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Policy PointsHealth care systems around the world rely on a range of methods to ensure the affordability of prescription drugs, including negotiating prices soon after drug approval and relying on formal clinical assessments that compare newly approved therapies with existing alternatives.The negotiation framework established under the Inflation Reduction Act is far more limited than other frameworks explored in this study. Adding elements from these frameworks could lead to more effective price negotiation in the United States. Context: In 2022, Congress passed the Inflation Reduction Act, which allowed Medicare, for the first time, to begin negotiating the prices for certain high‐cost brand‐name prescription drugs. Many other industrialized countries negotiate drug prices, and we sought to compare and contrast key features of the negotiation process across several health systems. We focused, in particular, on the criteria for selecting drugs for price negotiation, procedures for negotiation, factors that influence negotiated prices, and how prices are implemented. Methods: We included four G7 countries in our analysis (Canada, France, Germany, and the United Kingdom [England]), two Benelux countries (Belgium and the Netherlands), and one Scandinavian country (Norway) with long‐established frameworks for drug price negotiation. We also analyzed the Veterans Affairs Health System in the United States. For each system, we gathered relevant legislation, government publications, and guidelines to understand negotiation frameworks, and we reached out to key drug price negotiators in each system to conduct semistructured interviews. All interviews were recorded, transcribed, and coded, and data were analyzed based on an internal assessment tool that we developed. Findings: All eight systems negotiate the prices of brand‐name prescription drugs soon after approval and rely on formal clinical assessments that compare newly approved drugs with existing therapies. Systems in our study differed on characteristics such as whether the body performing clinical assessments is separate from the negotiating authority, how added health benefit is assessed, whether explicit willingness‐to‐pay thresholds are employed, and how specific approaches for priority disease areas are taken. Conclusions: High‐income countries around the world adopt different approaches to conducting price negotiations on brand‐name drugs but coalesce around a set of practices that will largely be absent from the current Medicare negotiation framework. US policymakers might consider adding some of these characteristics in the future to improve negotiation outcomes. [ABSTRACT FROM AUTHOR]

Background: Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described. Methods: This was a cross‐sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation‐adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$. Results: Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021). Conclusions: While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed. [ABSTRACT FROM AUTHOR]

Objective: Quantify the cost benefits of otoplasty under local as opposed to general anaesthesia. Design: A cost analysis of all components of otoplasty surgery under local anaesthesia (LA) in a minor operating room (OR) and general anaesthesia in a main OR was performed. Setting: Our institution, compared to provincial/federal data, with costs converted into 2022 Canadian dollars. Patients, Participants: Patients undergoing otoplasty under LA in the last year. Interventions: An efficiency analysis was performed by means of an opportunity cost, and the cost of failure was added to the overall LA costs. Main Outcome Measure: Expenses for infrastructure, surgical and anaesthetic material, salaries, and personnel costs were derived from the literature, our hospital OR catalog and federal/provincial salary data, respectively. The cost of failure to tolerate local anaesthesia for such cases was also tabulated. Results: The true cost of LA otoplasty was computed as the absolute cost ($611.73) added to the cost of failure ($10.80), resulting in a total of $622.53/procedure. The true cost of GA otoplasty was calculated as the absolute cost ($2033.05) added to the opportunity cost ($1108.94), representing 3141.99$/procedure. The total savings when performing LA otoplasty to GA otoplasty are thus 2519.44$/case, with 1 GA otoplasty costing 5.05 LA otoplasties. Conclusion: Otoplasty under local anaesthesia offers significant cost savings when compared with the same procedure under general anaesthesia. Economic considerations must be given particular attention given the elective nature of this procedure, which is often publicly funded. [ABSTRACT FROM AUTHOR]

BACKGROUND: Health care costs attributed to COPD have been estimated at $4.7 trillion globally in the next 30 years. With the global burden of COPD rising, identification of interventions that might lead to health care cost savings is an imperative. Although many studies report the effect of COPD self-management interventions on subject outcomes and health care utilization, few data describe their effect on health care costs. METHODS: Using data linkage and established case-costing methods with provincial Canadian health databases, we established public health care costs (acute and community) for 12 months following randomization for the 462 participants enrolled in our randomized controlled trial of the Program of Integrated Care for Patients with COPD and Multiple Comorbidities. RESULTS: Total median (interquartile range) in-hospital costs in the 12 months follow-up for all (intervention and control) 462 trial participants were CAD $4,769 ($417-16,834) (equivalent to US $3,566 [$312-12,588]). Total costs incurred in the community were higher at CAD $8,011 ($4,749-13,831) (equivalent to US $5,990 [$3,551-10,342]). Controlling for sex, income quintile, Johns Hopkins Aggregated Diagnosis Groups score, and living in an urban locality, we found lower community health care costs but no differences in acute care costs for participants receiving our multicomponent COPD exacerbation prevention management intervention compared to usual care. CONCLUSIONS: Controlling for important confounders, we found lower public community health care costs but no difference in acute health care costs with our multicomponent COPD exacerbation prevention management intervention compared to usual care. Community health care costs were almost double those incurred compared to acute health care costs. Given this finding, although most COPD exacerbation management interventions generally focus on reducing the use of acute care, interventions that enable health care cost savings in the community require further exploration. [ABSTRACT FROM AUTHOR]

Introduction: Prompt bystander cardiopulmonary resuscitation (CPR) can double the chance of cardiac arrest survival. Rural and remote communities experience longer emergency service wait times and have lower rates of bystander-CPR compared to their urban counterparts. Our study addresses this disparity. Methods: We designed a 1.5-h free hands-only CPR course tailored to secondary school students in rural and remote communities taught by medical students. We evaluated our course using pre-test and post-test surveys. Results: We taught over 300 secondary students in 5 days. Less than one-third of students had previously taken a CPR course. We found that brief CPR instruction taught by medical students was effective in both improving students' knowledge of CPR (t[528] = −26, P < 0.01) and perceived comfort in performing CPR (t[548] = −12, P < 0.01). Conclusion: CPR courses taught by medical students are effective, low cost, and may help address regional health care disparities. Teaching CPR to rural/remote communities may have secondary benefits such as promoting health care careers to rural youth. We encourage other health professional programmes to consider engaging students in CPR outreach projects. Introduction: Une réanimation cardio-pulmonaire rapide peut doubler les chances de survie en cas d'arrêt cardiaque. Les communautés rurales et éloignées connaissent des temps d'attente plus longs dans les services d'urgence et ont des taux plus faibles de RCP par rapport à leurs homologues urbains. Notre étude porte sur cette disparité. Méthodes: Nous avons conçu un cours de RCP pratique et gratuit d'une heure et demie, adapté aux élèves du secondaire des communautés rurales et isolées et dispensé par des étudiants en médecine. Nous avons évalué notre cours à l'aide d'enquêtes pré-test et post-test. Résultats: En 5 jours, nous avons enseigné à plus de 300 élèves du secondaire. Moins d'un tiers des élèves avaient déjà suivi un cours de RCP. Nous avons constaté qu'une brève formation à la RCP dispensée par des étudiants en médecine était efficace pour améliorer les connaissances des élèves en matière de RCP (t[528] = −26, P < 0,01) et la perception de leur aisance à pratiquer la RCP (t[548] = −12, P < 0,01). Conclusion: Les cours de RCP dispensés par les étudiants en médecine sont efficaces, peu coûteux et peuvent contribuer à lutter contre les disparités régionales en matière de soins de santé. L'enseignement de la RCP aux communautés rurales/éloignées peut avoir des avantages secondaires tels que la promotion des carrières dans le domaine de la santé auprès des jeunes ruraux. Nous encourageons d'autres programmes professionnels de santé à envisager d'engager leurs étudiants dans des projets de sensibilisation à la RCP. [ABSTRACT FROM AUTHOR]

Objective: To estimate the impact on clinical outcomes and healthcare resource use from recommending that patients with 1–2 low-risk adenomas (LRAs) return to routine fecal immunochemical test (FIT) screening instead of surveillance colonoscopy, from a Canadian provincial healthcare system perspective. Methods: The OncoSim-Colorectal microsimulation model simulated average-risk individuals eligible for FIT-based colorectal cancer (CRC) screening in Alberta, Canada. We simulated two surveillance strategies that applied to individuals with 1–2 LRAs (<10 mm) removed as part of the average risk CRC screening program: (a) Surveillance colonoscopy (status quo) and (b) return to FIT screening (new strategy); both at 5 years after polypectomy. A 75 ng/mL FIT positivity threshold was used in the base case. The simulations projected average annual CRC outcomes and healthcare resource use from 2023 to 2042. We conducted alternative scenarios and sensitivity analyses on key variables. Results: Returning to FIT screening (versus surveillance colonoscopy) after polypectomy was projected to have minimal impact on long-term CRC incidence and deaths (not statistically significant). There was a projected decrease of one (4%) major bleeding event and seven (5%) perforation events per year. There was a projected increase of 4800 (1.5%) FIT screens, decrease of 3900 (5.1%) colonoscopies, and a decrease of $3.4 million (1.2%) in total healthcare costs per year, on average. The annual colonoscopies averted and healthcare cost savings increased over time. Results were similar in the alternative scenarios and sensitivity analyses. Conclusions: Returning to FIT screening would have similar clinical outcomes as surveillance colonoscopy but could reduce colonoscopy demand and healthcare costs. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Mini-percutaneous nephrolithotomy (mPCNL) has been described as an alternative to standard nephrolithotomy (sPCNL) for select stones. Studies suggest that mPCNL has comparable stone-free rates, with potential for decreased complications and shorter hospital stay. Costs associated with both procedures present a challenge to Canadian institutions due to capital acquisitions of equipment and ongoing disposables. The objective of this study was to compare the cost-effectiveness of both procedures at our institution. METHODS: A decision tree analytic model was developed to compare costs and outcomes of both procedures. Primary outcomes included assessment of total capital, operative, and hospitalization costs. Cost and outcome of peri- and postoperative parameters were obtained using a retrospective analysis of 20 mPCNL and 84 sPCNL procedures on 1-2.5 cm stones between January 2020 and June 2022, and supplemented with internal hospital expenditure records and literature outcome data. Descriptive statistics and regression models were performed. RESULTS: The estimated total cost-per-patient was $7427.05 and $5036.29 for sPCNL and mPCNL, respectively, resulting in cost-savings of $2390.76 in favor of mPCNL, with a comparable stone-free rate. The savings were due to lower costs associated with complications and hospital stay. mPCNL had higher capital costs ($95 116.00) compared to sPCNL ($78 517.00), but per-procedure operative costs were lower for mPCNL ($2504.48) compared to sPCNL ($3335.72). Cost-per-case regression of total costs intersected at 5.51 cases when accounting for operative and hospitalization costs, and at 20 cases when only considering operative costs. CONCLUSIONS: Despite higher upfront costs, mCPNL may represent a valid, cost-effective alternative to sPCNL for select stones due to clinical and economic benefits in Canadian institutions. [ABSTRACT FROM AUTHOR]

Background: Indigenous populations have increased risk of developing diabetes and experience poorer treatment outcomes than the general population. The FORGE AHEAD program partnered with First Nations communities across Canada to improve access to resources by developing community-driven primary healthcare models. Methods: This was an economic assessment of FORGE AHEAD using a payer perspective. Costs of diabetes management and complications during the 18-month intervention were compared to the costs prior to intervention implementation. Cost-effectiveness of the program assessed incremental differences in cost and number of resources utilization events (pre and post). Primary outcome was all-cause hospitalizations. Secondary outcomes were specialist visits, clinic visits and community resource use. Data were obtained from a diabetes registry and published literature. Costs are expressed in 2023 Can$. Results: Study population was ~ 60.5 years old; 57.2% female; median duration of diabetes of 8 years; 87.5% residing in non-isolated communities; 75% residing in communities < 5000 members. Total cost of implementation was $1,221,413.60 and cost/person $27.89. There was increase in the number and cost of hospitalizations visits from 8/$68,765.85 (pre period) to 243/$2,735,612.37. Specialist visits, clinic visits and community resource use followed this trend. Conclusion: Considering the low cost of intervention and increased care access, FORGE AHEAD represents a successful community-driven partnership resulting in improved access to resources. [ABSTRACT FROM AUTHOR]

Social prescribing is a means for trusted individuals in clinical and community settings to connect people who have non-medical, health-related social needs to non-clinical supports and services within the community through a non-medical prescription. Evaluations of social prescribing programs for the pediatric population have demonstrated statistically significant improvements in participants' mental, physical, and social wellbeing and reductions in healthcare demand and costs. Experts have pointed to the particularly powerful impact of social prescribing on children's mental health, suggesting that it may help to alleviate the strain on the overburdened mental health system. Social prescribing shows promise as a tool to move pediatric care upstream by addressing non-medical, health-related social needs, hence why there is an urgent need to direct more attention towards the pediatric population in social prescribing research, policy, and practice. This demands rapid action by researchers, policymakers, and child health professionals to support advancements in this area. [ABSTRACT FROM AUTHOR]

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Background Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients. Methods We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat. Results We included a total of 125 854 patientdays. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention. Conclusions A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results. [ABSTRACT FROM AUTHOR]

We used a prevalence-based approach to estimate the economic costs associated with low muscle strength, as assessed using handgrip strength, in Canadian adults. We estimated the annual economic burden of low muscle strength at $3.0 billion, representing 2.2% of the 2021 Canadian burden of illness costs. The two most expensive chronic diseases attributable to low muscle strength were cardiovascular disease ($899 million) and type 2 diabetes ($880 million). A 10% decrease in the prevalence of low handgrip strength would save approximately $546 million per year, equivalent to an 18.1% cost reduction. Strategies to increase population-level muscle strength are needed to reduce healthcare costs and improve health. The economic cost associated with low muscle strength in Canadian adults is unknown. The total annual economic burden of low muscle strength in Canadian adults represents 2.2% of the overall burden of illness costs in 2021. We estimated that $546 million per year would be saved if the prevalence of low handgrip strength was reduced by 10%. [ABSTRACT FROM AUTHOR]

• The global uniform exponential stability is established for zero-order delayed systems. • The stability results for impulsive dynamical networks are obtained. • The event-triggered impulsive control (ETIC) is designed to stabilize dynamical networks. • ETIC has lower impulse frequency and control cost than the classic impulsive control. • A non-instantaneous ETIC is proposed to improve the instantanity and discontinuity of ETIC. This paper studies the stability for impulsive dynamical networks (IDN) where different nodes may have different impulse time sequences. By deriving the conditions of global uniform exponential stability for zero-order delayed systems, the criteria of stability for IDN are established. The stability results for IDN are then used to design event-triggered impulsive control (ETIC) for stabilization of continuous-time dynamical networks (CDN). In every node of CDN, three levels of event-triggering conditions are set for ETIC. The exponential stabilization of CDN is shown to be achieved by the designed ETIC and it also shows that the ETIC is robust w.r.t. time-delays. Moreover, a non-instantaneous ETIC (NI-ETIC) is proposed for the stabilization of CDN. Three examples with numerical simulations are given to show that the designed ETIC has lower impulse frequency and cost of control than the classic time-triggered impulsive control. It is also shown that the discontinuity and the instantanity of ETIC are improved by the NI-ETIC. [ABSTRACT FROM AUTHOR]

Background: With the emergence of therapies for mantle cell lymphoma (MCL), understanding the treatment patterns and burden of illness among older patients with MCL in Canada is essential to inform decision making. Methods: A retrospective study using administrative data matched individuals aged ≥65 who were newly diagnosed with MCL between 1 January 2013 and 31 December 2016 with general population controls. Cases were followed for up to 3 years in order to assess healthcare resource utilization (HCRU), healthcare costs, time to next treatment or death (TTNTD), and overall survival (OS); all were stratified according to first-line treatment. Results: This study matched 159 MCL patients to 636 controls. Direct healthcare costs were highest among MCL patients in the first year following diagnosis (Y1: CAD 77,555 ± 40,789), decreased subsequently (Y2: CAD 40,093 ± 28,720; Y3: CAD 36,059 ± 36,303), and were consistently higher than the costs for controls. The 3-year OS after MCL diagnosis was 68.6%, with patients receiving bendamustine + rituximab (BR) experiencing a significantly higher OS compared to patients treated with other regimens (72.4% vs. 55.6%, p = 0.041). Approximately 40.9% of MCL patients initiated a second-line therapy or died within 3 years. Conclusion: Newly diagnosed MCL presents a substantial burden to the healthcare system, with almost half of all patients progressing to a second-line therapy or death within 3 years. [ABSTRACT FROM AUTHOR]

Rapid growth in pharmaceutical spending is a major challenge in Canada. To control rising costs, the Canadian government implemented a generic pricing policy in 2013, which reduced prices for some prescription generic drugs by roughly 50%. This article explores the effects of the Canadian pricing policy on drug expenditures and drug utilization among seniors. Using a unique prescription claims data, this article adopts a difference-in-differences methodology to estimate the policy effects, and it further investigates the mechanisms by exploring the demand-side incentives and the role of health insurance design with a triple-difference approach. Exploiting the policy variation across drugs and provinces, the results suggest that the policy has reduced drug expenditure per capita, largely because of the inelastic demand among seniors. Although the policy leads to lower out-of-pocket costs for seniors facing coinsurance than for those with a fixed copayment, individual utilization and total demand display no differences across cost sharing. The price regulation in Canada was successful in reducing drug expenditures per capita. The success rests on the interaction with demand-side regulations and demand incentives. The evidence of cost containment in Canada can provide some insights to other countries with similar needs and priority. • Whether pharmaceutical price regulation is effective in reducing expenditures is inconclusive, with both positive and negative results documented in previous research. • This article contributes by providing evidence from Canada. It also contributes to understanding the policy mechanisms, with a focus on the demand-side incentives and the role of health insurance, which were rarely discussed in previous research. • The mechanism analysis suggests that the ability of price controls rests on the interaction with demand-side regulations and incentives. The success in cost containment in Canada can provide some insights to other countries with similar needs and priority. [ABSTRACT FROM AUTHOR]

Background: Continuous oral targeted therapies (OTT) represent a major economic burden on the Canadian healthcare system, due to their high cost and administration until disease progression/toxicity. The recent introduction of venetoclax-based fixed-duration combination therapies has the potential to reduce such costs. This study aims to estimate the prevalence and the cost of CLL in Canada with the introduction of fixed OTT. Methods: A state transition Markov model was developed and included five health states: watchful waiting, first-line treatment, relapsed/refractory treatment, and death. The number of CLL patients and total cost associated with CLL management in Canada for both continuous- and fixed-treatment-duration OTT were projected from 2020 to 2025. Costs included drug acquisition, follow-up/monitoring, adverse event, and palliative care. Results: The CLL prevalence in Canada is projected to increase from 15,512 to 19,517 between 2020 and 2025. Annual costs were projected at C$880.7 and C$703.1 million in 2025, for continuous and fixed OTT scenarios, respectively. Correspondingly, fixed OTT would provide a total cost reduction of C$213.8 million (5.94%) from 2020 to 2025, compared to continuous OTT. Conclusions: Fixed OTT is expected to result in major reductions in cost burden over the 5-year projection, compared to continuous OTT. [ABSTRACT FROM AUTHOR]

Background Generic drugs have been seen as a potentially powerful way to alleviate the financial burden on patients and health care systems. Two strategies for achieving rational prices of generic drugs are tiered pricing framework and pooled purchasing power. We compare the pan-Canadian Tiered Pricing Framework (TPF) and the Chinese National Volume-Based Procurement (NVBP) as comparators to explore the similarities and differences between the two mechanisms and summarise lessons for other jurisdictions. Methods This comparative study applies Donabedian's structure-process-outcome framework to systematically analyse the macro contexts, procedures, and long- and short-term results of each pricing mechanism, and the interactions between them. Results Structure: TPF is an upstream initiative aimed at lowering the prices of generic drugs and increasing coverage and price consistency. NVBP is a downstream national initiative prioritised for reducing drug prices to achieve value-based purchasing. Process: By associating the number of manufacturers with price cuts, TPF leaves the choice to manufacturers to decide if they want to enter a specific market. In contrast, the Chinese government determines NVBP list and has the authority to choose manufacturer(s) with the lowest price(s). TPF provides clear price information to potential suppliers with unclear order quantity. The NVBP drug price is determined by tendering, while procurement volume is clear and massive. Outcome: The effectiveness of TPF and NVBP is similar, with both achieving a 53% price cut. Both TPF and NVBP experienced efficiency improvement since their establishment, with 98 and 86 drugs priced per year. By comparing 60 drugs covered by both programmes, the NVBP price is 57% of that of the TPF counterpart on average (1.1 to 301.6%), by purchase power parity. Conclusions The tiered pricing scheme is feasible in regions with a stable and mature pharmaceutical market, typically seen in high-income countries, while tendering is more workable in low- and middle-income countries where the pharmaceutical market is weak and unstable. Experience in the two countries shows that a coordinated pricing mechanism involves many piecemeal interactive problems, which a sophisticated system with a robust long-range plan may address better. [ABSTRACT FROM AUTHOR]

HIV pre-exposure prophylaxis (PrEP) should be free across Canada for all those who meet evidence-based guidelines. PrEP is a highly effective tool for preventing HIV acquisition that has been approved for use in Canada since 2016. However, without public drug plans or private insurance, generic PrEP costs approximately $200 to $250 CAD monthly. Current PrEP programs across Canada are a confusing patchwork system with variability in coverage and prohibitive co-payments, making PrEP too expensive for many equity-deserving groups. However, publicly funded PrEP programs are demonstrated to be cost-effective and even cost-saving by reducing the long-term healthcare expenditures associated with managing HIV. PrEP is not just an individual-level clinical tool. It is a public health intervention. Alongside "treatment as prevention," PrEP is an important population-level strategy for eliminating new HIV infections in Canada and can play a role in helping to address complex health inequities affecting communities highly affected by HIV. Navigating drug coverage for patients consumes time and resources among healthcare providers that could be spent helping to improve other social determinants of health. Affordability will remain the foremost barrier to PrEP access until PrEP is made free to all those who meet evidence-based guidelines. [ABSTRACT FROM AUTHOR]

Introduction: Wait times to see an orthopaedic consultant can be lengthy. Remote communities such as Labrador City and Goose Bay, located in Labrador in the province of Newfoundland and Labrador, often do not have an orthopaedic specialist locally and patients are required to travel great distances to attend clinic appointments. The objectives of this report are to describe our Orthopaedic Outreach Programme where patients receive fracture assessments and care for musculoskeletal concerns at two local clinics by a visiting orthopaedic surgeon. We also describe the justification for the Orthopaedic Outreach Programme and list the benefits; financial and otherwise. Methods: A review of the programme, operating out of Happy Valley-Goose Bay and Labrador City, using electronic medical records, was undertaken from 1st January 2015 to 31st December 2019 including demographics and procedures completed. Travel and hotel costs were estimated. Results: Over the last 5 years, the Orthopaedic Outreach Programme treated 1,698 patients at the 2 clinics. Cost savings were estimated at $366,768 per annum. The cost savings over the last 5 years were estimated at a total of $1,833,840. This does not account for patient's time off work and lost revenue that would occur when they make the trip to St John's for a clinic appointment. Conclusions: Our Orthopaedic Outreach Programme was implemented to improve access to orthopaedic services in the remote areas of Labrador. This report aims to describe the result of a programme focused on providing orthopaedic care to individuals who would otherwise be required to travel great distances for their care. [ABSTRACT FROM AUTHOR]

Billing and insurance--related costs are a significant source of wasteful health care spending in Organization for Economic Cooperation and Development nations, but these administrative burdens vary across national systems. We executed a microlevel accounting of these costs in different national settings at six provider locations in five nations (Australia, Canada, Germany, the Netherlands, and Singapore) that supplements our prior study measuring the costs in the US. We found that billing and insurance--related costs for inpatient bills range from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill (purchasing power parity adjusted). We created a taxonomy of billing and insurance--related activities (eligibility, coding, submission, and rework) that was applied to data from the six sites and allows cross-national comparisons. Higher costs in the US and Australia are attributed to high coding costs. Much of the savings achieved in some nations is attributable to assigning tasks to people in lower-skill job categories, although most of the savings are due to more efficient billing and insurance--related processes. Some nations also reduce these costs by offering financial counseling to patients before treatment. Our microlevel approach can identify specific cost drivers and reveal national billing features that reduce coding costs. It illustrates a valuable pathway for future research in understanding and mitigating administrative costs in health care. [ABSTRACT FROM AUTHOR]

Background: Kidney transplantation (KT) is often reported in the literature as associated with cost savings. However, existing studies differ in their choice of comparator, follow-up period, and the study perspective. Also, there may be unobservable heterogeneity in health care costs in the patient population which may divide the population into groups with differences in cost distributions. This study estimates the cost savings associated with KT from a payer perspective and identifies and characterizes both high and low patient cost groups. Method: The current study was a population-based retrospective before-and-after study. The timespan involved at most three years before and after KT. The sample included end-stage kidney disease patients in Nova Scotia, a province in Canada, who had a single KT between January 1, 2011, and December 31, 2018. Each patient served as their control. The primary outcome measure was total annual health care costs. We estimated cost savings using unadjusted and adjusted models, stratifying the analyses by donor type. We quantified the uncertainty around the estimates using non-parametric and parametric bootstrapping. We also used finite mixture models to identify data-driven cost groups based on patients' pre-transplantation annual inpatient costs. Results: The mean annual cost savings per patient associated with KT was $19,589 (95% CI: $14,013, $23,397). KT was associated with a 24–29% decrease in mean annual health care costs per patient compared with the annual costs before KT. We identified and characterized patients in three cost groups made of 2.9% in low-cost (LC), 51.8% in medium-cost (MC) and 45.3% in high-cost (HC). Cost group membership did not change after KT. Comparing costs in each group before and after KT, we found that KT was associated with 17% mean annual cost reductions for the LC group, 24% for the MC group and 26% for the HC group. The HC group included patients more likely to have a higher comorbidity burden (Charlson comorbidity index ≥ 3). Conclusions: KT was associated with reductions in annual health care costs in the short term, even after accounting for costs incurred during KT. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion. Method: This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant. Results: Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol. Discussion: This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life. Public Significance: This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost‐savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life. [ABSTRACT FROM AUTHOR]

Background: Complex airway disease such as Chronic Rhinosinusitis with Asthma or Aspirin Exacerbated Respiratory Disease requires a multidisciplinary approach to management and treatment. Many centers in the USA have created collaborative multidisciplinary clinics to support the management of these patients; however, similar structures do not appear to exist in Canada. Methods: This mixed methods study used a combination of structured interviews and a cross-sectional national survey. Interviewees included members of the Canadian Rhinology Working Group and survey participants were a combination of academic and community Rhinologists, Respirologists and Allergists. All participation was voluntary and selection criteria was based on their involvement in treating complex airway disease. Our objective was to identify the current state of diagnosis and treatment of complex airway patients in Canada between Rhinology, Respirology and Allergy and understand the barriers, challenges and propose solutions to establishing a multidisciplinary airway clinic in Canada. Results: Four Rhinologists participated in qualitative interviews and a convenience sample of 42 specialists through our known network responded to our quantitative survey. From our survey, 54.8% believed multidisciplinary clinics were necessary in the management of complex airway disease, providing better outcomes and cost-savings (69%, 45.2%). Most specialties agreed that history, physical, pulmonary function and skin prick testing was important for diagnosis (92.9%, 92.9%, 88.1%). If clinicians were to participate in a multidisciplinary clinic, they would be willing to forego an average of 14.2% of their mean daily income for that clinic. The ideal clinic location was split between a neutral shared location vs. a Rhinology clinic space (38.1%, 45.2%). Conclusions: Complex airway diseases are currently managed in subspecialty silos resulting in fragmented care. Our study highlights gaps in management, areas for improvement and support for establishing multidisciplinary complex airway disease clinics in Canada to better treat this population. [ABSTRACT FROM AUTHOR]

Background: In 2019, more than $34.5 billion was spent on prescription drugs in Canada. However, little is known about the distribution of this spending across medications and settings (outpatient and inpatient) over time. The objective of this paper is to describe the largest expenditures by medication class over time in inpatient and outpatient settings. This information can help to guide policies to control prescription medication expenditures. Methods: IQVIA's Canadian Drugstore and Hospital Purchases Audit data from January 1, 2001, to December 31, 2020, were used. In this dataset, purchasing was stratified by outpatient drugstore and inpatient hospital. Spending trajectories in both settings were compared to total expenditure over time. Total expenditure of the 25 medications with the largest expenditure were compared over time, stratified by setting. Nominal costs were used for all analysis. Results: In 2001, spending in the outpatient and inpatient settings was greatest on atorvastatin ($467.0 million) and erythropoietin alpha ($91.2 million), respectively. In 2020, spending was greatest on infliximab at $1.2 billion (outpatient) and pembrolizumab at $361.6 million (inpatient). Annual outpatient spending, although increasing, has been growing at a slower rate (5.3%) than inpatient spending (7.0%). In both settings, spending for the top 25 medications has become increasingly concentrated on biologic agents, with a reduction in the diversity of therapeutic classes of agents over time. Discussion: Identification of the concentration on spending on biologic agents is a key step in managing costs of prescription medications in Canada. Given the increases in spending on biologic agents over the last 20 years, current cost-control mechanisms may be insufficient. Future research efforts should focus on examining the effectiveness of current cost-control mechanisms and identifying new approaches to cost control for biologic agents. [ABSTRACT FROM AUTHOR]

New drugs are expensive, in part due to excessive drug development costs. Governments are trying to reduce drug prices. This can delay access to effective agents. A country's access to new drugs correlates with prices they agree to pay. After Health Canada approves a drug, the Canadian Agency for Drug and Technologies in Health (CADTH) assesses it. CADTH's approval is usually contingent on it costing ≤CAD 50,000 per quality adjusted life year (QALY) gained. This value (unchanged from the 1970s) is inappropriately low. An inflation-adjusted CAD 50,000 1975 QALY should translate into a CAD 250,000 2021 QALY. CADTH's target also does not consider that drug development costs have risen much faster than inflation or that new precision therapies may only be used in small populations. In a separate process, proposals from the Patented Medicines Price Review Board (PMPRB) would decrease initial Canadian drug prices by 20%, but prices would fall further as sales increased, with ultimate price reductions of up to 80%. PMPRB claims its proposal would not reduce drug access, but multiple analyses strongly suggest otherwise. Government price controls target the symptom (high prices), not the disease. They translate into shortages without solving the problem. CADTH and PMPRB approaches both threaten access to effective drugs. [ABSTRACT FROM AUTHOR]

Background: The medication reconciliation (MedRec) process conducted at hospital admission uses either a proactive or retroactive model. Many hospitals have experienced challenges with MedRec, particularly its proactive model. Objective: The aim of this study was to analyze and quantify the retroactive and proactive MedRec models. Settings: The study was conducted at Campbellton Regional Hospital, a member of Vitalité Health Network in Canada. Method: This prospective, observational study was conducted at Regional Hospital over a 3-month period. All patients undergoing MedRec during this time were included. Main Outcome Measure: The primary endpoint was to compare the time components of the process for the two models, while the secondary endpoint was to determine the types of intentional and unintentional medication discrepancies. Results: After 249 MedRecs had been reviewed, 180 patients were enrolled. The total number of medications reconciled was 2118. Of the 180 patients, 84 (46%) were evaluated using the proactive model. The median time from admission to the MedRec process was significantly shorter for the proactive model (48 min) than the retroactive model (1135 min) [p < 0.001]. The percentage of documented intentional medication modifications in the proactive model (16.3%) was more than twice that in the retroactive model (7.3%) [p < 0.001]. Patients evaluated by the proactive model had a significantly shorter hospital stay than those evaluated by the retroactive model (p < 0.001). Conclusion: This study demonstrated that implementation of the proactive model was feasible. Compared with the retroactive model, the proactive model had a positive impact on preventing discrepancies with timeliness and efficiency. [ABSTRACT FROM AUTHOR]

Regardless of a product's country of registration, a current and updated pharmaceutical product dossier is mandatory. But any kind of post-approval change to pharmaceutical products requires prior permission or at least notification to the regulatory authorities of the country. The reason behind the post approval changes may vary including product quality advancement, reduction of cost or improvement of the appearance of a product label, etc. As it is compulsory to provide the details of post-approval changes made in pharmaceutical products, thorough knowledge of guidance documents of concerned regulatory authority is vital. Therefore, understanding a need for post-approval changes together with avoiding any unnecessary changes is an integral part of the medicinal product's lifecycle management. Not only the changes of finished pharmaceutical products, but regulatory authorities also concern about the necessity of changes of active pharmaceutical ingredients, as these changes may impact on finished product's quality. The present article focuses on a comprehensive review of the requirements of post-approval changes related to active pharmaceutical ingredients for Canada, Australia, and Saudi Arabia, which may help pharmaceutical industries to comply with the requirements simultaneously in the proposed countries. [ABSTRACT FROM AUTHOR]

Aim: To explore emergency nurses' perceptions of how a nurse‐driven patient needs assessment tool, the synergy tool, influenced their workload management. Background: Quadruple Aim, particularly the fourth aim of improved staff work experiences, served as the conceptual framework to engage nurses in a participatory action research project. This project took place between 2017 and 2020 in two tertiary care emergency departments in one large Canadian city. Method: This study employed a qualitative descriptive component, focus group interviews and nurse comments on two open‐ended survey questions. Results: Use of the synergy tool heightened nurses' awareness of patients' holistic care needs. Nurses also stated how patient needs assessment data helped them identify unsafe workloads. Conclusions: The synergy tool, adapted for emergency department use by nurses, was a means to engage and empower nurses. Patient needs assessment data from the tool identified staffing gaps, resulting in additional nursing staff for both emergency departments. Implications for Nursing Management: A focus on patient needs assessment can be an effective way to address nurses' workload concerns. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this quality improvement study was to examine the impact of a Vascular Access Clinical Nurse Specialist (VA-CNS) on patient and organizational outcomes. Description of the Project/Program: The VA-CNS role was created and implemented at an acute care hospital in Thunder Bay, Ontario, Canada. The VA-CNS collected data on clinical activities and interventions performed from April 1 to March 29, 2019. The dataset and its associated qualitative clinical outcomes were analyzed using deductive content analysis. Furthermore, a cost analysis was performed by the hospital accountant on these clinical outcomes. Outcome: Over a 1-year period, there were 547 patients protected from an unwarranted peripherally inserted central catheter (PICC) insertion among 302 patient consultations for the VA-CNS. A total of 322 ultrasound-guided peripheral intravenous catheters were inserted and 45 PICC insertions completed at the bedside. The cost associated with the 547 patients not receiving a PICC line result in an estimated savings of $113,301. The VA-CNS role demonstrated a positive payback of $417,525 to the organization. Conclusion: The results of this quality improvement project have demonstrated the positive impacts of the VACNS on patient and organizational outcomes. This role may be of benefit and worth its adoption for other health systems with similar patient populations. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate alternative methods to calculate and/or attribute economic surplus in the cost-effectiveness analysis of single or short-term therapies.Methods: We performed a systematic literature review of articles describing alternative methods for cost-effectiveness analysis of potentially curative therapies whose assessment using traditional methods may suggest unaffordable valuations owing to the magnitude of estimated long-term quality-adjusted life-year (QALY) gains or cost offsets. Through internal deliberation and discussion with staff at the Health Technology Assessment bodies in England and Canada, we developed the following 3 alternative methods for further evaluation: (1) capping annual costs in the comparator arm at $150 000 per year; (2) "sharing" the economic surplus with the health sector by apportioning only 50% of cost offsets or 50% of cost offsets and QALY gains to the value of the therapy; and (3) crediting the therapy with only 12 years of the average annual cost offsets or cost offsets and QALY gains over the lifetime horizon. The impact of each alternative method was evaluated by applying it in an economic model of 3 hypothetical condition-treatment scenarios meant to reflect a diversity of chronicity and background healthcare costs.Results: The alternative with greatest impact on threshold price for the fatal pediatric condition spinal muscular atrophy type 1 was the 12-year cutoff scenario. For a hypothetical one-time treatment for hemophilia A, capping cost offsets at $150 000 per year had the greatest impact. For chimeric antigen receptor T-cell treatment of non-Hodgkin's lymphoma, capping cost offsets or using 12-year threshold had little impact, whereas 50% sharing of surplus including QALY gains and cost offsets greatly reduced threshold pricing.Conclusions: Health Technology Assessment bodies and policy makers will wrestle with how to evaluate single or short-term potentially curative therapies and establish pricing and payment mechanisms to ensure sustainability. Scenario analyses using alternative methods for calculating and apportioning economic surplus can provide starkly different assessment results. These methods may stimulate important societal dialogue on fair pricing for these novel treatments. [ABSTRACT FROM AUTHOR]

Improving access to domestic and international markets can create large economic benefits. Multimodal infrastructure corridors of road, rail, utilities and communications can improve accessibility by reducing interprovincial and international trade costs. Depending on the geographical area they serve and the modes of transport and types of connections they promote, infrastructure corridors can create trade-offs and synergies between different kinds of economic, social, and environmental outcomes. Yet the implied effects can vary across different regions, population segments and industries. A complete review of a proposed infrastructure corridor package involves a rigorous analysis of all of these potential effects. In this paper, we focus more specifically on quantifying potential gains from reductions in trade costs on Alberta's economy and identify the importance of improved access to lower cost transportation options like rail for select commodities. We find that lowering trade costs substantially increases Alberta's real GDP through its effect on international and interprovincial trade flows. Although interprovincial tariffs on domestic goods are forbidden by the Canadian Constitution, the economic effect of internal non-tariff trade barriers is substantial. Albrecht and Tombe (2016) show that eliminating these interprovincial trade costs would increase Canada's GDP between three to seven per cent. These barriers represent additional costs on Canadian firms and adversely affect their competitiveness in domestic and international markets. High interprovincial trade costs may also pose an additional barrier to entry for foreign firms otherwise willing to enter the Canadian market. As a result of this, Canadian firms end up producing at a less efficient scale and pass the cost of these inefficiencies to consumers. Interprovincial trade costs therefore hurt both producers and consumers. Gains from improved infrastructure are also amplified by the interconnected nature of industries. Output of one industry is often an input for another industry. Shipments cross provincial and national borders as part of these supply-chain relationships which allow for more efficient production but at the same time create additional trade costs on producers. Infrastructure corridors provide one option to lower these trade costs by increasing transportation capacity, creating savings in travel time and distance, creating better quality physical transport infrastructure, simplifying the regulatory and legislative differences across provinces and territories, and improving access to information, to name a few. To quantify the potential effect of increased transportation infrastructure on trade costs, we combine rich data on interprovincial trade flows and shipment-level information on volumes, values, and transportation costs by mode. We empirically estimate the potential for increased rail shipment capacity on shipment costs between various internal trade pairs within Canada. Two key results stand out. First, we find that while distance is an important factor, a higher share of shipments by rail is associated with markedly lower trade costs. Specifically, we find a 10 percentage point increase in the share of value shipped by rail is associated with a 3.2 per cent lower aggregate cost of trade after controlling for commodity, source, and destination of shipments. Second, we also find important differences in the relevance of rail across commodities. We find larger trade costs reductions for coal, mineral products, and fuel oils. The focus on rail is an important one for Alberta since coastal or canal shipping is not a feasible alternative. As a natural next step, we then evaluate the potential gains to Alberta's economy from increased access to internal and international markets that improved infrastructure might provide. We find that lowering trade costs substantially increases Alberta's real GDP through its effect on international and interprovincial trade flows, in both the short run and the long run. The results show that, in the short run, lower trade costs by one per cent increases real GDP by roughly 0.8 per cent and lower trade costs by five per cent increases real GDP by roughly 4.4 per cent. These correspond to approximately $3 billion to $15 billion per year in additional economic activity in Alberta. We find larger gains in the long-run, equivalent to roughly a one per cent increase in real GDP for each one per cent reduction in trade costs. Gains from lower trade costs come primarily through lower cost access to imported inputs and final goods. There are also gains from increased demand by purchases outside Alberta on goods produced by Albertans. This increases real incomes and productivity, which is captured by the increase in real GDP. The combined results of lower import costs and an increase in GDP imply an about six per cent long-run increase in real personal income, equal to an extra $6,423 annually for the median Alberta family. This is a level effect and represents a persistent increase, not a one-time bump. That is, GDP is permanently higher and by extension, annual personal incomes are also permanently higher. Although we don't explore the infrastructure investment options for lowering the trade costs by these levels, the corresponding impacts on real GDP of doing so indicate how high the costs of expanding infrastructure could be while still yielding net benefits to Alberta. An infrastructure corridor could facilitate the expansion of Canada's rail shipment capacity. While many transportation modes could expand within such a corridor -- including roads, pipelines, transmission lines and so on -- our data allow us to specifically quantify the extent to which Alberta's economy could gain from more access to lower cost shipment options like rail. Rail shipment costs are lower than truck transportation when distances are sufficiently long. We find that each one percentage point increase in the share of non-air trade sent by rail is associated with a 0.32 per cent lower trade cost. This implies that if the share shipped by rail increased by 10 percentage points, then trade costs to and from Alberta would, on average, decline by 3.2 per cent. Expanding the rail capacity is particularly valuable for Alberta, since increasing the share of exports shipped by rail by ten 10 percentage points may increase Alberta's GDP by nearly 1.5 per cent in the short-run and over 2.5 per cent in the long-run -- equivalent to over $9 billion per year in economic activity. This is a relatively large increase in economic productivity -- equivalent to roughly $4,500 per household, on average, per year -- and, in addition, it abstracts from other potential sources of gains, such as increased labour migration into the province. The combined increase in GDP and lower import costs from increased rail penetration imply an increase in real personal income. It is more modest here at approximately 3.3 per cent (rather than six per cent), but still very significant and equal to an extra $3,419 annually for the median Alberta family. As before, it is important to note that this is a level effect and represents a persistent increase and permanently higher annual GDP and annual personal incomes. Our analysis is only a first step and explores only one potential effect of expanding infrastructure capacity. Overall, the potential for positive economic effects from multimodal infrastructure corridors is compelling and warrants additional investigation. Governments can play a role by supporting expanded research activities into the feasibility and potential benefits of dedicated multimodal infrastructure corridors in Canada. In addition, though we made progress using detailed shipment-level data, there are shortcomings in coverage and detail that constrain the scope for potential research. Governments should therefore increase the collection and reporting of relevant data on internal trade to facilitate research into the costs producers and consumers face, and the potential gains from internal trade liberalization. Despite the value of expanding research capacity, our analysis points clearly towards the potential gains from internal trade liberalization. Expanded transportation infrastructure capacity can lower trade costs, and therefore governments hoping to expand internal trade should explore means of increasing such capacity, especially the possibility of increased rail shipment capacity. [ABSTRACT FROM AUTHOR]

Background: Continuous oral targeted therapy (OTT) for chronic lymphocytic leukemia (CLL) represents an effective therapy but also a major economic burden on the healthcare system. This study aimed to estimate future direct costs, along with the prevalence, of CLL in the era of continuous OTT in Canada. Methods: The economic burden of OTT was modelled and compared to chemoimmunotherapy (CIT), for CLL treatment. The burden was assessed/projected from 2011 to 2025. For the OTT scenario, CIT was considered the standard of care before 2015, while OTT was considered standard of care for patients with either unmutated immunoglobulin heavy-chain variable (IGHV) or del(17p)/TP53 mutations starting in 2015 and, from 2020 onwards, for all first-line treatments except for patients with mutated IGHV. A Markov model was developed including four health states: watchful-waiting, first-line treatment, relapse and death. Costs of therapy, follow-up/monitoring and adverse events were included. Key clinical parameters were extracted from pivotal clinical trials. Results: As incidence rates and rate of survival are increasing, the prevalence of CLL in Canada is projected to increase 1.8-fold, from 8301 patients in 2011 to 14,654 by 2025. Correspondingly, the total annual costs of CLL management are predicted to increase 15.7-fold, from $60.8 million to $957.5 million during that same period. Conclusions: Although OTT enhances survival for patients with CLL, it is nonetheless associated with an important economic burden due to the projected vast increase in costs from 2011 to 2025. Changes in clinical strategies, such as implementation of a fixed OTT treatment duration, could help alleviate financial burden. [ABSTRACT FROM AUTHOR]

Background: We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture.Methods: Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness.Results: Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of -$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of -$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant.Conclusion: A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents. [ABSTRACT FROM AUTHOR]

In many countries, health technology assessment (HTA) organizations determine the economic value of new drugs and make recommendations regarding appropriate pricing and coverage in national health systems. In the US, recent policy proposals aimed at reducing drug costs would link drug prices to six countries: Australia, Canada, France, Germany, Japan, and the UK. We reviewed these countries' methods of HTA and guidance on price and coverage recommendations, analyzing methods and guidance documents for differences in (1) the methodologies HTA organizations use to conduct their evaluations and (2) considerations they use when making recommendations. We found important differences in the methods, interpretations of HTA findings, and condition-specific carve-outs that HTA organizations use to conduct evaluations and make recommendations. These variations have ethical implications because they influence the recommendations of HTA organizations, which affect access to the drug through national insurance and price negotiations with manufacturers. The differences in HTA approaches result from the distinct political, social, and cultural contexts of each organization and its value judgments. New cost-containment policies in the US should consider the ethical implications of the HTA reviews that they are considering relying on to negotiate drug prices and what values should be included in US pricing policy. [ABSTRACT FROM AUTHOR]

Breast cancer is the most common cancer in women worldwide. Most current guidelines recommend using multigene profiling assays to aid the decision on the addition of chemotherapy to adjuvant hormone therapy for women who present with early‐stage, hormone receptor‐positive, HER2‐negative disease. One of these assays is the Oncotype DX, which predicts the disease recurrence risk and adjuvant chemotherapy benefits. Given its high cost, there is an economic incentive to evaluate its surrogates, such as the Magee equations. We assessed health system costs associated with the use of the Magee scores. A probabilistic decision tree was used to calculate the difference in mean health system costs based on data obtained from a randomized trial and the published literature. Costs were calculated from a perspective of Canada's publicly funded health care system. A series of sensitivity analysis was conducted to assess the robustness of the study findings. The Magee equations were associated with a total cost savings of C$100 per patient (95% CI, −C$3068 to C$5022) compared with standard of care. The difference in costs was highly sensitive to the extent that the Magee scores could reduce the frequency of adjuvant chemotherapy and Oncotype DX requests. [ABSTRACT FROM AUTHOR]

Study Question: Is it cost-effective to use in vitro fertilisation and preimplantation genetic testing of monogenic defects (IVT/PGT-M) to prevent transmission of BRCA1/2 mutations to second-generation new births in comparison with naturally conceived births?Summary Answer: In this cost-effectiveness analysis, we found that IVF/PGT-M is cost-effective for BRCA1 and BRCA2 mutation carriers if using a willingness to pay of $50 000 per quality-adjusted life-year (QALY).What Is Known Already: Carriers of a BRCA1 or BRCA2 mutation have a significantly increased risk of several types of cancer throughout their lifetime. The cost of risk reduction, screening and treatment of cancer in this population is high. In addition, there is a 50% chance of passing on this genetic mutation to each child. One option to avoid transmission of an inherited deleterious gene to one's offspring involves in vitro fertilisation with preimplantation genetic testing.Study Design, Size, Duration: We implemented a state transition model comparing the healthcare impact of a cohort of healthy children born after IVF/PGT-M, who have a population risk of developing cancer, to a cohort of naturally conceived live-births, half of whom are carriers of the BRCA mutation. Transition probabilities are based on published sources, a lifetime horizon and a perspective of a provincial Ministry of Health in Canada.Participants/materials, Setting, Methods: The target population is the second-generation new births who have at least one parent with a known BRCA1 or BRCA2 mutation.Main Results and the Role Of Chance: At a willingness-to-pay threshold of $50 000 per QALY, IVF/PGT-M is a cost-effective intervention for carriers of either BRCA mutation. For BRCA1, the incremental cost-effectiveness ratio (ICER) for IVF/PGT-M is $14 242/QALY. For BRCA2, the ICER of intervention is $12 893/QALY. Probabilistic sensitivity analysis results show that IVF/PGT-M has a 98.4 and 97.3% chance of being cost-effective for BRCA1 and BRCA2 mutation carriers, respectively, at the $50 000/QALY threshold.Limitations, Reasons For Caution: Our model did not include the short-term negative effect of IVF/PGT-M on the woman's quality of life; in addition, our model did not consider any ethical issues related to post-implantation genetic testing.Wider Implications Of the Findings: In countries in which the healthcare of a large segment of the population is covered by a single payer system such as the government, it would be cost-effective for that payer to cover the cost of IVF/PGT-M for couples in which one member has a BRCA mutation, in order to avoid the future costs and disutility of managing offspring with an inherited BRCA mutation.Study Funding/competing Interest(s): Dr Wong's research program was supported by the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council (NSERC), the Canadian Liver Foundation and an Ontario Ministry of Research, Innovation and Science Early Researcher Award. All authors declared no conflict of interests. [ABSTRACT FROM AUTHOR]

One of the glaring gaps in Canada's universal healthcare system is the low level of public financing of prescription drugs - 42.7% of total spending in 2018. At the federal level there is renewed interest in moving towards universal coverage, supported by a recently commissioned report on how to achieve it. It will take superb political navigation to extract Canadian pharmaceutical policy and practice from the grasp of interests that profit handsomely from the status quo. This perspective suggests the conditions under which a genuinely fair, effective, and efficient pharmacare plan can emerge. [ABSTRACT FROM AUTHOR]

This review uncovers the extent to which immigrant and minority women find HPV self-sampling an acceptable and feasible alternative to PAP testing for screening for cervical cancer. A focused literature review was conducted using CINAHL, Medline, Proquest and Pubmed databases to search for content relating to acceptability or feasibility of HPV self-testing for immigrant populations or minorities. 575 prospective relevant papers were included in the final analysis and 28 selected using the inclusion and exclusion criteria. HPV self-sampling was found to be acceptable and feasible among immigrant and minority women. Participants studied indicated the importance of providing in-depth educational documents, diagrams, illustrations and supplementary resources in future HPV self-sampling studies. HPV self-sampling has the potential to significantly increase cervical cancer screening participation rates amongst immigrant and minority women. Future research studies should incorporate methods to increase the efficacy and acceptability of HPV self-testing amongst immigrant and minority women. [ABSTRACT FROM AUTHOR]

Background: Presently, there is equipoise regarding the surgical technique used to manage the appendiceal stump during laparoscopic appendectomy. The purpose of this research was to determine whether the routine use of loop ligature, compared to stapling, is cost effective from a hospital payer perspective.Methods: A retrospective cohort study was conducted amongst patients undergoing emergency laparoscopic surgery for acute appendicitis at two major academic hospitals. In order to eliminate possible systematic bias arising from one technique being preferentially employed with more complex presentations, patients were divided into study groups based on the technique routinely employed by their surgeon, loop ligature (LLA) versus stapler (LSA). Pediatric patients and open appendectomies were excluded. Costs were determined using a previously published model derived from publicly available data from the Ontario Case Costing Initiative, in conjunction with local cost data for disposable procurement. Secondary outcomes included operating room time, length of stay, and complication rates.Results: Between Jan 1, 2014 and Dec 31, 2015, 567 adult patients had an emergency laparoscopic appendectomy for acute appendicitis. In comparing surgeons who routinely employed LLA to LSA, there was a significant decrease in total mean hospital cost with LLA ($1988 ± $143 vs. $2253 ± $99, p = 0.002). In addition, mean disposable cost was reduced for surgeons using LLA ($310 ± $27 vs. $668 ± $26, p < 0.001). This reduction in cost was not associated with a difference in length of stay (1.5 vs. 1.4 days, p = 0.28) or complication rates (8% vs. 10%, p = 0.43).Conclusions: These findings suggest that surgeons who routinely use loop ligature to secure the appendiceal base during emergency laparoscopic appendectomy offer more cost-effective care compared to stapler users, saving their institution more than $200 per case with no clear disadvantages. A shift from routine use of staplers to loop ligature should result in significant overall cost savings to the hospital. [ABSTRACT FROM AUTHOR]

Background/context Unnecessary laboratory testing leads to considerable healthcare costs. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), often add little value to patient management at significant cost. We undertook a choosing wisely based quality improvement initiative to reduce the frequency of testing. Objectives To reduce the ratio of AST/ALT and BUN/Cr to less than 5% for all inpatient and outpatient test orders. Measures Absolute number and ratio of AST/ALT and BUN/Cr; AST, ALT, BUN and Cr tests per 100 hospital days; projected annualised cost savings and monthly acute inpatient bed days. Improvements We created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback and removed AST and BUN from institutional order sets. Impact/results The ratios of AST/ALT and BUN/Cr decreased significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), although the goal of 0.05 was not achieved due to a delay in adopting the choosing wisely strategies during the study time period by some inpatient units. The number of tests per 100 hospital days decreased from 20 to 7 AST (95% CI 19 to 20.5, 5.6 to 8.7, p<0.001) and from 72 to 17 BUN (95% CI 70 to 73.4, 16.6 to 22.9, p<0.001). The initiative resulted in a projected annualised cost savings of C$221 749. Discussion A significant decrease in the AST/ALT and BUN/Cr ratios can be achieved with a multimodal approach and will result in substantial healthcare savings. [ABSTRACT FROM AUTHOR]

Nowadays, with the evolution of digital video broadcasting, as well as, the advent of high speed broadband networks, a new era of TV services has emerged known as IPTV. IPTV is a system that exploits the high speed broadband networks to deliver TV services to the subscribers. From the service provider viewpoint, the challenge in IPTV systems is how to build delivery networks that exploits the resources efficiently and reduces the service cost, as well. However, designing such delivery networks are affected by many factors including choosing the suitable network architecture, load balancing, resources waste, and cost reduction. Furthermore, IPTV contents characteristics; particularly size, popularity, and interactivity play an important role in balancing the load and avoiding the resources waste for delivery networks. Ignoring the content status in solving delivery networks issues particularly replica placement, request distribution, and resource allocation problems leads to load imbalance, which in turn, leads to performance degradation in IPTV system. In this survey paper, we introduce IPTV delivery networks terminology and taxonomy. Upon that, we investigate the challenges related to the contents' awareness in those delivery networks. At the end of the paper, we propose a content-awareness in ITV delivery networks and CDN as the future direction and discuss its importance in different aspects as request redirection, resource allocation, and replica placement. [ABSTRACT FROM AUTHOR]

Of the few socialized railroads in the United States, the largest is the Grand Trunk Western, which is controlled by the Canadian government. The operating losses of the Grand Trunk became so large that the Canadian National management decided that they should no longer be incurred. A new local management was installed with directions to adopt efficiency criteria. While operating losses have been cut from $27 million in 1970 to $7.5 million in 1975, it is unlikely that such losses can be cut further without major abandonments of light-density railroad lines. Coordination with other carriers in southern Michigan and major disinvestment can only derive from long-run investment efficiency as a policy goal and intense efforts to secure ICC permits to abandon losing lines. [ABSTRACT FROM AUTHOR]

Reliable construction project cost estimation relies on accurate quantity takeoffs (QTOs), traditionally done with error-prone 2-D drawings, but the emergence of Building Information Modeling (BIM) has improved QTO speed, accuracy, and reliability. However, the quality of BIM models can influence quantity accuracy, an aspect often overlooked in research on automating QTO with BIM. This paper develops an integrated framework to automatically extract and visualize construction quantities from BIM models. The system includes a Quantity Precision Check (QPC) module for automating more accurate QTO outputs. These outputs are then automatically transferred to an external database and visualized through a user-friendly dashboard on the Microsoft Power BI platform. This dashboard allows for comparisons between 2-D and BIM quantities and helps track changes in quantities over time due to design changes. The system was successfully validated in an infrastructure construction project in Canada, where it identified a 39% inconsistency in wall elements' material quantities and reduced steel quantity by 10% due to design changes. Overall, the system offers a speedy, reliable, and efficient tool for construction estimators, site managers, and cost control teams to provide accurate quantities to the procurement team and make swift decisions in response to design change impacts on construction costs. • This study introduces an automated QPC/QTO system for architectural and structural BIM models. • A QPC/QTO system workflow was developed to automatically calculate their quantities and check their accuracy in the BIM model. • The Data Extraction and Analysis Module was developed to automatically calculate, and check the accuracy of the quantities of each category. • The Data Visualization Module was developed to visualize the final QTO results and inconsistencies in BIM parameters after each update. • The system can be used as a fast and reliable tool for construction estimators to provide accurate quantities to the procurement team. [ABSTRACT FROM AUTHOR]

Introduction Outside of randomized controlled clinical trials, the understanding of the effectiveness and costs associated with targeted therapies for metastatic renal cell carcinoma (mrcc) is limited in Canada. The purpose of the present study was to use real-world prospective data to assess the effectiveness and cost of targeted therapies for patients with mrcc. Methods The Canadian Kidney Cancer Information System, a pan-Canadian database, was used to identify prospectively collected data relating to patients with mrcc. First- and subsequent-line time to treatment termination (ttt) was determined from therapy initiation time (sunitinib or pazopanib) to discontinuation of therapy. Kaplan- Meier survival curves were used to estimate the unadjusted and adjusted overall survival (os) by treatment. Unit treatment cost was used to estimate the cost by line of treatment and the total cost of therapy for the management of patients with mrcc. Results The study included 475 patients receiving sunitinib or pazopanib in the first-line setting. Patients were treated mostly with sunitinib (81%); 19% of patients were treated with pazopanib. The median ttt in the first line was 7.7 months for patients receiving sunitinib and 4.6 months for those receiving pazopanib (p < 0.001). The adjusted os was 32 months with sunitinib and 21 months with pazopanib (hazard ratio: 1.61; p < 0.01). The total median cost of first- and second-line treatments was $56,476 (interquartile range: $23,738-$130,447) for patients in the sunitinib group and $46,251 (interquartile range: $28,167-$91,394) for those in the pazopanib group. Conclusions For the two therapies, os differed significantly, with a higher median os being observed in the sunitinib group. The cost of treatment was higher in the sunitinib group, which is to be expected with longer survival. [ABSTRACT FROM AUTHOR]

The methodology developed in this study presents an approach to the concurrent evaluation of Risk Management (RM) effectiveness during project execution. The method proposed is an adaptation of an approach developed and advocated by Khlebopros et al. (2007) for the mathematical modelling of complex systems, namely the analysis and effects of natural catastrophes. Hence, the method utilizes a phase portrait approach to identify the Prime Cost (PC) of RM of a project. Furthermore, the method provides an approach for comparing the individual identified risks with this PC, and subsequently highlighting a way of classifying and prioritising risks into a rank order for RM attention. The MERA (Multiple Estimating Risk Analysis) approach was utilized for the quantification of risk impact and ultimately the creation of the phase portrait. Besides being accurate and intuitively understandable, the methodology is relatively simple to implement and provides a rapid visualisation of the overall risk extent of a project. [ABSTRACT FROM AUTHOR]

Fracture liaison services (FLS), implemented in different ways and countries, are reported to be a cost-effective or even a cost-saving secondary fracture prevention strategy. This presumed favorable cost-benefit relationship is encouraging and lends support to expanded implementation of FLS per International Osteoporosis Foundation Best Practice Standards. This study summarizes the economic impact and cost-effectiveness of FLS implemented to reduce subsequent fractures in individuals with osteoporosis. This systematic review identified studies reporting economic outcomes for FLS in osteoporotic patients aged 50 and older through a comprehensive search of MEDLINE, EMBASE, Cochrane Central, and PubMed of studies published January, 2000 to December, 2016. Grey literature (e.g., Google scholar, conference abstracts/posters) were also hand searched through February 2017. Two independent reviewers screened titles and abstracts and conducted full-text review on qualified articles. All disagreements were resolved by discussion between reviewers to reach consensus or by a third reviewer. In total, 23 qualified studies that evaluated the economic aspects of FLS were included: 16 cost-effectiveness studies, 2 cost-benefit analyses, and 5 studies of cost savings. Patient populations varied (prior fragility fracture, non-vertebral fracture, hip fracture, wrist fracture), and FLS strategies ranged from mail-based interventions to comprehensive nurse/physician-coordinated programs. Cost-effectiveness studies were conducted in Canada, Australia, USA, UK, Japan, Taiwan, and Sweden. FLS was cost-effective in comparisons with usual care or no treatment, regardless of the program intensity or the country in which the FLS was implemented (cost/QALY from $3023-$28,800 US dollars (USD) in Japan to $14,513-$112,877 USD in USA. Several studies documented cost savings. FLS, implemented in different ways and countries, are reported to be cost-effective or even cost-saving. This presumed favorable cost-benefit relationship is encouraging and lends support to expanded implementation of FLS per International Osteoporosis Foundation Best Practice Standards. [ABSTRACT FROM AUTHOR]

Objectives: The incremental costs of expanding antiretroviral (ARV) drug treatment to all HIV‐infected patients are substantial, so cost‐saving initiatives are important. Our objectives were to determine the acceptability and financial impact of de‐simplifying (i.e. switching) more expensive single‐tablet formulations (STFs) to less expensive generic‐based multi‐tablet components. We determined physician and patient perceptions and acceptance of STF de‐simplification within the context of a publicly funded ARV budget. Methods: Programme costs were calculated for patients on ARVs followed at the Southern Alberta Clinic, Canada during 2016 (Cdn$). We focused on patients receiving Triumeq® and determined the savings if patients de‐simplified to eligible generic co‐formulations. We surveyed all prescribing physicians and a convenience sample of patients taking Triumeq® to see if, for budgetary purposes, they felt that de‐simplification would be acceptable. Results: Of 1780 patients receiving ARVs, 62% (n = 1038) were on STF; 58% (n = 607) of patients on STF were on Triumeq®. The total annual cost of ARVs was $26 222 760. The cost for Triumeq® was $8 292 600. If every patient on Triumeq® switched to generic abacavir/lamivudine and Tivicay® (dolutegravir), total costs would decrease by $4 325 040. All physicians (n = 13) felt that de‐simplifying could be safely achieved. Forty‐eight per cent of 221 patients surveyed were agreeable to de‐simplifying for altruistic reasons, 27% said no, and 25% said maybe. Conclusions: De‐simplifying Triumeq® generates large cost savings. Additional savings could be achieved by de‐simplifying other STFs. Both physicians and patients agreed that selective de‐simplification was acceptable; however, it may not be acceptable to every patient. Monitoring the medical and cost impacts of de‐simplification strategies seems warranted. [ABSTRACT FROM AUTHOR]