Background Osteoporotic hip fractures are common injuries typically occurring in patients who are older and medically frail. Studies have suggested that creation of a multidisciplinary team including orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists, to comanage these patients can decrease complication rates, improve time to surgery, and reduce hospital length of stay; however, they have yet to achieve widespread implementation, partly owing to concerns regarding resource requirements necessary for a comanagement program. Questions/Purposes We performed an economic analysis to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be a cost-effective intervention at hospitals with moderate volume. We also calculated what annual volume of cases would be needed for a comanagement program to ''break even'', and finally we evaluated whether universal or risk-stratified comanagement was more cost effective. Methods Decision analysis techniques were used to model the effect of implementing a systems-based strategy to improve inpatient perioperative care. Costs were obtained from best-available literature and included salary to support personnel and resources to expedite time to the operating room. The major economic benefit was decreased initial hospital length of stay, which was determined via literature review and meta-analysis, and a health benefit was improvement in perioperative mortality owing to expedited preoperative evaluation based on previously conducted meta-analyses. A break-even analysis was conducted to determine the annual case volume necessary for comanagement to be either (1) cost effective (improve health-related quality of life enough to be worth additional expenses) or (2) result in cost savings (actually result in decreased total expenses). This calculation assumed the scenario in which a hospital could hire only one hospitalist (and therapist and social worker) on a full-time basis. Additionally, we evaluated the scenario where the necessary staff was already employed at the hospital and could be dedicated to a comanagement service on a part-time basis, and explored the effect of triaging only patients considered high risk to a comanagement service versus comanaging all geriatric patients. Finally, probabilistic sensitivity analysis was conducted on all critical variables, with broad ranges used for values around which there was higher uncertainty. Results For the base case, universal comanagement was more cost effective than traditional care and risk-stratified comanagement (incremental cost effectiveness ratios of All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity...

Personalized medicine -the targeting of therapies to individuals on the basis of their biological, clinical, or genetic characteristics -is thought to have the potential to transform health care. While much emphasis has been placed on the value of personalized therapies, less attention has been paid to the value generated by the diagnostic tests that direct patients to those targeted treatments. This paper presents a framework derived from information economics for assessing the value of diagnostics. We demonstrate, via a case study, that the social value of such diagnostics can be very large, both by avoiding unnecessary treatment and by identifying patients who otherwise would not get treated. Despite the potential social benefits, diagnostic development has been discouraged by cost-based, rather than value-based, reimbursement.

Compared with non-Hispanic whites, cost-effectiveness of implementing hypertension guidelines would extend to a larger proportion of non-Hispanic black hypertensive patients.

Background: The purpose of this study is to evaluate the knowledge and attitudes on osteoporosis among firsttime spine surgery patients. Methods: An electronic survey consisting of demographics, prior experience with osteoporosis, and the Facts on Osteoporosis Quiz (FOOQ) was sent via email to first-time spine surgery patients. Patients were then randomized into 2 groups: 1 received a brief osteoporosis information packet prior to beginning the FOOQ, and 1 proceeded directly to the survey. Results: A total of 63 patients who participated in this study, 29 in the information packet group and 34 in the non-information packet group, completed the survey. The mean FOOQ scores for the information packet patients was 16.37 (6 2.35) and for the non-information packet patients was 15.62 (6 2.87), with a P value of .12. There were no statistically significant differences between the 2 groups in terms of patient demographics or prior experience with osteoporosis. The information packet group trended to higher interest with a P value of .068. Conclusions: Our study demonstrates high FOOQ scores among all first-time spine patients as compared to historical scores in general at-risk populations. No statistical differences between FOOQ scores were noted between the group that received the information packet and the control group. This study demonstrates that patients new to spine care have a good understanding of osteoporosis and are thus willing to participate in osteoporosis treatment as part of their spine care.

Objectives: Patients with non-valvular atrial fibrillation (NVAF) are routinely prescribed anticoagulants to prevent stroke. Traditional anticoagulants like warfarin are less expensive and less effective at preventing stroke than some novel oral anti-coagulants (NOACs). This study uses a widely published microsimulation model to compare population-wide outcomes associated with alternative approaches to preventing stroke among NVAF patients. Methods: The Health Economics Medical Innovation Simulation (THEMIS) was used to analyze clinical and economic outcomes among a representative sample of Americans age 51+. The lifetime evolution of disease and functional status was modeled for each individual under four scenarios: status quo using current NVAF treatment patterns, and three scenarios where NVAF patients are treated with apixaban, dabigatran, or rivaroxaban, respectively. Markov state transition probabilities were derived from the Health and Retirement Study; published cost estimates for stroke and other adverse events were used. NOAC prices were assumed to fall by 80% at patent expiration. The number of stroke-free years, bleeds and total medical expenditures were calculated for the entire population through 2062. Findings: Over 50 years, the three NOAC scenarios resulted in 28-31 million more stroke-free years and higher total medical expenditures compared to the status quo. Among NOACs, apixaban and dabigatran resulted in similar stroke outcomes, but apixaban had 1.4 million fewer bleeds and $6.9 billion lower total medical expenditures compared to dabigatran across the age 51+ population. Rivaroxaban resulted in higher stroke incidence, more major bleeds and higher total medical expenditures than the other two NOACs. Conclusions: While using NOACs in NVAF treatment raises drug costs compared to current practice, it also reduces stroke incidence. Among NOACs, apixaban does so at lower cost, with fewer bleeding events than either dabigatran or rivaroxaban.