Cost-Effectiveness Analysis of Ultrasound Screening for Thyroid Cancer in Asymptomatic Adults

Objectives: This study evaluated the long-term cost-effectiveness of ultrasound screening for thyroid cancer compared with non-screening in asymptomatic adults.Methods: Applying a Markov decision-tree model with effectiveness and cost data from literature, we compared the long-term cost-effectiveness of the two strategies: ultrasound screening and non-screening for thyroid cancer. A one-way sensitivity analysis and a probabilistic sensitivity analysis were performed to verify the stability of model results.Results: The cumulative cost of screening for thyroid cancer was $18,819.24, with 18.74 quality-adjusted life years (QALYs), whereas the cumulative cost of non-screening was $15,864.28, with 18.71 QALYs. The incremental cost-effectiveness ratio of $106,947.50/QALY greatly exceeded the threshold of $50,000. The result of the one-way sensitivity analysis showed that the utility values of benign nodules and utility of health after thyroid cancer surgery would affect the results.Conclusions: Ultrasound screening for thyroid cancer has no obvious advantage in terms of cost-effectiveness compared with non-screening. The optimized thyroid screening strategy for a specific population is essential.

Sequential Shortest Path Interdiction with Incomplete Information and Limited Feedback

We study sequential shortest path interdiction, where in each period an interdictor with incomplete knowledge of the arc costs blocks at most [Formula: see text] arcs, and an evader with complete knowledge about the costs traverses a shortest path between two fixed nodes in the interdicted network. In each period, the interdictor, who aims at maximizing the evader’s cumulative cost over a finite time horizon, and whose initial knowledge is limited to valid lower and upper bounds on the costs, observes only the total cost of the path traversed by the evader, but not the path itself. This limited information feedback is then used by the interdictor to refine knowledge of the network’s costs, which should lead to better decisions. Different interdiction decisions lead to different responses by the evader and thus to different feedback. Focusing on minimizing the number of periods it takes a policy to recover a full information interdiction decision (that taken by an interdictor with complete knowledge about costs), we show that a class of greedy interdiction policies requires, in the worst case, an exponential number of periods to converge. Nonetheless, we show that under less stringent modes of feedback, convergence in polynomial time is possible. In particular, we consider different versions of imperfect randomized feedback that allow establishing polynomial expected convergence bounds. Finally, we also discuss a generalization of our approach for the case of a strategic evader, who does not necessarily follow a shortest path in each period.

Physical Activity and Cumulative Long-Term Care Cost among Older Japanese Adults: A Prospective Study in JAGES

This study aimed to determine the impact of physical activity on the cumulative cost of long-term care insurance (LTCI) services in a cohort of community-dwelling people (65 years and older) in Japan. Using cohort data from the Japan Gerontological Evaluation Study (JAGES) on those who were functionally independent as of 2010/11, we examined differences in the cumulative cost of LTCI services by physical activity. We followed 38,875 participants with LTCI service costs for 59 months. Physical activity was assessed by the frequency of going out and time spent walking. We adopted a generalized linear model with gamma distribution and log-link function, and a classical linear regression with multiple imputation. The cumulative LTCI costs significantly decreased with the frequency of going out and the time spent walking after adjustment for baseline covariates. LTCI’s cumulative cost for those who went out once a week or less was USD 600 higher than those who went out almost daily. Furthermore, costs for those who walked for less than 30 min were USD 900 higher than those who walked for more than 60 min. Physical activity among older individuals can reduce LTCI costs, which could provide a rationale for expenditure intervention programs that promote physical activity.

Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review

Background Infectious complications of injection drug use (IDU) often require lengthy inpatient treatment. Our objective was to identify the number of admissions related to IDU in Regina, Canada, as well as describe patient demographics and comorbidities, yearly mortality, readmission rate, and cumulative cost of these hospitalizations between January 1 and December 31, 2018. Additionally, we sought to identify factors that increased risk of death or readmission. Methods This study is a retrospective chart review conducted at the two hospitals in Regina. Eligible study cases were identified by querying the discharge database for predetermined International Classification of Diseases code combinations. Electronic medical records were reviewed to assess whether each admission met inclusion criteria, and hospitalization and patient data were subsequently extracted for all included admissions. Mortality data were gleaned from hospital and Ministry of Health databases. Data were analyzed using Excel and IBM SPSS Statistics to identify common comorbidities, admission diagnoses, and costs, as well as to compare patients with a single admission during the study period to those with multiple admissions. Logistic regression analysis was used to identify the relationship between individual variables and in- and out-of-hospital annual mortality. Results One hundred and forty-nine admissions were included, with 102 unique patients identified. Common comorbidities included hepatitis C (47%), human immunodeficiency virus (HIV) (25%), and comorbid psychiatric disorders (19%). In 23% of all admissions, patients left hospital prior to treatment completion, and 27% of patients experienced multiple admissions. Female patients and those with chronic pain were more likely to be readmitted (p = 0.024 and p = 0.029, respectively). Patients admitted with infective endocarditis were more likely to die during hospitalization (p = 0.0001). The overall mortality was 15% in our cohort. The estimated cumulative cost of inpatient treatment of complications of IDU in Regina was $3.7 million CAD in 2018. Conclusion Patients with history of IDU and hospital admission experience high mortality rates in Regina, a city with paucity of inpatient supports for persons who use injection drugs. Needle syringe programs, opioid agonist therapy, and safe consumption sites have been shown to improve outcomes as well as reduce healthcare costs for this patient population. We will use our findings to advocate for increased access to these harm reduction strategies in Regina, particularly for inpatients.

Low-Cost Active Anomaly Detection with Switching Latency

Consider the problem of detecting anomalies among multiple stochastic processes. Each anomaly incurs a cost per unit time until it is identified. Due to the resource constraints, the decision-maker can select one process to probe and obtain a noisy observation. Each observation and switching across processes accompany a certain time delay. Our objective is to find a sequential inference strategy that minimizes the expected cumulative cost incurred by all the anomalies during the entire detection procedure under the error constraints. We develop a deterministic policy to solve the problem within the framework of the active hypothesis testing model. We prove that the proposed algorithm is asymptotic optimal in terms of minimizing the expected cumulative costs when the ratio of the single-switching delay to the single-observation delay is much smaller than the declaration threshold and is order-optimal when the ratio is comparable to the threshold. Not only is the proposed policy optimal in the asymptotic regime, but numerical simulations also demonstrate its excellent performance in the finite regime.

The Cost of Care Associated with Microvascular Free Tissue Transfer by Anatomical Region: A Time-Driven Activity-Based Model

Background Microvascular free tissue transfer (FTT) is a reliable method for reconstruction of complex soft tissue defects. The goal of this study was to utilize time-driven activity-based cost (TDABC) accounting to measure the total cost of care of FTT and identify modifiable cost drivers. Methods A retrospective review was performed on patients requiring FTT at a single, level-I academic trauma center from 2013 to 2019. Patient and surgical characteristics were collected, and six prospective FTT cases were observed via TDABC to collect direct and indirect costs of care. Results When stratified by postoperative stay at intensive care units (ICUs), the average cost of care was $21,840.22, while cases without ICU stay averaged $6,646.61. The most costly category was ICU stay, averaging $8,310.99 (40.9% of nonstratified overall cost). Indirect costs were the second most costly category, averaging $4,388.07 (21.6% of nonstratified overall cost). Overall, 13 of 100 reviewed cases required some form of revision free-flap, increasing cumulative costs to $7,961.34 for cases with non-ICU stay and $22,233.85 for cases with ICU stay, averaging up to $44,074.07 for patients who stayed in the ICU for both procedures. An increase in cumulative cost was also observed within the timeframe of the investigation, with average costs of $8,484.00 in 2013 compared to $45,128 for 2019. Conclusion Primary drivers for cost in this study were ICU stay and revision/reoperation. Better understanding the cost of FTT allows for cost reduction through the development of new protocols that drive intraoperative efficiency, reduce ICU stays, and optimize outcomes.

CC-486 Reduces Hospitalization and Associated Estimated Costs in Patients with Acute Myeloid Leukemia (AML) in First Remission after Intensive Chemotherapy: Results from the QUAZAR AML-001 Maintenance Trial

BACKGROUND: AML is an aggressive malignancy primarily affecting older individuals. Although 40%-60% of patients (pts) aged >60 years attain complete remission (CR) with IC, 80%-90% of them eventually relapse. In the continuum of AML care, the greatest expenditures are associated with relapsed/refractory disease, and hospitalization is the largest component (~70%) of direct AML healthcare costs (Pandya, 2020). In the randomized, phase III QUAZAR AML-001 Maintenance Trial, CC-486, an oral hypomethylating agent, significantly prolonged overall (OS) and relapse-free survival (RFS) vs. placebo (PBO) in pts with newly diagnosed (ND) AML in first remission following IC. OBJECTIVE: Determine rates of hospitalization and days in hospital with CC-486 and PBO in QUAZAR AML-001, and quantify associated costs of hospitalization using unit costs estimated from a US claims database. METHODS: In QUAZAR AML-001, eligible pts were age ≥55 years, with de novo or secondary AML, intermediate- or poor-risk cytogenetics, and ECOG PS ≤3; achieved first CR or CR with incomplete count recovery (CRi) after IC ± consolidation; and were not candidates for hematopoietic stem cell transplant (HSCT). Within 4 months of CR/CRi, pts were randomized 1:1 to CC-486 300 mg or PBO, administered once-daily on days 1-14 of repeated 28-day cycles. Pts who received ≥1 dose of study drug were followed for hospitalizations and durations of stay from date of informed consent through 28 days after last dose. The mean number of days hospitalized per month (30 days) in each treatment arm was computed by dividing the aggregate number of hospitalized days by the number of ongoing pts at each time-point. Rates of hospitalization and days in hospital were also adjusted for duration of CC-486 and PBO exposure. 95% confidence intervals (CI) for relative risk (RR) estimates and associated P values are based on asymptotic methods. Patients with a primary diagnosis of AML, preceded by ≥6 months (baseline) without a claim for AML were identified in the IBM MarketScan Commercial & Medicare database from April 2013 to July 2019. A stepwise procedure was then used to include pts aged ≥55 years at diagnosis, without a diagnosis of another primary cancer or HSCT, and with insurance coverage during the entire 6-month baseline period. Unit cost of hospitalization was derived as the average total AML-related hospitalization costs incurred per day of stay, adjusted for inflation to 2019 US dollars. RESULTS: In all, 469 pts were enrolled in QUAZAR AML-001 and received CC-486 (N=236) or PBO (N=233). Total exposure to CC-486 was 363.8 pt-years (PY) and to PBO was 234.9 PY. In all, 108 pts (45.8%) in the CC-486 arm and 118 (50.6%) in the PBO arm were hospitalized. The total numbers of hospitalizations were 173 in the CC-486 arm and 151 in the PBO arm; however, the exposure-adjusted rate of hospitalization was significantly lower in the CC-486 arm: 0.48/PY vs. 0.64/PY, respectively (RR 0.740 [95%CI 0.595, 0.920]; P = 0.0068) (Table). The total number of days hospitalized was 2872 in the CC-486 arm and 3139 in the PBO arm, and the exposure-adjusted days-in-hospital rate was significantly lower in the CC-486 arm (7.89/PY vs. 13.36/PY in the PBO arm; RR 0.591 [95%CI 0.562, 0.621]; P < 0.0001) (Table). Of the ND-AML cohort identified in the MarketScan database, 3058 pts had ≥ 1 noncapitated hospitalization and provided the basis for estimated hospitalization-related costs. Median age and sex distribution of these pts were generally consistent with those of pts in QUAZAR AML-001. The mean AML-related hospitalization cost incurred in the database was $7,126/day (2019 USD). Thus, based on exposure-adjusted days-in-hospital rates in the CC-486 and PBO arms (7.89/PY and 13.36/PY, respectively), the estimated mean costs of hospitalization in QUAZAR AML-001 were $56,224/PY in the CC-486 arm and $95,201/PY in the PBO arm. Cumulative cost savings in the CC-486 arm compared with PBO ranged from $2,837 in month 2 to $40,909 by month 24 (Figure). CONCLUSION: CC-486 was associated with significantly reduced exposure-adjusted risk of hospitalization and days in hospital compared with PBO, which are estimated to result in substantial cumulative cost savings. Significantly prolonged RFS with CC-486 vs. PBO in this study (10.2 vs. 4.8 months; P = 0.0001) may translate into substantial economic benefits, with lower hospitalization-related costs due to reduced rates of hospitalization and days in hospital. Disclosures Oliva: Alexion: Consultancy; Apellis: Consultancy; Abbvie: Consultancy; Amgen: Consultancy; Novartis: Consultancy; BMS: Consultancy, Honoraria, Patents & Royalties, Speakers Bureau. Oriol:Amgen: Consultancy, Speakers Bureau; Janssen: Consultancy; Sanofi: Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. La Torre:Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Skikne:Bristol Myers Squibb: Current Employment. Beach:Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Kumar:Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Dong:Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Chen:Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Ranjan:SmartAnalyst India Pvt. Ltd.: Current Employment. Kiendrebeogo:SmartAnalyst, Inc.: Current Employment. Braun:Servier: Research Funding; Daiichy-Sankyo: Honoraria.