Illustrating potential efficiency gains from using cost-effectiveness evidence to reallocate Medicare expenditures

This article is available open access through the publisher’s website at the linke below. Copyright @ 2013, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).This article has been made available through the Brunel Open Access Publishing Fund.Objectives - The Centers for Medicare & Medicaid Services does not explicitly use cost-effectiveness information in national coverage determinations. The objective of this study was to illustrate potential efficiency gains from reallocating Medicare expenditures by using cost-effectiveness information, and the consequences for health gains among Medicare beneficiaries. Methods - We included national coverage determinations from 1999 through 2007. Estimates of cost-effectiveness were identified through a literature review. For coverage decisions with an associated cost-effectiveness estimate, we estimated utilization and size of the “unserved” eligible population by using a Medicare claims database (2007) and diagnostic and reimbursement codes. Technology costs originated from the cost-effectiveness literature or were estimated by using reimbursement codes. We illustrated potential aggregate health gains from increasing utilization of dominant interventions (i.e., cost saving and health increasing) and from reallocating expenditures by decreasing investment in cost-ineffective interventions and increasing investment in relatively cost-effective interventions. Results - Complete information was available for 36 interventions. Increasing investment in dominant interventions alone led to an increase of 270,000 quality-adjusted life-years (QALYs) and savings of $12.9 billion. Reallocation of a broader array of interventions yielded an additional 1.8 million QALYs, approximately 0.17 QALYs per affected Medicare beneficiary. Compared with the distribution of resources prior to reallocation, following reallocation a greater proportion was directed to oncology, diagnostic imaging/tests, and the most prevalent diseases. A smaller proportion of resources went to cardiology, treatments (including drugs, surgeries, and medical devices, as opposed to nontreatments such as preventive services), and the least prevalent diseases. Conclusions - Using cost-effectiveness information has the potential to increase the aggregate health of Medicare beneficiaries while maintaining existing spending levels.The Commonwealth Fun

UNUSUAL WINTERING DISTRIBUTION AND MIGRATORY BEHAVIOR OF THE WHOOPING CRANE (GRUS AMERICANA) IN 2011–2012

The last, self-sustaining population of Whooping Cranes (Grus americana), the Aransas-Wood Buffalo population, has overwintered almost exclusively along the Gulf Coast of Texas, USA, in and around the Aransas National Wildlife Refuge during recent decades. In late autumn and winter 2011–2012, Whooping Cranes were observed several hundred kilometers from coastal wintering grounds, with at least 13 Whooping Cranes in central Texas, south-central Kansas, and central Nebraska from November 2011 to early March 2012. Notably, family groups of Whooping Cranes were observed around a Texas reservoir, Granger Lake, over a 3-month period. An extreme drought, coupled with record warm temperatures in the southern and central United States, may have interacted to influence behaviors and distributions of Whooping Cranes during winter 2011–2012. Such observations suggest that Whooping Cranes may be more opportunistic in use of wintering habitat and/or more likely to re-colonize inland historical sites than previously thought. Continued documentation of Whooping Cranes overwintering in areas other than the Texas coast and/or altering timing of migration will be important for protection and management of additional winter habitat as well as for informing population estimates for the Aransas-Wood Buffalo Population of Whooping Cranes

Tristate Primary Care Research Network

No abstract available

Alpha-1 Antitrypsin is Markedly Decreased Following Pulmonary F. tularensis Challenge

Neutrophils form the first line of defense during infection and are indispensable in this function. The neutrophil elastase is a key effector molecule of the innate immune system with potent antimicrobial activity against Gram-negative bacteria, spirochaetes, and fungi. However, the release of neutrophil elastase during bacterial infection must be checked otherwise its release in the extracellular milieu will result in damage to surrounding tissues. Alpha-1 antitrypsin is a small glycoprotein clade A serpine serine protease inhibitor and has been shown to increase in humans following bacterial and viral infection. Francisella tularensis is a Gram-negative facultative intracellular bacterium and the causative agent of tularemia. Type A strains are the most virulent with an infectious dose as low as 10 colony forming units and a mortality rate of 30–60% among untreated cases of pneumonic tularemia. We report here significant reduction of this major inhibitor of the neutrophil elastase in plasma of F. tularensis LVS and F. tularensis (type A) SCHU S4 infected animals following pulmonary challenge. Associated with an imbalance of protease–antiprotease function at the alveolar level in lungs of infected animals, increased elastase activity was observed in lung lavage fluids accompanied by decrease lung function, i.e., loss of lung elastance with concomitant increase of pulmonary hysteresivity. Consistent with a competent acute phase response following F. tularensis LVS and F. tularensis (type A) SCHU S4 pulmonary challenge and proposed up-regulation of plasma haptoglobin during the course of the acute phase reaction, haptoglobin was observed significantly increased. These data suggest that unchecked neutrophil serine protease activity may arise from F. tularensis targeted reduction of plasma α(1)-antitrysin promoting lung tissue damage facilitating increased dissemination of this bacterium in infected animals

Current use and potential value of cost-effectiveness analysis in U.S. health care : the case of Medicare national coverage determinations

There is a growing recognition that we cannot afford the provision of all new health care technologies, even those that are proven to be beneficial. This is increasingly true in the US, where health care spending is on an unsustainable upward trajectory. US health care spending is greatly in excess of that of other countries; however, with respect to key health metrics, the US health care system performs relatively poorly. Despite this, unlike many other developed countries economic evaluation, and more specifically cost effectiveness evidence, is used sparingly in the US health care system. Notably, the Centers for Medicare and Medicaid Services (CMS), administrators of the Medicare programme, state that cost-effectiveness evidence is not relevant to coverage decisions for medical technology and interventions evaluated as part of National Coverage Determinations (NCDs). The empirical aspect of this thesis evaluates the current use and potential value of using cost-effectiveness evidence in CMS NCDs. A database was built using data obtained from NCD decision memoranda, the medical literature, a Medicare claims database, and Medicare reimbursement information. The findings of the empirical work show that, CMS’s stated position notwithstanding, cost-effectiveness evidence has been cited or discussed in a number of coverage decisions, and there is a statistically significant difference between positive and non-coverage decisions with respect to cost effectiveness. When controlling for factors likely to have an effect on coverage decisions, the availability of cost-effectiveness evidence is a statistically significant predictor of coverage. In addition, the quality of the supporting clinical evidence, the availability of alternative interventions, and the recency of the decision are statistically significant variables. Further, when hypothetically reallocating resources in accordance with cost-effectiveness substantial gains in aggregate health are estimated. It is shown that using cost-effectiveness to guide resource allocation has an effect on resource allocation across patient populations and types of technology.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

An assessment of the methodological quality of published network meta-analyses: a systematic review

Objective To assess the methodological quality of published network meta-analysis. Design Systematic review. Methods We searched the medical literature for network meta-analyses of pharmaceuticals. We assessed general study characteristics, study transparency and reproducibility, methodological approach, and reporting of findings. We compared studies published in journals with lower impact factors with those published in journals with higher impact factors, studies published prior to January 1st, 2013 with those published after that date, and studies supported financially by industry with those supported by non-profit institutions or that received no support. Results The systematic literature search identified 854 citations. Three hundred and eighteen studies met our inclusion criteria. The number of network meta-analyses has grown rapidly, with 48% of studies published since January 2013. The majority of network meta-analyses were supported by a non-profit institution or received no support (68%). We found considerable inconsistencies among reviewed studies. Eighty percent reported search terms, 61% a network diagram, 65% sufficient data to replicate the analysis, and 90% the characteristics of included trials. Seventy percent performed a risk of bias assessment of included trials, 40% an assessment of model fit, and 56% a sensitivity analysis. Among studies with a closed loop, 69% examined the consistency of direct and indirect evidence. Sixty-four percent of studies presented the full matrix of head-to-head treatment comparisons. For Bayesian studies, 41% reported the probability that each treatment was best, 31% reported treatment ranking, and 16% included the model code or referenced publicly-available code. Network meta-analyses published in higher impact factors journals and those that did not receive industry support performed better across the assessment criteria. We found few differences between older and newer studies. Conclusions There is substantial variation in the network meta-analysis literature. Consensus among guidelines is needed improve the methodological quality, transparency, and consistency of study conduct and reporting

Planning and delivery of intensity modulated bolus electron conformal therapy

PURPOSE: Bolus electron conformal therapy (BECT) is a clinically useful, well-documented, and available technology. The addition of intensity modulation (IM) to BECT reduces volumes of high dose and dose spread in the planning target volume (PTV). This paper demonstrates new techniques for a process that should be suitable for planning and delivering IM-BECT using passive radiotherapy intensity modulation for electrons (PRIME) devices. METHODS: The IM-BECT planning and delivery process is an addition to the BECT process that includes intensity modulator design, fabrication, and quality assurance. The intensity modulator (PRIME device) is a hexagonal matrix of small island blocks (tungsten pins of varying diameter) placed inside the patient beam-defining collimator (cutout). Its design process determines a desirable intensity-modulated electron beam during the planning process, then determines the island block configuration to deliver that intensity distribution (segmentation). The intensity modulator is fabricated and quality assurance performed at the factory (.decimal, LLC, Sanford, FL). Clinical quality assurance consists of measuring a fluence distribution in a plane perpendicular to the beam in a water or water-equivalent phantom. This IM-BECT process is described and demonstrated for two sites, postmastectomy chest wall and temple. Dose plans, intensity distributions, fabricated intensity modulators, and quality assurance results are presented. RESULTS: IM-BECT plans showed improved D CONCLUSION: These results demonstrated the feasibility of translating IM-BECT to the clinic using the techniques presented for treatment planning, intensity modulator design and fabrication, and quality assurance processes

Immunization with Dendritic Cells Pulsed ex vivo with Recombinant Chlamydial Protease-Like Activity Factor Induces Protective Immunity Against Genital Chlamydia muridarum Challenge

We have shown that immunization with soluble recombinant chlamydial protease-like activity factor (rCPAF) and a T helper 1 type adjuvant can induce significantly enhanced bacterial clearance and protection against Chlamydia-induced pathological sequelae in the genital tract. In this study, we investigated the use of bone marrow derived dendritic cells (BMDCs) pulsed ex vivo with rCPAF + CpG in an adoptive subcutaneous immunization for the ability to induce protective immunity against genital chlamydial infection. We found that BMDCs pulsed with rCPAF + CpG efficiently up-regulated the expression of activation markers CD86, CD80, CD40, and major histocompatibility complex class II (MHC II), and secreted interleukin-12, but not IL-10 and IL-4. Mice adoptively immunized with rCPAF + CpG-pulsed BMDCs or UV-EB + CpG-pulsed BMDCs produced elevated levels of antigen-specific IFN-γ and enhanced IgG1 and IgG2a antibodies. Moreover, mice immunized with rCPAF + CpG-pulsed BMDCs or UV-EB + CpG-pulsed BMDCs exhibited significantly reduced genital Chlamydia shedding, accelerated resolution of infection, and reduced oviduct pathology when compared to infected mock-immunized animals. These results suggest that adoptive subcutaneous immunization with ex vivo rCPAF-pulsed BMDCs is an effective approach, comparable to that induced by UV-EB–BMDCs, for inducing robust anti-Chlamydia immunity