Predicting time to nursing home placement based on activities of daily living scores – a modelling analysis using data on Alzheimer's disease patients receiving rivastigmine or donepezil

Abstract

Objective: To quantify the impact of activities of daily living (ADL) scores on the risk of nursing home placement (NHP) in Alzheimer's disease (AD) patients.

Setting: Models predicting NHP for AD patients have depended on cognitive deterioration as the primary measure. However, there is increased recognition that both patient functioning and cognition are predictive of disease progression.

Methods: Using the database from a prospective, randomised, double-blind trial of rivastigmine and donepezil, two treatments indicated for AD, Cox regression models were constructed to predict the risk of NHP using age, gender, ADL and MMSE (Mini-Mental State Examination) scores as independent variables.

Participants: Patients aged 50–85 years, with MMSE scores of 10–20, and a diagnosis of dementia of the Alzheimer type.

Results: Cox regression analyses indicated that being female, older age, lower ADL score at baseline, and deterioration in ADL all significantly increased the risk of NHP. Over 2 years, risk of NHP increased by 3% for each 1-point deterioration in ADL score independent of cognition.

Conclusion: Data analyses from this long-term clinical trial established that daily functioning is an important predictor of time to NHP. Further research may be required to confirm whether this finding translates to the real world.     

农民参加新型农村合作医疗的影响因素及满意度分析——基于安徽省13县368个农户调查的实证研究

笔者采用问卷调查的方式,对农民参加新型农村合作医疗的影响因素以及参合人员对新农合的满意度进行了实证分析。分析结果表明,人均收入、家庭规模和性别与农民的参合意愿没有显著的相关性,而文化程度、家庭成员构成、家庭成员的健康状况、农民参合的缴费水平以及新农合的名义报销水平等与农民的参合意愿显著相关。参合农民对新农合满意评价较为集中和稳定,但仍然存在医疗卫生服务机构在技术、收费、态度等方面不能满足农民需求的问题。     

WELFARE GAINS OF AID INDEXATION IN SMALL OPEN ECONOMIES

Foreign-aid flows to poor, aid-dependent economies are highly volatile and pro-cyclical. Shortfalls in aid coincide with shortfalls in GDP and government revenues. This increases the consumption volatility in aid dependent countries, thereby causing substantial welfare losses. This paper finds that indexing aid flows to exogenous shocks, like a change in the terms of trade, can significantly improve the welfare of an aid-dependent country by lowering its output and consumption volatility. Compared to the benchmark specification with stochastic aid flows, indexation of aid flows to terms-of-trade shocks can reduce the cost of business-cycle fluctuations in the recipient country by 4% of permanent consumption. Moreover, use of indexed aid can allow donors to reduce the aid flows by 3% without lowering the level of welfare in the recipient country.     

司来吉兰联合多奈哌齐治疗帕金森病患者的临床疗效

目的探讨司来吉兰联合多奈哌齐治疗帕金森病患者的临床疗效。方法选取2018年1月至2020年3月辽宁省健康产业集团阜新矿总院收治的帕金森病患者92例为研究对象,随机分为对照组与观察组,各46例。对照组患者给予司来吉兰治疗,观察组患者采用多奈哌齐与司来吉兰联合治疗。比较两组患者治疗效果、氧化应激水平、简易智能精神状态检查量表(MMSE)评分、蒙特利尔认知评估量表(MoCA)评分、帕金森病综合评分量表(UPDRS)评分及不良反应发生率。结果观察组治疗有效率为93.48%,低于对照组的78.26%,差异有统计学意义(P<0.05);治疗后,观察组患者谷胱甘肽、超氧化物歧化酶高于对照组,丙二醛低于对照组,差异有统计学意义(P<0.05);治疗后观察组患者MMSE评分、MoCA评分高于对照组,UPDRS评分低于对照组,差异有统计学意义(P<0.05);观察组患者不良反应发生率是8.68%,低于对照组的13.03%,但差异无统计学意义(P>0.05)。结论对帕金森病患者予以多奈哌齐与司来吉兰联合治疗,能取得较好的治疗效果,减轻氧化应激反应,运动功能、认知功能和精神状态改善,减少不良反应发生率,促进机体康复。     

Cost-effectiveness of angiotensin-converting enzyme inhibitors versus angiotensin II receptor blockers as first-line treatment in autosomal dominant polycystic kidney disease

Background: Autosomal dominant polycystic kidney disease (ADPKD) is a rare kidney disorder impacting ～1:2,500 individuals among the general US population. Hypertension is a significant predictor of ADPKD progression, and a risk factor for development of cardiovascular disease (CVD), the most common cause for mortality among ADPKD patients. Angiotensin-converting enzymes inhibitors (ACE-I) are widely used as first-line treatment in ADPKD for the management of hypertension. However, their cost-effectiveness relative to other hypertensive medications, such as angiotensin II receptor blockers (ARB), has never been assessed.

Objective: To determine if ARB are more cost-effective than ACE-Is as first-line treatment in ADPKD.

Methods: A Markov-state decision model was constructed for estimation of cost and outcome benefits in hypertensive ADPKD patients. Transition probabilities were extrapolated from a retrospective cohort study comparing chronic kidney disease (CKD) stage transitions in ADPKD patients. Annual pharmaceutical costs per average daily dose per CKD stage were extracted from a US healthcare claims database. Median total healthcare costs per CKD stage or transplant were extracted from the published literature. The time horizon was set to 30 years, with 1-year duration to cycle shift. A cost-effectiveness analysis was conducted to estimate the incremental cost-effectiveness ratio (ICER) of ACE-I vs ARB per additional year of prevented transplant and/or death. A one-way probabilistic sensitivity analysis was conducted, with 10% variation in probabilities and cost.

Results: Total annual healthcare costs accrued after 30 years among ADPKD patients taking ACE-Is was estimated to be $3,505,028.41, compared to ARB at $3,644,327.65. Life expectancy was increased by 1.39 years among patients taking ACE-I. Approximate 10-year survival in patients taking ACE-Is was 47% compared to ARB at 34%.

Conclusions: ACE-I dominated ARB and displayed greater cost-effectiveness due to lower cost and increased capacity to prolong years of life without transplant or death among hypertensive ADPKD patients. This model strengthens the value of ACE-I over ARB as first-line treatment for hypertension management in ADPKD patients.     

The budget impact and cost-effectiveness of defibrotide for treatment of veno-occlusive disease with multi-organ dysfunction in patients post-hematopoietic stem cell transplant

Background: A Phase-3 study of defibrotide compared with historical controls demonstrated a 23% improvement in 100-day survival post-hematopoietic stem cell transplantation (HSCT) among patients with veno-occlusive disease with multi-organ dysfunction (VOD with MOD).

Aim: To estimate the budget impact and cost-effectiveness of introducing defibrotide to a transplant center.

Methods: The authors developed a budget impact model from the perspective of a bone-marrow transplant center. It was estimated that 2.3% of adults and 4.2% of children would develop VOD with MOD following HSCT based on a retrospective hospital database analysis and the effect that treating patients with defibrotide would have on costs for adult and pediatric centers was estimated. A cost-utility analysis (CUA) was also developed to capture the long-term cost-effectiveness of defibrotide. Projected life expectancies in the two groups were estimated based on trial data, transplant registry data, studies of long-term survival among HSCT patients, and US population life-tables.

Results: There was an estimated 3% increase ($330,706) per year in total adult transplantation center costs associated with adopting defibrotide, and a <1% increase ($106,385) for pediatric transplant centers, assuming 100 transplants per year. In the CUA, the lifetime increase in cost per patient was $106,928, life expectancy increased by 3.74 years, and quality-adjusted life-years (QALYs) increased by 2.24. The incremental cost-effectiveness ratio (ICER) was $47,736 per QALY gained; 88% probability defibrotide was cost-effective at a $100,000/QALY threshold.

Conclusion: The budget impact of defibrotide for a transplant center is relatively modest compared to the overall cost of transplantation. Defibrotide provides an important survival advantage for VOD with MOD patients, and the life years gained lead to defibrotide being highly cost-effective.     

Clinical,humanistic, and economic outcomes between drug-eluting stent (DES) and bare metal stent (BMS): 18-month follow-up study

Background: Percutaneous coronary intervention (PCI) is one of the most performed interventions for ischemic heart diseases. In Hong Kong, the total number of patient discharges and deaths for ischemic heart diseases in 2009 was 33,363, including 4,360 deaths. There are over 5,000 cases of PCI yearly. This study aimed to compare clinical, economic, and humanistic outcomes among patients receiving drug-eluting stent (DES) or bare metal stent (BMS) in Hong Kong.

Methods: Patients who received stent implantation between September 15, 2009 and October 11, 2010 in Prince of Wales Hospital, Hong Kong, were recruited and followed for 18 months. Occurrence of major adverse cardiac events (cardiac death, non-fatal MI, TLR and TVR) was employed as the clinical outcome measurements. Improvement in quality-of-life by stent interventions was measured as quality-adjusted life-year (QALY). EQ-5D questionnaire was adopted to assess the QALY gained. Cost-utility analysis and cost-effectiveness analysis for BMS and DES were employed as the economic outcome measurement.

Results: Six hundred and eighty-four patients (DES?=?402; BMS?=?282) were included. From 0–18 months, TLR rate (2.7% vs 3.5%, p?=?.549) and TVR rate (3.7% vs 6.4%, p?=?.111) were lower in the DES group, but without statistical significance. EQ VAS (71.06?±?14.56 vs 71.07?±?16.57, p?=?.998) and utility score (0.81?±?0.17 vs 0.78?±?0.16, p?=?.162) were comparable between DES and BMS group. Overall, the cost per QALY gained was HKD + 1,178,100 and ICER was HKD + 187,000 (1USD?=?7.8 HKD).

Conclusions: No significant difference in TVR, TLR rates, EQ VAS, and utility score was found between the DES and BMS group. The higher cost of index procedure for the DES group was found to be partly offset by reduced cost of follow-up, offering cost-effectiveness in ACS patients, predominantly in STEMI patients. DES was recommended for STEMI patients.     

Optimal choice of prevention and cure under uncertainty on disease effect and cure effectiveness

This paper studies optimal prevention and cure when an agent copes with two different sources of uncertainty: uncertainty on disease effect and uncertainty on cure effectiveness. We first analyze how optimal choices are affected by uncertainty when prevention and cure do not interact. Under both types of uncertainty, we obtain that the optimal level of prevention rises. Furthermore, we characterize for each source of uncertainty the conditions for the optimal level of cure to increase. We show that these conditions are related to different measures of prudence in health and cross-prudence in wealth. Lastly, we generalize our results to the case where prevention and cure interact and characterize for each source of uncertainty the conditions for the optimal level of prevention and cure to jointly increase. These conditions are similar to those obtained in the case without uncertainty but, in this context, Edgeworth–Pareto complementarity is also required.     

Identifying cost-effective screening algorithms for active hepatitis C virus infections in a high prevalence setting

Objective: To evaluate the cost-effectiveness of different screening patterns for active chronic hepatitis C virus (HCV) infections utilizing the hepatitis C core antigen test compared to standard care in the context of a general screening program in a high-prevalence country.

Methods: This study developed a decision analytic model to estimate the cost-effectiveness of four screening algorithms for the detection of active HCV infections among asymptomatic individuals with an unknown HCV status in a context of high (>5%) HCV prevalence. Three algorithms started with a serological test for antibodies (AB) followed by a nucleic acid test for HCV-RNA (RNA), the HCVAg (AG) assay, or both. An additional single marker screening strategy with AG was added to the analysis. By the example of the Republic of Georgia, strategies were compared in terms of total costs for screening and diagnosis of an active infection from a health system perspective.

Results: Replacing RNA with AG for confirmation of positive AB identified fewer active infections (–110 per 100,000 screened subjects) at significantly reduced total costs (–$2.74 per screened) and costs per diagnosed infection (–$44). Adding a subsequent RNA confirmatory test on AG negative results captured at least the same rate compared to the standard (AB followed by RNA) at still reduced costs (–$1.16 per subject screened, –$22 per case detected). Utilizing AG as the frontline test revealed the highest detection rate (97.9%) at the highest costs (+$3.80 per subject, +$323 per case detected vs standard).

Conclusion: A combined pattern of HCV AB screening followed by sequential confirmation with AG and RNA on AG negatives would provide equal or better diagnostic performance at lower cost over a broad range of scenarios. Potential long-term consequences of screening strategies to patients and society have to be considered, since the latency period for HCV to develop into severe liver disease is long.