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      Access to health care for older people with intellectual disability: a modelling study to explore the cost-effectiveness of health checks

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          Abstract

          Background

          Whilst people with intellectual disability grow older, evidence has emerged internationally about the largely unmet health needs of this specific ageing population. Health checks have been implemented in some countries to address those health inequalities. Evaluations have focused on measuring process outcomes due to challenges measuring quality of life outcomes. In addition, the cost-effectiveness is currently unknown. As part of a national guideline for this population we sought to explore the likely cost-effectiveness of annual health checks in England.

          Methods

          Decision-analytical Markov modelling was used to estimate the cost-effectiveness of a strategy, in which health checks were provided for older people with intellectual disability, when compared with standard care. The approach we took was explorative. Individual models were developed for a selected range of health conditions, which had an expected high economic impact and for which sufficient evidence was available for the modelling. In each of the models, hypothetical cohorts were followed from 40 yrs. of age until death. The outcome measure was cost per quality-adjusted life-year (QALY) gained. Incremental cost-effectiveness ratios (ICER) were calculated. Costs were assessed from a health provider perspective and expressed in 2016 GBP. Costs and QALYs were discounted at 3.5%. We carried out probabilistic sensitivity analysis. Data from published studies as well as expert opinion informed parameters.

          Results

          Health checks led to a mean QALY gain of 0.074 (95% CI 0.072 to 0.119); and mean incremental costs of £4787 (CI 95% 4773 to 5017). For a threshold of £30,000 per QALY, health checks were not cost-effective (mean ICER £85,632; 95% CI 82,762 to 131,944). Costs of intervention needed to reduce from £258 to under £100 per year in order for health checks to be cost-effective.

          Conclusion

          Whilst findings need to be considered with caution as the model was exploratory in that it was based on assumptions to overcome evidence gaps, they suggest that the way health systems deliver care for vulnerable populations might need to be re-examined. The work was carried out as part of a national guideline and informed recommendations about system changes to achieve more equal health care provisions.

          Electronic supplementary material

          The online version of this article (10.1186/s12889-019-6912-0) contains supplementary material, which is available to authorized users.

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          Most cited references46

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          A review of health utilities using the EQ-5D in studies of cardiovascular disease

          Background The EQ-5D has been extensively used to assess patient utility in trials of new treatments within the cardiovascular field. The aims of this study were to review evidence of the validity and reliability of the EQ-5D, and to summarise utility scores based on the use of the EQ-5D in clinical trials and in studies of patients with cardiovascular disease. Methods A structured literature search was conducted using keywords related to cardiovascular disease and EQ-5D. Original research studies of patients with cardiovascular disease that reported EQ-5D results and its measurement properties were included. Results Of 147 identified papers, 66 met the selection criteria, with 10 studies reporting evidence on validity or reliability and 60 reporting EQ-5D responses (VAS or self-classification). Mean EQ-5D index-based scores ranged from 0.24 (SD 0.39) to 0.90 (SD 0.16), while VAS scores ranged from 37 (SD 21) to 89 (no SD reported). Stratification of EQ-5D index scores by disease severity revealed that scores decreased from a mean of 0.78 (SD 0.18) to 0.51 (SD 0.21) for mild to severe disease in heart failure patients and from 0.80 (SD 0.05) to 0.45 (SD 0.22) for mild to severe disease in angina patients. Conclusions The published evidence generally supports the validity and reliability of the EQ-5D as an outcome measure within the cardiovascular area. This review provides utility estimates across a range of cardiovascular subgroups and treatments that may be useful for future modelling of utilities and QALYs in economic evaluations within the cardiovascular area.
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            Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study.

            The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. We aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension. We did a Markov model-based probabilistic cost-effectiveness analysis. We used a hypothetical primary-care population aged 40 years or older with a screening blood-pressure measurement greater than 140/90 mm Hg and risk-factor prevalence equivalent to the general population. We compared three diagnostic strategies-further blood pressure measurement in the clinic, at home, and with an ambulatory monitor-in terms of lifetime costs, quality-adjusted life years, and cost-effectiveness. Ambulatory monitoring was the most cost-effective strategy for the diagnosis of hypertension for men and women of all ages. It was cost-saving for all groups (from -£56 [95% CI -105 to -10] in men aged 75 years to -£323 [-389 to -222] in women aged 40 years) and resulted in more quality-adjusted life years for men and women older than 50 years (from 0·006 [0·000 to 0·015] for women aged 60 years to 0·022 [0·012 to 0·035] for men aged 70 years). This finding was robust when assessed with a wide range of deterministic sensitivity analyses around the base case, but was sensitive if home monitoring was judged to have equal test performance to ambulatory monitoring or if treatment was judged effective irrespective of whether an individual was hypertensive. Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs. Additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs. National Institute for Health Research and the National Institute for Health and Clinical Excellence. Copyright © 2011 Elsevier Ltd. All rights reserved.
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              Impact of hip fracture on hospital care costs: a population-based study

              Summary Using a large cohort of hip fracture patients, we estimated hospital costs to be £14,163 and £2139 in the first and second year following fracture, respectively. Second hip and non-hip fractures were major cost drivers. There is a strong economic incentive to identify cost-effective approaches for hip fracture prevention. Introduction The purpose of this study was to estimate hospital costs of hip fracture up to 2 years post-fracture and compare costs before and after the index fracture. Methods A cohort of patients aged over 60 years admitted with a hip fracture in a UK region between 2003 and 2013 were identified from hospital records and followed until death or administrative censoring. All hospital records were valued using 2012/2013 unit costs, and non-parametric censoring methods were used to adjust for censoring when estimating average annual costs. A generalised linear model examined the main predictors of hospital costs. Results A cohort of 33,152 patients with a hip fracture was identified (mean age 83 years (SD 8.2). The mean censor-adjusted 1- and 2-year hospital costs after index hip fracture were £14,163 (95 % confidence interval (CI) £14,008 to £14,317) and £16,302 (95 % CI £16,097 to £16,515), respectively. Index admission accounted for 61 % (£8613; 95 % CI £8565 to £8661) of total 1-year hospital costs which were £10,964 higher compared to the year pre-event (p < 0.001). The main predictors of 1-year hospital costs were second hip fracture, other non-hip fragility fractures requiring hospitalisation and hip fracture-related complications. Total UK annual hospital costs associated with incident hip fractures were estimated at £1.1 billion. Conclusions Hospital costs following hip fracture are high and mostly occur in the first year after the index hip fracture. Experiencing a second hip fracture after the index fracture accounted for much of the increase in costs. There is a strong economic incentive to prioritise research funds towards identifying the best approaches to prevent both index and subsequent hip fractures.
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                Author and article information

                Contributors
                0044-20-7955-6238 , A.bauer@lse.ac.uk
                L.taggart@ulster.ac.uk
                Jill.rasmussen@psi-napse.com
                Chris.hatton@lancaster.ac.uk
                Lesley.owen@nice.org.uk
                M.knapp@lse.ac.uk
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                7 June 2019
                7 June 2019
                2019
                : 19
                : 706
                Affiliations
                [1 ]ISNI 0000 0001 0789 5319, GRID grid.13063.37, Personal Social Services Research Unit, , London School of Economics and Political Science, ; Houghton Street, London, England WC2A 2AE UK
                [2 ]ISNI 0000000105519715, GRID grid.12641.30, Institute of Nursing & Health Research, , Ulster University, ; N Ireland, Newtownabbey, BT37 0QB UK
                [3 ]ISNI 0000 0001 2157 6250, GRID grid.451233.2, Royal College of General Practitioners (RCGP), ; 30 Euston Square, London, England NW1 2FB UK
                [4 ]ISNI 0000 0000 8190 6402, GRID grid.9835.7, Centre for Disability Research, Division of Health Research, , Lancaster University, ; Lancaster, England LA1 4YG UK
                [5 ]ISNI 0000 0004 1794 1878, GRID grid.416710.5, National Institute for Health and Care Excellence, ; 10 Spring Gardens, London, England SW1A 2BU UK
                Author information
                http://orcid.org/0000-0001-5156-1631
                Article
                6912
                10.1186/s12889-019-6912-0
                6556058
                31174506
                fe99c183-8acf-46f3-8700-ba7dc975663c
                © The Author(s). 2019

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 17 October 2018
                : 29 April 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100010377, National Institute for Health and Care Excellence;
                Award ID: Not applicable
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Public health
                health checks,assessment,prevention,early diagnosis,ageing,intellectual disability,health inequalities,cost-effectiveness,decision-analytic modelling

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