Hospital expenditure at the end-of-life: what are the impacts of health status and health risks?

Background: It is important for health policy and expenditure projections to understand the relationship between age, death and expenditure on health care (HC). Research has shown that older age groups incur lower hospital costs than previously anticipated and that remaining time to death (TTD) was a much stronger indicator for expenditure than age. How health behaviour or risk factors impact on HC utilisation and costs at the end of life is relatively unknown. Smoking and Body Mass Index (BMI) have featured most prominently and mixed findings exist as to the exact nature of this association.<p></p> Methods: This paper considers the relationship between TTD, age and expenditure for inpatient care in the last 12 quarters of life; and introduces measures of health status and risks. A longitudinal dataset covering 35 years is utilised, including baseline survey data linked to hospital and death records. The effect of age, TTD and health indicators on expenditure for inpatient care is estimated using a two-part model.<p></p> Results: As individuals approach death costs increase. This effect is highly significant (p<0.01) from the last until the 8th quarter before death and influenced by age. Statistically significant effects on costs were found for: smoking status, systolic blood pressure and lung function (FEV1). On average, smokers incurred lower quarterly costs in their last 12 quarters of life than non-smokers (~7%). Participants’ BMI at baseline did show a negative association with probability of HC utilisation however this effect disappeared when costs were estimated.<p></p> Conclusions: Health risk measures obtained at baseline provide a good indication of individuals’ probability of needing medical attention later in life and incurring costs, despite the small size of the effect. Utilising a linked dataset, where such measures are available can add substantially to our ability to explain the relationship between TTD and costs.<p></p&gt

Evaluating the impact of the Alcohol Act on off-trade alcohol sales: a natural experiment in Scotland

<b>Background and aims</b> A ban on multi-buy discounts of off-trade alcohol was introduced as part of the Alcohol Act in Scotland in October 2011. The aim of this study was to assess the impact of this legislation on alcohol sales, which provide the best indicator of population consumption.<p></p> <b>Design Setting and Participants</b> Interrupted time-series regression was used to assess the impact of the Alcohol Act on alcohol sales among off-trade retailers in Scotland. Models accounted for underlying seasonal and secular trends and were adjusted for disposable income, alcohol prices and substitution effects. Data for off-trade retailers in England and Wales combined (EW) provided a control group.<p></p> <b>Measurements</b> Weekly data on the volume of pure alcohol sold by off-trade retailers in Scotland and EW between January 2009 and September 2012.<p></p> <b>Findings</b> The introduction of the legislation was associated with a 2.6% (95% CI -5.3 to 0.2%, P = 0.07) decrease in off-trade alcohol sales in Scotland, but not in EW (-0.5%, -4.6 to 3.9%, P = 0.83). A statistically significant reduction was observed in Scotland when EW sales were adjusted for in the analysis (-1.7%, -3.1 to -0.3%, P = 0.02). The decline in Scotland was driven by reduced off-trade sales of wine (-4.0%, -5.4 to -2.6%, P < 0.001) and pre-mixed beverages (-8.5%, -12.7 to -4.1%, P < 0.001). There were no associated changes in other drink types in Scotland, or in sales of any drink type in EW.<p></p> <b>Conclusions</b> The introduction of the Alcohol Act in Scotland in 2011 was associated with a decrease in total off-trade alcohol sales in Scotland, largely driven by reduced off-trade wine sales

Population ageing in Scotland - implications for healthcare expenditure

POPULATION AGEING IN SCOTLAND - IMPLICATIONS FOR HEALTHCARE EXPENDITURE Population ageing is a major concern for developed countries in terms of public expenditure required to pay for health care (HC). The broad aim of this thesis is to contribute to and expand the debate on the independent effects that population ageing and the time immediately before death (TTD) have on HC expenditure in Scotland. This study analyses, for the first time in Scotland, how HC expenditure projections are influenced through the application of two approaches; the first only accounting for an increasing proportion of the elderly population, and the second also implementing a TTD component. Several issues that are under-researched or have not been addressed in TTD studies previously, are explored and alternative approaches are presented. Utilising two large linked datasets this thesis addresses important methodological issues. Alternative methods to cost inpatient hospital stays are examined as this has pivotal implications for any analysis undertaken to estimate the independent effect of TTD and age on HC expenditure. Explanatory variables that have previously not been considered, such as health risk and health status measures at baseline, are included in these analyses. The issue of sample selection, arising through the inclusion/exclusion of survivors in a TTD study is investigated and the impact of individuals’ socio-economic status on costs is examined. The analysis of alternative costing methods clearly showed that any inference that can be made from econometric modelling of costs, where the marginal effect of explanatory variables is assessed, is substantially influenced by the chosen costing method. The application of a Healthcare Resource Group (HRG) costing method was recommended. This study found that TTD, age and the interactions between these two factors were significant predictors for HC expenditure. The analysis further identified some of the health status and health risk measures to be important predictors of future HC expenditure. An examination of how sample selection impacts on estimated costs at the end of life showed that if survivors were excluded from the analysis, costs might be overestimated. Drawing on a representative sample of the Scottish population, the investigation of the association that the socio-economic status had with HC costs suggested that less is spent on individuals from more deprived areas. This might partly be explained through the decreased probability of accessing hospital services for individuals from more deprived areas. Furthermore, results showed that projected HC expenditure for acute inpatient care for the year 2028 was overestimated by ~7% when an approach that only accounts for the higher proportion of elderly people in a population in the future is being used as compared to an approach that also accounts for the effect that remaining TTD has on costs

The SCottish Alcoholic Liver disease Evaluation: a population-level matched cohort study of hospital-based costs, 1991-2011

Studies assessing the costs of alcoholic liver disease are lacking. We aimed to calculate the costs of hospitalisations before and after diagnosis compared to population controls matched by age, sex and socio-economic deprivation. We aimed to use population level data to identify a cohort of individuals hospitalised for the first time with alcoholic liver disease in Scotland between 1991 and 2011.Incident cases were classified by disease severity, sex, age group, socio-economic deprivation and year of index admission. 5 matched controls for every incident case were identified from the Scottish population level primary care database. Hospital costs were calculated for both cases and controls using length of stay from morbidity records and hospital-specific daily rates by specialty. Remaining lifetime costs were estimated using parametric survival models and predicted annual costs. 35,208 incident alcoholic liver disease hospitalisations were identified. Mean annual hospital costs for cases were 2.3 times that of controls pre diagnosis (£804 higher) and 10.2 times (£12,774 higher) post diagnosis. Mean incident admission cost was £6,663. Remaining lifetime cost for a male, 50-59 years old, living in the most deprived area diagnosed with acoholic liver disease was estimated to be £65,999 higher than the matched controls (£12,474 for 7.43 years remaining life compared to £1,224 for 21.8 years). In Scotland, alcoholic liver disease diagnosis is associated with significant increases in admissions to hospital both before and after diagnosis. Our results provide robust population level estimates of costs of alcoholic liver disease for the purposes of health-care delivery, planning and future cost-effectiveness analyses

Cost-effectiveness of treating hepatitis C in Seychelles

Introduction: approximately eighty million people around the world are living with hepatitis C, and 700,000 people die every year, due to hepatitis C related complications. In Seychelles, a total of 777 cases of hepatitis C were reported from 2002 to 2016, but up to mid of 2016, the cases were not being treated. Treatment with Harvoni, a combination of sofosbuvir and ledipasvir (SOF/LDV), is now being offered on the condition that the patient does not, or has stopped, injecting drugs. This paper is the first to establish the cost effectiveness of treating all cases of hepatitis C in Seychelles with Harvoni, as compared to no treatment. Methods: data extracted from literature was used to populate an economic model to calculate cost-effectiveness from Seychelles' Government perspective. The model structure was also informed by the systematic review and an accompanying grading of economic models using the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) checklist. A Markov model was developed, employing a lifetime horizon and costs and benefits were analysed from a payer's perspective and combined into incremental cost effectiveness ratios (ICERs). Results: the direct-acting antiviral (DAA), Harvoni, was found to be cost-saving in Seychelles hepatitis C virus (HCV) cohort, as compared to no treatment, with an ICER of € 753.65/QALY. The treatment was also cost-saving when stratified by gender, with the ICER of male and female being € 783.74/QALY and € 635.20/QALY, respectively. Moreover, the results obtained from acceptability curves showed that treating patients with Harvoni is the most cost-effective option, even for low thresholds. Conclusion: treating hepatitis C cases in Seychelles is cost-saving. It is worth developing a treatment programme to include all cases of hepatitis C, regardless of status of drug injection

Cost-effectiveness of HBV and HCV screening strategies:a systematic review of existing modelling techniques

Introduction: Studies evaluating the cost-effectiveness of screening for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are generally heterogeneous in terms of risk groups, settings, screening intervention, outcomes and the economic modelling framework. It is therefore difficult to compare cost-effectiveness results between studies. This systematic review aims to summarise and critically assess existing economic models for HBV and HCV in order to identify the main methodological differences in modelling approaches. Methods: A structured search strategy was developed and a systematic review carried out. A critical assessment of the decision-analytic models was carried out according to the guidelines and framework developed for assessment of decision-analytic models in Health Technology Assessment of health care interventions. Results: The overall approach to analysing the cost-effectiveness of screening strategies was found to be broadly consistent for HBV and HCV. However, modelling parameters and related structure differed between models, producing different results. More recent publications performed better against a performance matrix, evaluating model components and methodology. Conclusion: When assessing screening strategies for HBV and HCV infection, the focus should be on more recent studies, which applied the latest treatment regimes, test methods and had better and more complete data on which to base their models. In addition to parameter selection and associated assumptions, careful consideration of dynamic versus static modelling is recommended. Future research may want to focus on these methodological issues. In addition, the ability to evaluate screening strategies for multiple infectious diseases, (HCV and HIV at the same time) might prove important for decision makers

The role of universal health coverage in secondary prevention: a case study of Ghana’s National Health Insurance Scheme and early-onset hypertension

Background: Launched in 2003, Ghana’s National Health Insurance Scheme (NHIS) was a move towards Universal Health Coverage. There is a dearth of studies that have since investigated the effect of the scheme on non-communicable diseases (NCDs) like hypertension. While a major cause of mortality and morbidity, hypertension remains mostly undiagnosed in Ghana. Secondary prevention comprising early detection and prompt treatment is, hence, important in reducing disease burden. This study assessed the association between active NHIS membership and the likelihood of having early-onset hypertension detected and treated. Methods: A cross-sectional analysis of the 2014 Ghana Demographic and Health Survey (male dataset) was conducted. Unadjusted analysis used binary logistic regression with active NHIS membership as the independent variable and detection of early-onset hypertension as the dependent variable. Early-onset hypertension was defined as the onset of hypertension at 55 years or younger. Covariates for the adjusted regression models were age, BMI, smoking status, place of residence, wealth, and education level. The association between membership and treatment was also assessed. Results: Unadjusted and adjusted results showed that the odds of early-onset hypertension being detected in participants with active NHIS membership were respectively 2.4 (95% CI:1.56 – 3.59, p=0.000) and 2.2 (95% CI 1.43 – 3.24, p=0.000) that of those without active membership. There was no significant association between membership and treatment. Conclusion: This study suggests that NHIS membership may play a beneficial role in the secondary prevention of NCDs in Ghana. Further research is, nevertheless, needed to understand how membership, NCDs, and other contextual factors are interrelated

Understanding Pathways into Care homes using Data (UnPiCD study) a retrospective cohort study using national linked health and social care data: a retrospective cohort study using national linked health and social care data

Background: Pathways into care are poorly understood but important life events for individuals and their families. UK policy is to avoid moving-in to care homes from acute hospital settings. This assumes that moves from secondary care represent a system failure. However, those moving to care homes from community and hospital settings may be fundamentally different groups, each requiring differing care approaches. Objective: To characterise individuals who move-in to a care home from hospital and compare with those moving-in from the community. Design and setting: A retrospective cohort study using cross-sectoral data linkage of care home data. Methods: We included adults moving-in to care homes between 1/4/13 and 31/3/16, recorded in the Scottish Care Home Census. Care home data were linked to general and psychiatric hospital admissions, community prescribing and mortality records to ascertain comorbidities, significant diagnoses, hospital resource use, polypharmacy and frailty. Multivariate logistic regression identified predictors of moving-in from hospital compared to from community. Results: We included 23,892 individuals moving-in to a care home, 13,564 (56.8%) from hospital and 10,328 (43.2%) from the community. High frailty risk adjusted Odds Ratio (aOR) 5.11 (95% Confidence Interval (CI): 4.60–5.68), hospital discharge with diagnosis of fracture aOR 3.91 (95%CI: 3.41–4.47) or stroke aOR 8.42 (95%CI: 6.90–10.29) were associated with moving-in from hospital. Discharge from in-patient psychiatry was also a highly significant predictor aOR 19.12 (95%CI: 16.26–22.48). Conclusions: Individuals moving-in to care homes directly from hospital are clinically distinct from those from the community. Linkage of cross-sectoral data can allow exploration of pathways into care at scale

The feasibility of a randomised controlled trial to compare the cost-effectiveness of palliative cardiology or usual care in people with advanced heart failure: Two exploratory prospective cohorts

© 2018, © The Author(s) 2018. Background: The effectiveness of cardiology-led palliative care is unknown; we have insufficient information to conduct a full trial. Aim: To assess the feasibility (recruitment/retention, data quality, variability/sample size estimation, safety) of a clinical trial of palliative cardiology effectiveness. Design: Non-randomised feasibility. Setting/participants: Unmatched symptomatic heart failure patients on optimal cardiac treatment from (1) cardiology-led palliative service (caring together group) and (2) heart failure liaison service (usual care group). Outcomes/safety: Symptoms (Edmonton Symptom Assessment Scale), Kansas City Cardiomyopathy Questionnaire, performance, understanding of disease, anticipatory care planning, cost-effectiveness, survival and carer burden. Results: A total of 77 participants (caring together group = 43; usual care group = 34) were enrolled (53% men; mean age 77 years (33–100)). The caring together group scored worse in Edmonton Symptom Assessment Scale (43.5 vs 35.2) and Kansas City Cardiomyopathy Questionnaire (35.4 vs 39.9). The caring together group had a lower consent/screen ratio (1:1.7 vs 1: 2.8) and few died before approach (0.08% vs 16%) or declined invitation (17% vs 37%). Data quality: At 4 months, 74% in the caring together group and 71% in the usual care group provided data. Most attrition was due to death or deterioration. Data quality in self-report measures was otherwise good. Safety: There was no difference in survival. Symptoms and quality of life improved in both groups. A future trial requires 141 (202 allowing 30% attrition) to detect a minimal clinical difference (1 point) in Edmonton Symptom Assessment Scale score for breathlessness (80% power). More participants (176; 252 allowing 30% attrition) are needed to detect a 10.5 change in Kansas City Cardiomyopathy Questionnaire score (80% power; minimum clinical difference = 5). Conclusion: A trial to test the clinical effectiveness (improvement in breathlessness) of cardiology-led palliative care is feasible