La atención primaria en los Estados Unidos y la experiencia peruana en perspectiva

Due to a complex payment system, the health system of the United States is fragmented, expensive, and achieves the goal of improving the health of the entire population. Excessive health costs increase the budget deficit in the US. This situation makes to the government to have greater willingness to try new approaches in the delivery of health services. Is well know that the states that have a solid system of primary health care (PC), spent less money in diseases and have lower utilization of health services (reflected in fewer days of hospitalization). This is why the AP is spreading in the US making doctors, nurses and other providers to collaborate on new proposals for team-based care, coordinated and patient-oriented generating real benefits while controlling costs. The US experience with AP support evidence-based approach to propose, from a foreign perspective, strengthening the AP in Peru.Debido a un complejo sistema de pagos, el sistema de salud de los Estados Unidos (EE. UU.) es fragmentado, costoso, y alcanza el objetivo de mejorar la salud de toda la población. Los costos excesivos de salud incrementan el déficit económico en los EE. UU., y esto hace que su gobierno tenga mayor disposición a probar nuevos enfoques en la prestación de servicios de salud. Llama la atención que los estados norteamericanos que cuentan con un sistema de atención primaria (AP) sólido, tienen menores gastos por enfermedad y menor utilización de servicios de salud (reflejado en menos días de hospitalización). Es por esto que la AP está extendiéndose en los EE. UU., haciendo que médicos, enfermeras y otros proveedores colaboren en nuevas propuestas de atención basadas en equipo, coordinadas y orientadas al paciente generando beneficios reales, al mismo tiempo que controlan los costos. Esta experiencia estadounidense con una AP con enfoque basado en evidencias ayuda a proponer, desde una perspectiva extranjera, el fortalecimiento de la AP en el Perú

The results of a 2-year randomized trial of a worksite weight management intervention.

PURPOSE: We assessed the effectiveness of a worksite management intervention (the 3W program) for overweight and obese hotel employees. DESIGN: The program was tested in a 2-year cluster-randomized trial involving 30 hotels that employed nearly 12,000 individuals. SETTING: All participating hotels were on Oahu, Hawaii. The intervention was implemented within hotel worksites. SUBJECTS: Participants were included in the analysis if they had an initial body mass index (BMI) ≥ 25, were assessed at least twice, were not missing other data needed for the analysis, and did not switch to employment at a hotel in a different experimental condition. Of the 6519 employees we assessed, data from 1207 individuals (intervention: 598; control: 610) met these criteria and contributed to the analysis. INTERVENTION: The intervention had two components: (1) group meetings and (2) a workplace environment intervention. MEASURES: Weight and waist to height ratio (WHtR) were measured at three annual assessments. ANALYSIS: The effect of the intervention on change in BMI and WHtR was estimated in hierarchical mixed regression models using full maximum likelihood to estimate model parameters. RESULTS: The effects on change in BMI and WHtR were in the expected direction but were not statistically significant. CONCLUSION: The 3W program was not effective. The low intensity of the intervention may have contributed to its ineffectiveness

An Economic Evaluation of Colorectal Cancer Screening in Primary Care Practice

Background/Aims: This study evaluated the cost-effectiveness of interventions using electronic health records (EHR), automated mailings, and stepped increases in support to improve two-year colorectal cancer screening adherence. Methods: Analyses are based on a parallel-design, randomized trial in which three stepped interventions (EHR-linked mailings [“automated”], automated plus telephone assistance [“assisted”], or automated and assisted plus nurse navigation to testing completion or refusal [“navigated”]) were compared to usual care. Data were collected over August 2008–November 2011 with analysis in 2012–2013. Implementation resources were micro-costed; research and registry development costs were excluded. Incremental cost-effectiveness ratios (ICERs) were based on number of participants current for screening per guidelines over two years. Robustness of results was examined through bootstrapping. Results: Intervention delivery cost per participant current for screening ranged from $21 (automated) to$27 (navigated). When induced testing costs (e.g. screening colonoscopy) were included, automated (ICER: -$159) and assisted (ICER: -$36) were cost-saving relative to usual care. Savings arose from increased fecal occult blood testing, substituting for more expensive colonoscopies in usual care. Results were broadly consistent across demographic subgroups. More intensive interventions were consistently likely to be cost-effective relative to less intensive interventions with willingness to pay values of $600–$1,200 for a 1% increase in the rate of screening adherence yielding probability of cost-effectiveness of at least 80%. Discussion: The cost-effectiveness was demonstrated of a stepped approach to colorectal cancer screening promotion, especially one using automated data systems linked to electronic health records

C-C2-03: Incidence-based Costs of Multiple HAART Switches Among HIV-infected Patients in an HMO

Background: Highly active antiretroviral therapy (HAART) or combination antiretroviral (ARV) therapy is associated with reduced morbidity and mortality. Yet, many HIV-infected patients endure incomplete HIV suppression from HAART or combination ARV therapy, increasing cost and limiting effectiveness. Little is known about the direct healthcare costs of HIV+ patients requiring multiple HAART regimen switches because of incomplete HIV suppression. In an HMO-based population of HIV+ patients, we examined resource and cost implications of multiple relative to single (or no) HAART switches starting from first HAART regimen

PS2-34: Implementation Cost Analysis of Telephone and Internet-based Interventions for the Maintenance of Weight Loss

Objectives: The Weight Loss Maintenance Trial (WLM) was a multi-center, randomized trial comparing two weight loss maintenance interventions, a telephone-based personal contact program (PC) with monthly contacts primarily by phone and an Internet-based program (IT), to a self-directed control group, among overweight or obese individuals at high cardiovascular risk. This presentation describes the implementation costs of both interventions as well as the development costs of the IT program

Nonparticipation in a Population-Based Trial to Increase Colorectal Cancer Screening

Background Many trials have tested different strategies to increase colorectal cancer (CRC) screening. Few describe whether participants are representative of the population from which they are recruited. Purpose To determine risk factors related to nonparticipation among patients enrolled in an integrated health plan and not up to date for CRC testing, in a trial to increase screening rates. Methods Between July 2008 and October 2009, a total of 15,000 adults aged 50-74 years from 21 clinics in Washington State who were due for CRC screening were contacted. Nonparticipants were defined as English-speaking patients who did not engage in the call or refused participation while still potentially eligible. Log-binomial regression models were used to estimate the relative risk of nonparticipation. Analyses were completed between October 2010 and June 2011. Results Patients who were nonwhite, had less education, used tobacco, had less continuity of care, and had lower rates of preventive care and cancer screening were more likely to be nonparticipants. Patients reporting never having received any type of CRC testing or screening were also more likely not to participate (62% of nonparticipants vs 46% of participants; adjusted RR=1.58, 95% CI=1.47, 1.70). Reasons for refusal included costs, risks of procedures, and not wanting their medical records reviewed. Conclusions Patients eligible for but not participating in the trial were more likely to be from minority socioeconomic and racial groups and had behaviors that can negatively affect cancer outcomes. Additional efforts are needed to recruit patients who need CRC screening the most. Trial registration This trial is registered at clinicaltrials.gov NCT 00697047

Systems of Support to Increase Colorectal Cancer Screening and Follow-Up Rates (SOS): Design, Challenges, and Baseline Characteristics of Trial Participants

Background Screening decreases colorectal cancer (CRC) morbidity and mortality, yet remains underutilized. Screening breakdowns arise from lack of uptake and failure to follow-up after a positive screening test. Objectives Systems of support to increase colorectal cancer screening and follow-up (SOS) is a randomized trial designed to increase: (1) CRC screening and (2) follow-up of positive screening tests. The Chronic Care Model and the Preventive Health Model inform study design. Methods The setting is a large nonprofit healthcare organization. In part-1 study, patients age 50-75 due for CRC screening are randomized to one of 4 study conditions. Arm 1 receives usual care. Arm 2 receives automated support (mailed information about screening choices and fecal occult blood tests (FOBT)). Arm 3 receives automated and assisted support (a medical assistant telephone call). Arm 4 receives automated, assisted, and care management support (a registered nurse provides behavioral activation and coordination of care). In part-2, study patients with a positive FOBT or adenomas on flexible sigmoidoscopy are randomized to receive either usual care or nurse care management. Primary outcomes are: 1) the proportion with CRC screening, 2) the proportion with a complete diagnostic evaluation after a positive screening test. Results We sent recruitment letters to 15,414 patients and 4675 were randomized. Randomly assigned treatment groups were similar in age, sex, race, education, self-reported health, and CRC screening history. Conclusions We will determine the effectiveness and cost effectiveness of stepped increases in systems of support to increase CRC screening and follow-up after a positive screening test over 2 years

Effects of an urban light rail line on health care utilization and cost: A pre-post assessment

In September 2015, a new light rail transit (LRT) line opened in metro Portland, Oregon, USA. We used this natural experiment to conduct an interrupted time series analysis of the effects of LRT introduction on health care costs. We hypothesized that such costs would decline over time based on demonstrated health benefits of increased transit-related physical activity. We wanted to evaluate whether introducing new LRT would lower the trajectory of monthly health care costs generated by a large sample of members of an integrated health care plan living near a new LRT station (cases) relative to similar members who did not (controls). We hypothesized that new LRT would stimulate higher transit use and consequently, higher transit-related physical activity among plan members living relatively closer to the LRT. However, the new LRT did not lower health care costs as hypothesized, at least relative to prior costs and within the first 4.5 years after the LRT opening. Results were consistent across outpatient visit costs and medication costs, as well as when only the 10 percent most expensive health plan members were considered. Although we did not find evidence of transit-related reductions in health care costs, research into the potential influence of public transit on physical activity and downstream health care costs remains warranted. Mechanisms through which such influence manifests are complex. Our negative results based on extensive and objectively measured health care cost data will contribute to the accuracy and validity of future models of the societal benefits of public transit