AimsAtrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy.Methods and resultsA cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon.ConclusionsThis analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin.

Objective: To evaluate the clinical and economic impact of adopting noninvasive prenatal testing (NIPT) using circulating cell-free DNA as a first-line screening method for trisomy 21, 18, and 13 in the general pregnancy population. Methods: A decision-analytical model was developed to assess the impact of adopting NIPT as a primary screening test compared to conventional screening methods. The model takes the Belgium perspective and includes only the direct medical cost of screening, diagnosis, and procedure-related complications. NIPT costs are EUR 260. Clinical outcomes and the cost per trisomy detected were assessed. Sensitivity analysis measured the impact of NIPT false-positive rate (FPR) on modelled results. Results: The cost per trisomy detected was EUR 63,016 for conventional screening versus EUR 66,633 for NIPT, with a difference of EUR 3,617. NIPT reduced unnecessary invasive tests by 94.8%, decreased procedure-related miscarriages by 90.8%, and increased trisomies detected by 29.1%. Increasing the FPR of NIPT (from < 0.01 to 1.0%) increased the average number of invasive procedures required to diagnose a trisomy from 2.2 to 4.5, respectively. Conclusion: NIPT first-line screening at a reasonable cost is cost-effective and provides better clinical outcomes. However, modelled results are dependent on the adoption of an NIPT with a low FPR.

Supplemental Digital Content is available in the text.

Purpose: Medication nonadherence is a significant and multidimensional problem contributing to an increased risk of morbidity and mortality. Inconveniences in pharmacy and home contexts may increase nonadherence. This research examined inconveniences in pharmacy and home contexts associated with self-reported nonadherence, controlling for demographic and medication-taking covariates. Methods: Data from 4682 individuals who reported self-managing medications in an online marketing survey between October and December 2017 were analyzed in this secondary analysis. Nonadherence was dichotomized using a single question about likelihood to take medications as prescribed (adherence=always; nonadherence=most of the time, some of the time, never). Multivariable logistic regression with backwards elimination was used to examine the pharmacy (use of home delivery, number prescriptions picked up and visits to pharmacy) and home context (method used to organize/manage medications, satisfaction, and bother with management) variables and the demographic (age, sex, race/ethnicity, education, income, insurance) and medication (number of oral medications, medication changes and frequency of taking) covariates associated with nonadherence. Results: Overall, 25.8% of the responses indicated nonadherence. Nonadherence was more likely for individuals making fewer separate pharmacy trips (OR 0.98; 95% CI 0.97-0.99); picking up fewer prescriptions (OR 0.96; 95% CI 0.93-0.99); never, rarely or sometimes using mail order compared with always (OR 1.71; 95% CI 1.30-2.26); not satisfied with managing medications (OR 2.13; 95% CI 1.42-3.19); and using pill pouches and being bothered by them (OR 8.28; 95% CI 1.83-37.31). Using pill pouches or a pillbox and not being bothered by them significantly decreased nonadherence likelihood. Younger and female respondents and those reporting medication changes in the last year were also more likely to report nonadherence. Conclusion: Though reasons for nonadherence are multidimensional, this study suggests that inconveniences in both the pharmacy and home context are important. Improving adherence requires addressing issues of inconvenience across the care continuum.

conducted in 12 sites in Brazil to evaluate resource utilization in unresectable stage III and IV metastatic melanoma patients diagnosed or relapsed between 2008-2009. Frequencies of resources utilization were assessed and multiplied by unit costs, obtained by SIA-SUS (Outpatient Information System) for public health care costing and by CBHPM-2005 (Brazilian Hierarchy Classification of Medical Procedures) for private. RESULTS: Of 165 total patients eligible for the study, 119 (57 private sector and 62 public sector) received systemic therapy outside of clinical trials and were therefore eligible for the resource utilization analysis. Across three lines of therapy, 52.9% also received at least one surgery, and 27.7% also received radiotherapy. While receiving systemic therapy, 29.4% were hospitalized, 13.4% had an emergency room visit, 28.7% had an outpatient visit, and 10.1% had a transfusion. A similar proportion received surgery in the private and public health sector (56.1% and 50.0%, respectively), with mean costs USD278 (95%CI USD192-365) and USD437 (95%CI USD322-553), respectively. Hospitalizations were more common in the private sector (45.6%) than the public sector (14.5%). The duration of hospitalization among private patients had a mean duration of 8.7 days per month compared to 3.6 days. Mean costs of hospitalizations were USD1,697 (95%CI USD1,020-2,239) in the private sector and USD1,332 (95%CI USD821-1,842) in the public. CONCLUSIONS: In this real-world study in different regions in Brazil, per-patient medical costs in advanced melanoma patients were higher in the private sector than the public sector due to both higher unit cost per resource used and greater utilization of hospitalization.OBJECTIVES: Cervical cancer (CC) remains the leading cause of cancer death among Colombian women. Human papillomavirus (HPV) 16 and 18 infection is associated with CC while HPV 6 and 11 are related to genital warts (GW). Currently are available 2 vaccines against HPV. Bivalent protects against carcinogenic genotypes and tetravalent also protects against genotypes GW associated. We present the cost-effectiveness evaluation of the introduction of two vaccination strategies in Colombian women taking into account the current screening program. METHODS:We designed a Markov model, which simulates the natural history of CC and GW in a cohort of women. The occurrence parameters were extracted and validated with a literature review and national databases. The costs were estimated from costing of standard cases. We estimated the impact of the introduction of bivalent and tetravalent HPV vaccines. We compared the different strategies in a competitive scenario and built the ICERs. A sensitivity analysis was carried out. RESULTS: In a cohort of 430,859 women followed for the entire life without vaccination or screening programs 15,284 CC cases and 18,275 GW episodes may occur. The CC would cause 4733 deaths. The screening program would prevent 3015 CC deaths. Either vaccination alternatives prevents 1958 CC deaths additional to...

recently discharged (RD) cohort included patients with ≥ 1 SMI related hospitalization (first used as index event). The early episode (EE) cohort included patients with ≥ six-months of pre-index enrollment with no evidence of an antipsychotic or SMI diagnosis (first claim with either used as index event). The RD cohort included 11,050 patients:62% female; Age:9% 18-25, 35% 26-45, 56% 46-65. The EE cohort included 40,655 patients:63% female; Age:12% 18-25, 39% 26-45, 49% 46-65. RESULTS: Adherence to oral antipsychotic medications (defined as PDC ≥ .80) was 52.5% on average in the RD cohort, but only 16.1% on average in the EE cohort. Utilization rates per 1,000 patients were significantly higher in the RD cohort: PCP visits (6,170 vs 5,770); observation stays (400 vs. 160); emergency department visits (2,050 vs 1,170). Inpatient readmission rates were 220/1,000 in the EE cohort compared to 600/1,000 in the RD group. CONCLUSIONS: Adherence to treatment is low and variable among SMI patients, resulting in high rates of healthcare utilization. These stratified outcomes can be used by providers to target specific SMI patients to reduce utilization and costs of care.

spending using Dartmouth Atlas of Health Care online data. Results: Among the 155,841 patients, 5.9% had a depression diagnosis within 30 days after AMI admission. DACC-based ADRs captured considerable variation in depression diagnosis (IQR: 0.74 -1.21) and relatively low and high zip code-level ADRs were dispersed across the United States. ADRs for depression diagnosis were statistically significantly related to Medicare spending (Pearson correlation coefficient = 0.14, p < 0.01), but not local physician supply. ConClusions: Substantial geographic variation in depression diagnosis exists across the United States. Areas with higher general healthcare spending were more likely to have higher depression diagnosis rates. Further research is needed to explore if geographic variation in diagnosis affect health and economic outcomes to address whether depression was correctly, overor under-diagnosed. Disease-specific stuDiesDiabetes/enDocrine DisorDers -clinical outcomes studies pDb1 urinary tract infection among the sglt 2 inhibitors: a meta-analysis of 19 ranDomizeD controlleD trials

No abstract