No Association Between Breast Pain and Breast Cancer. A Prospective Cohort Study of 10,830 Symptomatic Women Presenting to a Breast Cancer Diagnostic Clinic

Background Women with breast pain constitute upto 20% of breast clinic attendees. Aim: To investigate breast cancer incidence in women presenting with breast pain and establish health economics of referring women with breast pain to secondary care. Design & Setting: Prospective cohort study of all consecutive women referred to a breast diagnostic clinic over 12 months. Methods: Women were categorised by presentation into 4 distinct clinical groups and cancer incidence investigated. Results: Of 10 830 women, 1972 (18%) were referred with breast pain, 6708 (62%) with lumps, 480 (4%) with nipple symptoms,1670 (15%) with ‘other’ symptoms. Mammography, performed in 1112 women with breast pain, identified cancer in 8 (0.7%). In 1972 women with breast pain, breast cancer incidence was 0.4% compared with ~5% in each of the three other clinical groups. Using ‘breast lump’ as reference, odds ratio (OR) of women referred with breast pain having breast cancer was 0.05 (95% confidence interval 0.02–0.09; P<0.001). Compared to reassurance in primary-care, referral was more costly (net cost £262) without additional health benefits (net Quality Adjusted Life Year (QALY) loss -0.012) Greatest impact on the incremental cost effectiveness ratio (ICER) was when QALY loss due to referral associated anxiety was excluded. Primary-care reassurance no longer dominated, but the ICER remained greater (£45,528/QALY) than typical UK National Health Service cost-effectiveness thresholds. Conclusions: This study shows that referring women with breast pain to a breast diagnostic clinic is an inefficient use of limited resources. Alternative management pathways could improve capacity and reduce financial burden.

A model framework for projecting the prevalence and impact of Long-COVID in the UK

The objective of this paper is to model lost Quality Adjusted Life Years (QALYs) from symptoms arising from COVID-19 disease in the UK population, including symptoms of ‘long-COVID’. The scope includes QALYs lost to symptoms, but not deaths, due to acute COVID-19 and long-COVID. The prevalence of symptomatic COVID-19, encompassing acute symptoms and long-COVID symptoms, was modelled using a decay function. Permanent injury as a result of COVID-19 infection, was modelled as a fixed prevalence. Both parts were combined to calculate QALY loss due to COVID-19 symptoms. Assuming a 60% final attack rate for SARS-CoV-2 infection in the population, we modelled 299,730 QALYs lost within 1 year of infection (90% due to symptomatic COVID-19 and 10% permanent injury) and 557,764 QALYs lost within 10 years of infection (49% due to symptomatic COVID-19 and 51% due to permanent injury). The UK Government willingness-to-pay to avoid these QALY losses would be £17.9 billion and £32.2 billion, respectively. Additionally, 90,143 people were subject to permanent injury from COVID-19 (0.14% of the population). Given the ongoing development in information in this area, we present a model framework for calculating the health economic impacts of symptoms following SARS-CoV-2 infection. This model framework can aid in quantifying the adverse health impact of COVID-19, long-COVID and permanent injury following COVID-19 in society and assist the proactive management of risk posed to health. Further research is needed using standardised measures of patient reported outcomes relevant to long-COVID and applied at a population level.

Effects of the First COVID-19 Lockdown on Ophthalmological Patient Care

Purpose To determine the effect of lockdown on medical care, with the example of ophthalmology. Methods Patients in a period during the first lockdown were compared to a non-lockdown period, with a total of 12 259 patients included in an observational study. Changes in different areas (elective, emergency, inpatients, surgeries) and eye care subspecialties were compared. Emergency patients were analyzed according to severity and urgency. Patients showing hints requiring treatment for urgent cardiovascular diseases were determined. Differences in patients who would have suffered severe vision loss without treatment were identified and the QALY (quality-adjusted life years) loss was determined accordingly. A model to prioritize patient visits after the end of lockdown or in future lockdown scenarios was developed. Data were collected at the University Eye Hospital LMU Munich and patient files were reviewed individually by ophthalmologists. Results The average patient number decreased by − 59.4% (p < 0.001), with a significant loss in all areas (elective, emergency, inpatients, surgeries; p < 0.001). There was a decline of − 39.6% for patients at high risk/high severity. Patients with indications of a risk factor of future stroke declined significantly (p = 0.003). QALY loss at the university eye hospital was 171, which was estimated to be 3160 – 24 143 for all of Germany. Working up high losses of outpatients during these 8 weeks of projected lockdown in Germany would take 7 – 23 weeks under normal circumstances, depending on ophthalmologist density. The prioritization model can reduce morbidity by up to 78%. Conclusion There was marked loss of emergency cases and patients with chronic diseases. Making up for the losses in examinations and treatments will theoretically take weeks to months. To reduce the risk of morbidity, we recommend a prioritization model for rescheduling and future lockdown scenarios.

HIV Care in Times of COVID-19 – Rapid Treatment Start Seems as Vital and Cost-Effective Approach in Central and Eastern Europe

Background: In times of SARS-CoV-2 epidemic it is essential to deliver specialist HIV care with a maximum effectiveness, but minimum epidemiological risk. Therefore, we aimed to determine whether rapid linkage tocare definedas starting combined antiretroviral therapy (cART) at the day of first visit in HIV clinic is a cost-effective approach.Methods:The analysis used Markov's lifetime model presented in our previous study. The input data used in the model were updated in terms of costs, life expectancy tables and patient’s characteristics. This analysis used information from the previous model about the additional cost of treatment and QALY lost in the life horizon for people newly infected with HIV. Number of new infected persons was estimated on the basis of available data.Results:Input data were available for 344 MSM patients who registered in HIV specialist care between 2016 and 2017. Estimated QALY loss due to no rapid treatmentin case of no taking (taking) into account viral load equal 0·018 (0·022), 0·039 (0·047), 0·131 (0·158) respectively in low, medium and high-risk transmission groups. RapidcART initiation was dominant regardless of the chosenscenarios. Conclusions:Taking into account HIV transmission in cost–effectiveness analysis indicates that rapid-initiation of HIV treatment is profitable.

A model framework for projecting the prevalence and impact of Long-COVID in the UK

Background The objective of this paper is to model lost Quality Adjusted Life Years (QALYs) from symptoms arising from COVID-19 in the UK population, including symptoms of 'long-COVID'. The scope includes QALYs lost to symptoms, but not deaths, due to acute COVID-19 and long COVID. Methods The prevalence of symptomatic COVID-19, encompassing acute symptoms and long-COVID symptoms, was modelled using a decay function. Permanent injury as a result of COVID-19 infection, was modelled as a fixed prevalence. Both parts are combined to calculate QALY loss due to COVID-19 symptoms. Results Assuming a 60% final attack rate for SARS-CoV-2 infection in the population, we modelled 299,719 QALYs lost within 1 year of infection (90% due to symptomatic COVID-19 and 10% permanent injury) and 557,754 QALYs lost within 10 years of infection (49% due to symptomatic COVID-19 and 51% due to permanent injury). The UK Government willingness-to-pay to avoid these QALY losses would be £17.9 billion and £32.2 billion, respectively. Additionally, 90,143 people were subject to permanent injury from COVID-19 (0.14% of the population). Conclusion Given the ongoing development in information in this area, we present a model framework for calculating the health economic impacts of symptoms following SARS-CoV-2 infection. This model framework can aid in quantifying the adverse health impact of COVID-19, long COVID and permanent injury following COVID-19 in society and assist the proactive management of risk posed to health. Further research is needed using standardised measures of patient reported outcomes relevant to long COVID and applied at a population level.

Burden of cardiovascular diseases associated with fine particulate matter in Beijing, China: an economic modelling study

ObjectiveTo evaluate the economic and humanistic burden associated with cardiovascular diseases that were attributable to fine particulate matter (≤ 2.5 μg/m3 in aerodynamic diameter; PM2.5) in Beijing.MethodsThis study used a health economic modelling approach to compare the actual annual average PM2.5 concentration with the PM2.5 concentration limit (35 µg/m3) as defined by the Chinese Ambient Air Quality Standard in terms of cardiovascular disease outcomes in Beijing adult population. The outcomes included medical costs, quality-adjusted life-years (QALYs) and net monetary loss (NML). Beijing annual average PM2.5 concentration was around 105 µg/m3 during 2013–2015. Therefore, we estimated the differences in cardiovascular outcomes of Beijing adults between exposure to the PM2.5 concentration of 105 µg/m3 and exposure to the concentration of 35 µg/m3. According to WHO estimates, the hazard ratios of coronary heart disease and stroke associated with the increase of PM2.5 concentration from 35 to 105 µg/m3 were 1.15 and 1.29, respectively.ResultsThe total 1-year excess medical costs of cardiovascular diseases associated with PM2.5 pollution in Beijing was US$147.9 million and the total 1-year QALY loss was 92 574 in 2015, amounting to an NML of US$2281.8 million. The expected lifetime incremental costs for a male Beijing adult and a female Beijing adult were US$237 and US$163, the corresponding QALY loss was 0.14 and 0.12, and the corresponding NML was US$3514 and US$2935.ConclusionsPM2.5-related cardiovascular diseases imposed high economic and QALY burden on Beijing society. Continuous and intensive investment on reducing PM2.5 concentration is warranted even when only cardiovascular benefits are considered.

Minimizing Population Health Loss in Times of Scarce Surgical Capacity

Background COVID-19 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model that supports prioritization of care from a utilitarian perspective, which is to minimize population health loss. Methods A cohort state-transition model was developed and applied to 43 semi-elective non-paediatric surgeries commonly performed in academic hospitals. Scenarios of delaying surgery from two weeks were compared with delaying up to one year, and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization global burden of disease study. For each surgery, the urgency was estimated as the average expected loss of Quality-Adjusted Life-Years (QALYs) per month. Results Given the best available evidence, the two most urgent surgeries were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 QALY loss/month, 95%-CI: 0.09-0.24) and transaortic valve implantation (0.15 QALY loss/month, 95%-CI: 0.09-0.24). The two least urgent surgeries were placing a shunt for dialysis (0.01, 95%-CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95%-CI: 0.01-0.02): these surgeries were associated with a limited amount of health lost on the waiting list. Conclusion Expected health loss due to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgeries to minimize population health loss in times of scarcity. This tool should yet be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.

The Impact of Chronic Discogenic Low Back Pain: Costs and Patients’ Burden

Introduction. Chronic discogenic low back pain (CDP) is frequently diagnosed in patients referred to specialized pain clinics for their back pain. The aim of this study is to assess the impact of CDP both on the individual patient and on society. Materials and Methods. Using the baseline records of 80 patients in a randomized trial assessing the effectiveness of a new intervention for CDP, healthcare and societal costs related to back pain are calculated. Furthermore, the impact of the condition on perceived pain, disability, health-related quality of life, Quality of life Adjusted Life Years (QALY), and QALY loss is assessed. Results. Using the friction costs approach, we found that the annual costs for society are €7,911.95 per CDP patient, 51% healthcare and 49% societal costs. When using the human capital approach, total costs were €18,940.58, 22% healthcare and 78% societal costs. Healthcare costs were mainly related to pain treatment. Mean pain severity was 6.5 (0–10), and 46% suffered from severe pain (≥7/10). Mean physical limitations rate was 43.7; 13.5% of the patients were very limited to disabled. QALY loss compared to a healthy population was 64%. Discussion. This study shows that in patients with CDP referred to a pain clinic, costs for society are high and the most used healthcare resources are pain therapies. Patients suffer severe pain, are physically limited, and experience a serious loss in quality of life.