isolated member of microbiota on diatom-hosts fitness and (4) the influence of microbiota in changing the phenotype of the diatom hosts with regards to toxin production. Analysis of the pyrosequencing-derived 16S rDNA data suggests that the three tested species of Pseudo-nitzschia, which vary in toxin production, have phylogenetically distinct bacterial communities, and toxic Pseudo-nitzschia have lower microbial diversity than non-toxic Pseudo-nitzschia. Transplant experiments showed that isolated members of the microbiota are mutualistic to their native hosts but some are commensal or parasitic to foreign hosts, hinting at co-evolution between partners. Moreover, Pseudo-nitzschia host can gain protection from algalytic bacteria by maintaining association with its microbiota. Pseudo-nitzschia also exhibit different phenotypic expression with regards to DA production, and this depends on the bacterial species with which the host associates. Hence, the influences of the microbiota on diatom host physiology should be considered when studying the biology and ecology of marine diatoms.
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Diatomeas/microbiología , Diatomeas/fisiología , Especificidad del Huésped , Ácido Kaínico/análogos & derivados , Microbiota/fisiología , Biodiversidad , Diatomeas/genética , Diatomeas/metabolismo , Ácido Kaínico/metabolismo , Microbiota/genética , ARN Ribosómico 16S/genética , ARN Ribosómico 18SRESUMEN
BACKGROUND: Venous thromboembolism (VTE), comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE), is commonly treated with a low-molecular-weight heparin such as enoxaparin plus a vitamin K antagonist (VKA) to prevent recurrence. Administration of enoxaparin + VKA is hampered by complexities of laboratory monitoring and frequent dose adjustments. Rivaroxaban, an orally administered anticoagulant, has been compared with enoxaparin + VKA in the EINSTEIN trials. The objective was to evaluate the cost-effectiveness of rivaroxaban compared with enoxaparin + VKA as anticoagulation treatment for acute, symptomatic, objectively-confirmed DVT or PE. METHODS: A Markov model was built to evaluate the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios associated with rivaroxaban compared to enoxaparin + VKA in adult patients treated for acute DVT or PE. All patients entered the model in the 'on-treatment' state upon commencement of oral rivaroxaban or enoxaparin + VKA for 3, 6, or 12 months. Transition probabilities were obtained from the EINSTEIN trials during treatment and published literature after treatment. A 3-month cycle length, US payer perspective ($2012), 5-year time horizon and a 3% annual discount rate were used. RESULTS: Treatment with rivaroxaban cost $2,448 per-patient less and was associated with 0.0058 more QALYs compared with enoxaparin + VKA, making it a dominant economic strategy. Upon one-way sensitivity analysis, the model's results were sensitive to the reduction in index VTE hospitalization length-of-stay associated with rivaroxaban compared with enoxaparin + VKA. At a willingness-to-pay threshold of $50,000/QALY, probabilistic sensitivity analysis showed rivaroxaban to be cost-effective compared with enoxaparin + VKA approximately 76% of the time. LIMITATIONS: The model did not account for the benefits associated with an oral and minimally invasive administration of rivaroxaban. 'Real-world' applicability is limited because data from the EINSTEIN trials were used in the model. Also, resource utilization and costs were based on the US healthcare system. CONCLUSION: Rivaroxaban is a cost-effective option for anticoagulation treatment of acute VTE patients.
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Anticoagulantes/economía , Enoxaparina/economía , Morfolinas/economía , Tiofenos/economía , Trombosis de la Vena/prevención & control , Vitamina K/economía , Anticoagulantes/uso terapéutico , Análisis Costo-Beneficio , Quimioterapia Combinada/economía , Enoxaparina/uso terapéutico , Humanos , Cadenas de Markov , Persona de Mediana Edad , Morfolinas/uso terapéutico , Años de Vida Ajustados por Calidad de Vida , Rivaroxabán , Tiofenos/uso terapéutico , Estados Unidos/epidemiología , Trombosis de la Vena/mortalidad , Vitamina K/uso terapéuticoRESUMEN
BACKGROUND: The cost of pregnancy is increasing over time despite the decline in pregnancy rates. OBJECTIVE: To fully elucidate and evaluate the cost drivers of pregnancy in the US for payers, a systematic review was conducted to understand the main cost components and primary factors that contribute to the direct costs of pregnancy, pregnancy-related complications and unintended pregnancy among women of childbearing age (15-44 years). DATA SOURCES: We performed electronic searches in the PubMed database from January 2000 to December 2012, and major women's health and pharmacoeconomics conference proceedings from 2011 to 2012. STUDY SELECTION: The systematic review is comprised of studies that reported pregnancy, pregnancy-related complications, unplanned pregnancy, and pregnancy-induced monetary costs. The review excluded narrative reports, systematic reviews, model-derived cost of pregnancy papers, non-US-based studies, and reports based solely on expert opinions. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers independently applied the inclusion criteria and assessed the quality of the data collected. Disagreements between reviewers were resolved by consensus or by arbitration through a third party, with reference to the original sources. We collected information on the study design and outcomes for each included study. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in designing, performing, and reporting of the systematic review. RESULTS: We identified 40 studies from electronic and handsearching methods. We classified studies based on the primary research topic focusing on the overall cost of pregnancy (N = 10), cost of pregnancy-related complications (N = 26), cost of unintended pregnancy (N = 2), cost of planned pregnancy (N = 1), or cost of pregnancy by facilities (N = 1). In the quality assessment, randomized, non-randomized, and retrospective database studies had low to moderate risk of bias. We determined primary cost drivers based on the highest cost reported in each study. The identified cost drivers were inpatient care, pregnancy delivery, multiple births, complicated cesarean sections, high-risk pregnancy, preterm birth, low birth weight, complications due to conditions such as hypertension, diabetes, anemia, and cancer, and in vitro fertilization. In 2008, the overall mean cost per hospital stay for pregnancy-related incidence ranged from $3,306 to $9,234 in 2012 dollars. The mean cost of pregnancy-related complications that led to preterm birth was as high as $326,953 for an infant born at 25 weeks. It is estimated that over 50 % of live births were unintended in the US. The difference in the cost of unintended pregnancy and intended pregnancy was approximately $536 million. LIMITATIONS: One limitation of the systematic review was the exclusion of model-based cost studies which were excluded because of the high level of variation and heterogeneity across sources of reported cost. Another limitation of the review is that the cost of pregnancy perspective is restricted to the US. CONCLUSION: Preventing pregnancy-related complications and reducing unintended pregnancies may lower the overall economic burden of pregnancy on the US health care system.