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Background There is growing evidence that specialized clinical services targeted toward individuals early in the course of a psychotic illness may be effective in reducing both the clinical and economic burden associated with these illnesses. Unfortunately, the United States has lagged behind other countries in the delivery of specialized, multi-component care to individuals early in the course of a psychotic illness. A key factor contributing to this lag is the limited available data demonstrating the clinical benefits and cost-effectiveness of early intervention for psychosis among individuals served by the American mental health system. Thus, the goal of this study is to present clinical and cost outcome data with regard to a first-episode psychosis treatment center within the American mental health system: the Early Psychosis Intervention Center (EPICENTER). Methods Sixty-eight consecutively enrolled individuals with first-episode psychosis completed assessments of symptomatology, social functioning, educational/vocational functioning, cognitive functioning, substance use, and service utilization upon enrollment in EPICENTER and after 6 months of EPICENTER care. All participants were provided with access to a multi-component treatment package comprised of cognitive behavioral therapy, family psychoeducation, and metacognitive remediation. Results Over the first 6 months of EPICENTER care, participants experienced improvements in symptomatology, social functioning, educational/vocational functioning, cognitive functioning, and substance abuse. The average cost of care during the first 6 months of EPICENTER participation was lower than the average cost during the 6-months prior to joining EPICENTER. These savings occurred despite the additional costs associated with the receipt of EPICENTER care and were driven primarily by reductions in the utilization of inpatient psychiatric services and contacts with the legal system. Conclusions The results of our study suggest that multi-component interventions for first-episode psychosis provided in the US mental health system may be both clinically-beneficial and cost-effective. Although additional research is needed, these findings provide preliminary support for the growing delivery of specialized multi-component interventions for first-episode psychosis within the United States. Trial registration ClinicalTrials.gov Identifier: NCT01570972 ; Date of Trial Registration: November 7, 2011

BackgroundEffective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST.ObjectiveTo perform a cost–utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency.Patients/InterventionsIn this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up.ResultsPST and HQACM participants were similar with regard to gender, age, and CHADS2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, −$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions.ConclusionWeekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.

INTRODUCTIONRapid HIV testing in high-risk populations can increase the number of persons who learn their HIV status and avoid spending clinic resources to locate persons identified as HIV infected. METHODSWe determined the cost to sexually transmitted disease (STD) clinics of point-of-care rapid HIV testing using data from 7 public clinics that participated in a randomized trial of rapid testing with and without brief patient-centered risk reduction counseling in 2010. Costs included counselor and trainer time, supplies, and clinic overhead. We applied national labor rates and test costs. We calculated median clinic start-up costs and mean cost per patient tested, and projected incremental annual costs of implementing universal rapid HIV testing compared with current testing practices. RESULTSCriteria for offering rapid HIV testing and methods for delivering nonrapid test results varied among clinics before the trial. Rapid HIV testing cost an average of US$22/patient without brief risk reduction counseling and US$46/patient with counseling in these 7 clinics. Median start-up costs per clinic were US$1100 and US$16,100 without and with counseling, respectively. Estimated incremental annual costs per clinic of implementing universal rapid HIV testing varied by whether or not brief counseling is conducted and by current clinic testing practices, ranging from a savings of US$19,500 to a cost of US$40,700 without counseling and a cost of US$98,000 to US$153,900 with counseling. CONCLUSIONSUniversal rapid HIV testing in STD clinics with same-day results can be implemented at relatively low cost to STD clinics, if brief risk reduction counseling is not offered.

BACKGROUNDResults of a recent demonstration project evaluating feasibility, acceptability, and cost of a Web-based sexually transmitted infection (STI) testing and e-prescription treatment program (eSTI) suggest that this approach could be a feasible alternative to clinic-based testing and treatment, but the results need to be confirmed by a randomized comparative effectiveness trial. METHODSWe modeled a decision tree comparing (1) cost of eSTI screening using a home collection kit and an e-prescription for uncomplicated treatment versus (2) hypothetical costs derived from the literature for referral to standard clinic-based STI screening and treatment. Primary outcome was number of STIs detected. Analyses were conducted from the clinical trial perspective and the health care system perspective. RESULTSThe eSTI strategy detected 75 infections, and the clinic referral strategy detected 45 infections. Total cost of eSTI was $94,938 ($1266/STI detected) from the clinical trial perspective and $96,088 ($1281/STI detected) from the health care system perspective. Total cost of clinic referral was $87,367 ($1941/STI detected) from the clinical trial perspective and $71,668 ($1593/STI detected) from the health care system perspective. CONCLUSIONSResults indicate that eSTI will likely be more cost-effective (lower cost/STI detected) than clinic-based STI screening, both in the context of clinical trials and in routine clinical care. Although our results are promising, they are based on a demonstration project and estimates from other small studies. A comparative effectiveness research trial is needed to determine actual cost and impact of the eSTI system on identification and treatment of new infections and prevention of their sequelae.

Objective: To investigate the lifelong health effects, costs, and cost-effectiveness of a quality improvement collaborative focusing on improving diabetes management in an integrated care setting. Study Design and Methods: Economic evaluation from a healthcare perspective with lifetime horizon alongside a nonrandomized, controlled, before-after study in the Netherlands. Analyses were based on 1861 diabetes patients in 6 intervention and 9 control regions, representing 37 general practices and 13 out-patient clinics. Change in the United Kingdom Prospective Diabetes Study score, remaining lifetime, and costs per quality-adjusted life year gained were calculated. Probabilistic life tables were constructed using the United Kingdom Prospective Diabetes Study risk engine, a validated diabetes model, and nonparametric bootstrapping of individual patient data. Results: Annual United Kingdom Prospective Diabetes Study risk scores reduced for cardiovascular events (hazard ratio: 0.83 and 0.98) and cardiovascular mortality (hazard ratio: 0.78 and 0.88) for men and women, respectively. Life expectancy improved by 0.97 and 0.76 years for men and women, and quality-adjusted life years by 0.44 and 0.37, respectively. Higher life expectancy in the intervention group increased lifelong costs by €860 for men and €645 for women. Initial program costs were about €22 per patient. The incremental costs per quality-adjusted life year were €1937 for men and €1751 for women compared with usual care costs. There is a probability >95% that the collaborative is cost-effective, using a threshold of €20,000 per quality-adjusted life year. Conclusion: Optimizing integrated and patient-centered diabetes care through a quality-improvement collaborative is cost-effective compared with usual care.

Background The success of a clinical trial is often dependant on whether recruitment targets can be met in the required time frame. Despite an increase in research into the benefits of exercise in people with multiple sclerosis (PwMS), no trial has reported detailed data on effective recruitment strategies for large-scale randomised controlled trials. The main purpose of this report is to provide a detailed outline of recruitment strategies, rates and estimated costs in the Exercise Intervention for Multiple Sclerosis (ExIMS) trial to identify best practices for future trials involving multiple sclerosis (MS) patient recruitment. Methods The ExIMS researchers recruited 120 PwMS to participate in a 12-week exercise intervention. Participants were randomly allocated to either exercise or usual-care control groups. Participants were sedentary, aged 18–65 years and had Expanded Disability Status Scale scores of 1.0–6.5. Recruitment strategies included attendance at MS outpatient clinics, consultant mail-out and trial awareness-raising activities. Results A total of 120 participants were recruited over the course of 34 months. To achieve this target, 369 potentially eligible and interested participants were identified. A total of 60 % of participants were recruited via MS clinics, 29.2 % from consultant mail-outs and 10.8 % through trial awareness. The randomisation yields were 33.2 %, 31.0 % and 68.4 % for MS clinic, consultant mail-outs and trial awareness strategies, respectively. The main reason for ineligibility was being too active (69.2 %), whilst for eligible participants the most common reason for non-participation was the need to travel to the study site (15.8 %). Recruitment via consultant mail-out was the most cost-effective strategy, with MS clinics being the most time-consuming and most costly. Conclusions To reach recruitment targets in a timely fashion, a variety of methods were employed. Although consultant mail-outs were the most cost-effective recruitment strategy, use of this method alone would not have allowed us to obtain the predetermined number of participants in the required time period, thus leading to costly extensions of the project or failure to reach the number of participants required for sufficient statistical power. Thus, a multifaceted approach to recruitment is recommended for future trials. Trial registration International Standard Randomised Controlled Trial Registry number: ISRCTN41541516 ; date registered: 5 February 2009.

Background Patients not attending to clinic appointments (no-show) significantly affects delivery, cost of care and resource planning. We aimed to evaluate the prevalence, predictors and economic consequences of patient no-shows. Method This is a retrospective cohort study using administrative databases for fiscal years 1997–2008. We searched administrative databases for no-show frequency and cost at a large medical center. In addition, we estimated no-show rates and costs in another 10 regional hospitals. We studied no-show rates in primary care and various subspecialty settings over a 12-year period, the monthly and seasonal trends of no-shows, the effects of implementing a reminder system and the economic effects of missed appointments. Results The mean no-show rate was 18.8 % (2.4 %) in 10 main clinics with highest occurring in subspecialist clinics. No-show rate in the women clinic was higher and the no-show rate in geriatric clinic was lower compared to general primary care clinic (PCP). The no-show rate remained at a high level despite its reduction by a centralized phone reminder (from 16.3 % down to 15.8 %). The average cost of no-show per patient was $196 in 2008. Conclusions Our data indicates that no-show imposed a major burden on this health care system. Further, implementation of a reminder system only modestly reduced the no-show rate.

This book unveils and demystifies a revolution occurring in health care in the United States and beyond and how it will reform the health care system. There is something new in health care. Retail clinics, sometimes partnering with prestigious health-care institutions such as the Cleveland Clinic, offer an affordable, accessible solution for delivering primary-care services to underserved populations. The Retail Revolution in Health Care presents an overview of the retail health trend and its implications for consumers, employers, health care providers, health care companies, insurers, and health policy makers. The authors examine the phenomenon of retail health care from an entrepreneurial perspective, discussing the growth of retail care beyond traditional retail establishments and possible performance indicators to assess health outcomes. They report on the differing perspectives of retail care from a variety of experts, including doctors, nurses, patients, and insurers. Finally, they address business realities in the United States and globally as they affect the clinics. Retail clinics will almost certainly play a key role as either an alternative to national health insurance or a component of health reform. This important book explores their part in furthering the availability of health care for all Americans.

Ambulatory surgery centres are becoming an attractive alternative to hospital-based outpatient departments; however, limited data exist on their cost efficacy in a publicly funded health care model. In this study, we aimed to compare costs for ambulatory sports medicine procedures performed at an ambulatory surgery centre and a hospital outpatient department. We retrospectively identified patients who underwent rotator cuff repair, anterior cruciate ligament reconstruction (ACLR), or hip arthroscopy between January 2020 and August 2022. We collected demographic characteristics, procedural costs, and procedural data. We used 2-sample t tests to compare care-related costs between groups treated in an ambulatory surgery centre and hospital outpatient department. After controlling for age and concomitant procedures, we included a total of 132 patients for analysis. Patients who underwent hip arthroscopy or rotator cuff repair in an ambulatory surgery centre had significantly shorter duration of total operating room time, and procedural duration was equivocal (p > 0.1) between sites. Procedure time for ACLR was significantly shorter in the group treated in an ambulatory surgery centre than in the group treated in a hospital outpatient department (p = 0.01). The total case costs for the ambulatory surgery centre were significantly lower for hip arthroscopy ($3543, standard deviation (SD) $365 v. $6209, SD $681; p < 0.05), rotator cuff repair ($4259, SD $934 v. $5786, SD $934; p < 0.05), and ACLR ($3136, SD $459 v. $4821, SD $1511; p < 0.05), despite a lack of differences in associated disposable implant costs for ACLR and rotator cuff repair (p > 0.1). Material costs were significantly lower in the group receiving hip arthroscopy at an ambulatory surgery centre than in the group receiving the same procedure at a hospital outpatient department (p < 0.05). There were no differences in immediate 6-week postoperative care–associated costs between groups (p > 0.4). Ambulatory sports medicine procedures performed at an ambulatory surgery centre were associated with significantly reduced operating room time and total cost compared with matched cases performed via a hospital outpatient department. Ambulatory surgery centres provide an opportunity to improve cost efficacy and reduce wait-lists for surgical care. Les centres de chirurgie ambulatoire deviennent une solution de rechange attrayante aux services de chirurgie ambulatoire des hôpitaux; par contre, on dispose de peu de données sur leur rapport coût:efficacité dans le contexte d’un système de santé public. Dans cette étude, nous avons comparé le coût des interventions en médecine sportive ambulatoire dans un centre de chirurgie ambulatoire et dans un service hospitalier ambulatoire. Nous avons rétrospectivement identifié les patients ayant subi une réparation de la coiffe des rotateurs, une reconstruction du ligament croisé antérieur (LCA) ou une arthroscopie de la hanche entre janvier 2020 et août 2022. Nous avons consigné les caractéristiques démographiques, le coût et les données des interventions. Nous avons utilisé les tests t de Student à 2 échantillons pour comparer le coût des soins entre les groupes traités dans un centre de chirurgie ambulatoire et un service hospitalier ambulatoire. Après la prise en compte de l’âge et des interventions concomitantes, nous avons inclus en tout 132 patients dans notre analyse. Les cas d’arthroscopie de la hanche ou de réparation de la coiffe des rotateurs en centre de chirurgie ambulatoire ont accaparé significativement moins de temps au bloc opératoire, et la durée des interventions était équivoque (p > 0,1) entre les sites. La durée de la reconstruction du LCA a été significativement plus brève en centre de chirurgie ambulatoire qu’en clinique hospitalière ambulatoire (p = 0,01). Le coût total par cas en centre de chirurgie ambulatoire a été significativement moindre pour l’arthroscopie de la hanche (3543 $, écart type [ÉT] 365 $ c. 6209 $, ÉT 681 $; p < 0,05), la réparation de la coiffe des rotateurs (4259 $, ÉT 934 $ c. 5786 $, ÉT 934 $; p < 0,05), et la reconstruction du LCA (3136 $, ÉT 459 $ c. 4821 $, ÉT 1511 $; p < 0,05), malgré le coût similaire des nécessaires jetables utilisés pour la reconstruction du LCA et la réparation de la coiffe des rotateurs (p > 0,1). Les coûts matériels ont été significativement moindres pour les arthroscopies effectuées dans un centre de chirurgie ambulatoire que pour les mêmes interventions pratiquées dans un service hospitalier ambulatoire (p < 0,05). On n’a noté aucune différence au plan des coûts associés aux soins postopératoires après 6 semaines entre les groupes (p > 0,4). Les interventions en médecine sportive effectuées dans un centre de chirurgie ambulatoire ont été associées à une réduction significative du temps opératoire et du coût total comparativement aux cas appariés recensés dans les cliniques hospitalières de chirurgie ambulatoire. Les centres de chirurgie ambulatoire offrent la possibilité d’améliorer le rapport coût:efficacité et de réduire les listes d’attente en chirurgie.

Background Studies show that hospital deaths bring significant health care costs, and the involvement of specialized palliative care can help to reduce these costs. The aim of this retrospective registry-based study was to evaluate end-of-life hospital costs in patients dying in a university hospital oncology ward, with or without specialized palliative outpatient clinic contact at any timepoint. Methods The study population consists of all patients who died in the Kuopio University Hospital oncology ward in the years 2012–2018 ( n  = 457). Hospital costs in the last 30 days of life and data on treatment decisions and background factors were gathered. Costs for patients with and without palliative care contact were compared. Effects of various variables on the costs were analyzed using gamma regression model. Results Both the last 14 days’ and 30 days’ hospital costs before death were significantly lower among those 65 patients [14.2%] who had had a specialist palliative care contact. This was seen in inpatient day costs, microbiology, radiation therapy, laboratory, drug, radiology, and total costs. In a multivariate analysis including age, gender, year of death, time from diagnosis to death, and cancer type, the costs for 30 days prior to death were 33% lower in those patients who had had palliative care contact. Conclusions Our results provide first indications that a contact to specialist palliative care in an outpatient clinic may reduce end-of-life hospital care costs in hospital-deceased cancer patients.