Despite the large numbers of persons living with dementia, the best approach to providing dementia care is unknown. To compare the effectiveness of health system dementia care (HSDC), community-based dementia care (CBDC), and usual care (UC) on person living with dementia and caregiver outcomes. The Dementia Care Study (D-CARE) was a pragmatic, 18-month, 3-armed, assessor-blinded randomized clinical trial conducted from June 2019 through August 2023 at 4 clinical trial sites in North Carolina, Texas, and Pennsylvania. Person living with dementia–caregiver dyads were included. Data were analyzed from December 2024 to June 2025. HSDC comanagement by nurse practitioners or physician assistants or CBDC provided telephonically by a social worker, nurse, or licensed therapist for 18 months. Prespecified outcomes included person living with dementia cognition, functional status, and quality of life; caregiver ratings of quality of care (10 items; range, 0-10) and satisfaction with care (11 items; range, 11-55), including how helpful the dementia care was, access to services, and support; positive aspects of caregiving; and overall caregiver burden as well as a measure of whether either the person living with dementia or caregiver benefitted. A total of 2176 person living with dementia–caregiver dyads were enrolled; 1271 persons living with dementia (58.4%) and 1650 caregivers (75.8%) were female, and their mean (SD) age were 80.6 (8.5) years and 65.2 (12.3) years, respectively. There were no treatment differences between groups in person living with dementia functional status, cognition, or quality of life or in overall caregiver burden or positive aspects of caregiving. Caregiver satisfaction with care was higher with both interventions compared with UC (HSDC: least-squares mean difference, 2.6 points; 98.3% CI, 1.0-4.2; P < .001; CBDC: least-squares mean difference, 3.3 points; 98.3% CI, 1.7-4.9; P < .001). The difference in caregiver satisfaction with care between the interventions and UC was apparent by 3 months and persisted through the study. Caregiver-rated quality of care was higher in the CBDC group compared with UC (least-squares mean ratio, 1.1; 98.3% CI, 1.0-1.3; P = .046). In this randomized clinical trial, HSDC and CBDC did not differ from UC on most person living with dementia and caregiver measures. However, caregivers reported higher satisfaction with both interventions compared with UC. These findings can help further refine comprehensive dementia care programs. ClinicalTrials.gov Identifier: NCT03786471

Background Hospitals have implemented diverse quality improvement (QI) interventions to reduce rates of catheter-associated urinary tract infections (CAUTIs). The economic value of these QI interventions is uncertain. Objective To systematically review economic evaluations of QI interventions designed to prevent CAUTI in acute care hospitals. Methods A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, WorldCat, IDWeek conference abstracts and prior systematic reviews was conducted from January 2000 to October 2020. We included English-language studies of any design that evaluated organisational or structural changes to prevent CAUTI in acute care hospitals, and reported programme and infection-related costs. Dual reviewers assessed study design, effectiveness, costs and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net cost/savings per hospital over 3 years. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter days per study. Results Fifteen unique economic evaluations were eligible, encompassing 74 hospitals. Across 12 studies amenable to standardisation, QI interventions were associated with a 43% decline in infections (mean IRR 0.57, 95% CI 0.44 to 0.70) and wide ranges of net costs (mean US$52 000, 95% CI -$288 000 to $392 000), relative to usual care. Conclusions QI interventions were associated with large declines in infection rates and net costs to hospitals that varied greatly but that, on average, were not significantly different from zero over 3 years. Future research should examine specific practices associated with cost-savings and clinical effectiveness, and examine whether or not more comprehensive interventions offer hospitals and patients the best value.

BACKGROUND/OBJECTIVESBriefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD).DESIGNProspective follow‐up study.SETTINGUniversity‐based dementia care management program.PARTICIPANTS1,091 PWD.MEASUREMENTSWe assessed cognition (Mini Mental State Examination (MMSE)—11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ‐S)—12 items), and functional ability (Activities of Daily Living (ADL)—6 items; Functional Activities Questionnaire (FAQ)—10 items). Item response theory was used to select subsets of items by identifying low item discrimination (<1.50), poor item fit (χ2), local dependence (LD), and with difficulty similar to other items. We estimated correlations between original and shorter scales and compared their associations with mortality. We added two symptoms (trouble swallowing, coughing when eating) reflecting late‐stage dementia complications, created a multi‐dimensional dementia assessment composite, and examined its association with mortality.RESULTSFive MMSE tasks were eliminated: two with low discrimination, two with difficulty similar to other items, and one with poor fit. The remaining tasks were correlated with the full MMSE at r = 0.82. We retained three ADLs that were correlated with the total ADL set at r = 0.95 and kept five FAQ items that were not LD (correlation with full FAQ, r = 0.97). Associations with mortality were similar between the longer and shorter scales. A higher score on the composite (range 0–100) indicates worse dementia impact and was associated with mortality (hazard ratio (HR) per scale point: 1.03 (1.02–1.04)).CONCLUSIONThese brief assessments and dementia composite may reduce administration time while preserving validity.

BACKGROUND/OBJECTIVESAlthough nurse practitioner dementia care co‐management has been shown to reduce total cost of care for fee‐for‐service (FFS) Medicare beneficiaries, the reasons for cost savings are unknown. To further understand the impact of dementia co‐management on costs, we examined acute care utilization, long‐term care admissions, and hospice use of program enrollees as compared with persons with dementia not in the program using FFS and managed Medicare claims data.DESIGNQuasi‐experimental controlled before‐and‐after comparison.SETTINGUrban academic medical center.PARTICIPANTSA total of 856 University of California, Los Angeles (UCLA) Alzheimer's and Dementia Care program patients were enrolled between July 1, 2012, and December 31, 2015, and 3,139 similar UCLA patients with dementia not in the program. Comparison patients were identified as having dementia using International Classification of Diseases‐9 codes and natural language processing of clinical notes. Coarsened exact matching was used to reduce covariate imbalance between intervention and comparison patients.INTERVENTIONDementia co‐management model using nurse practitioners partnered with primary care providers and community organizations.MEASUREMENTSAverage difference‐in‐differences per quarter over the 2.5‐year intervention period for all‐cause hospitalization, emergency department (ED) visits, intensive care unit (ICU) stays, and number of inpatient hospitalization days; admissions to long‐term care facilities; and hospice use in the last 6 months of life.RESULTSIntervention patients had fewer ED visits (odds ratio [OR] = .80; 95% confidence interval [CI] = .66–.97) and shorter hospital length of stay (incident rate ratio = .74; 95% CI = .55–.99). There were no significant differences between groups for hospitalizations or ICU stays. Program participants were less likely to be admitted to a long‐term care facility (hazard ratio = .65; 95% CI = .47–.89) and more likely to receive hospice services in the last 6 months of life (adjusted OR = 1.64; 95% CI = 1.13–2.37).CONCLUSIONComprehensive nurse practitioner dementia care co‐management reduced ED visits, shortened hospital length of stay, increased hospice use, and delayed admission to long‐term care.

Research ObjectiveTo alleviate the problem of primary care physician (PCP) shortage, policy makers have established new medical schools and expanded medical school class sizes over the last 15 years. However, few studies have examined whether the increased PCP supply improves access to care. We aimed to fill the gap by examining the effect of PCP supply on adults’ access to care and assessing the extent to which market adjustments mitigate PCP shortages.Study DesignWe used primary care service areas (PCSAs) as market areas and merged PCSA‐level PCP supply (PCPs per 1000 population) with individual‐level data from the 2004‐2013 Medical Expenditures Panel Survey (MEPS). The data on physician supply and number of patients that PCPs saw per day came from SK&A while all other measures were from the MEPS.We modeled the probability that adults had a nonemergency room usual source of care (USC) as a function of PCP supply and individual sociodemographic characteristics, health status, and beliefs and attitudes regarding health and health care. We estimated analogous models to examine how PCP supply affects travel time to the USC and the ability to get needed care right away and make appointments as soon as needed. To examine market adjustments, we assessed the relationship between PCP supply and whether PCPs offered night and weekend hours, how many patients PCPs saw per day, and how frequently individual adults had office visits. As sensitivity analyses, we tested alternative PCP definitions (eg, including vs. excluding obstetricians/gynecologists) and estimated the models separately for adults with and without health insurance. All the models controlled for nurse practitioners and physician assistants.Population Studied378 400 adults included in the 2004‐2013 MEPS.Principal FindingsPCP supply had no effect on the probability of having a USC or the ability to get needed care right away or make timely appointments by adults. By contrast, higher PCP supply reduced adults’ travel time to the USC. We also found evidence of market adjustments that enhanced the physicians’ capacity to see different patients in areas with low PCP supply. Specifically, PCPs in these areas were more likely to offer night and weekend hours and saw more patients per day (elasticity at mean = −0.19), while adults in these areas had fewer office visits (elasticity at mean = 0.07). Taken together, the latter two adjustments compensate for more than one‐fourth of the lost capacity to see different patients where there are fewer PCPs. The sensitivity analyses confirmed robustness of the results.ConclusionsSince both having a USC and the ability to get timely care when needed and make timely appointments are likely to be more important indicators of access than travel time to the USC, our findings suggest that more PCPs do not improve the most important access indicators for most U.S. adults. Market adjustments in areas with fewer PCPs are at least partly responsible for the lack of effects of PCP supply on having a USC.Implications for Policy or PracticeProducing more physicians may be a blunt instrument for improving access to care. Targeted policies are likely to be more efficient in improving access for adults who currently lack it.Primary Funding SourceAgency for Healthcare Research and Quality.

Importance Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.

BACKGROUND/OBJECTIVES Persons with Alzheimer disease and related dementias (ADRDs) require comprehensive care that spans health systems and community-based organizations. This study examined the clinical outcomes of a comprehensive dementia care program and identified subgroups who were more likely to benefit. DESIGN Observational, baseline and 1 year after intervention. SETTING Urban, academic medical center. PARTICIPANTS A total of 554 persons with dementia and their caregivers who had 1-year follow-up evaluations and data on clinical outcomes. INTERVENTION Health system-based comprehensive dementia care management program using nurse practitioner dementia care managers. MEASUREMENTS Patient measures included the Mini-Mental State Examination (MMSE), the Functional Activities Questionnaire, Basic and Instrumental Activities of Daily Living scales, the Cornell Scale for Depression in Dementia, and the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity. Caregiver measures included the Modified Caregiver Strain Index, the Patient Health Questionnaire-9, NPI-Q Distress, and the Dementia Burden Scale-Caregiver). We used established minimal clinically important differences and lowest tertiles of baseline symptoms to define improving symptoms and maintaining low symptoms as clinical benefit for patients and caregivers. RESULTS At year 1, persons with ADRD improved on all scales, except MMSE and functional status measures; caregivers improved on all scales. Using validated instruments, 314/543 (58%) of patients, 282/447 (63%) of caregivers, and 376/501 (75%) of patients or caregivers demonstrated clinical benefit. In adjusted multivariate models, at year 1, more behavioral symptoms and fewer depression symptoms at baseline were associated with patient improvement; and fewer baseline depression symptoms were associated with maintaining low behavioral symptoms. Male caregiver sex, higher baseline caregiver burden, and caring for patients with fewer baseline depression symptoms were associated with caregiver improvement. Male caregiver sex and patients with fewer depression symptoms, fewer behavioral symptoms, and more functional impairment at baseline were associated with caregivers maintaining low burden at 1 year. CONCLUSIONS Health system-based comprehensive dementia care management is a promising approach to improving clinical outcomes, with benefits for both patients and caregivers.

Dementia is associated with cognitive impairments, functional limitations, and behavioral and psychological symptoms. Briefer tools to assess these constructs could improve clinical work flow and enhance longitudinal follow-up of persons with dementia. We assessed cognitive abilities [Mini Mental State Exam (MMSE) – 30 items], functional status [Functional Activities Questionnaire (FAQ) – 10 items], depressive symptoms [Cornell Scale for Depression in Dementia (CDDS) – 19 items], and neuropsychiatric symptom severity [Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S) – 12 items] in a study of 1091 patients in UCLA's Alzheimer's and Dementia Care Program. Item response theory (IRT) was used to identify items with low discrimination values (<1.50), poor item level fit (χ2), local dependence (LD), or duplicative item difficulties. We estimated Pearson's correlations between the complete and brief scale versions and compared associations between the complete and brief scale versions and time to mortality. On the MMSE, 15 of 30 items were omitted for low discrimination (4 items), poor fit (5 items), and duplicative difficulty (6 items). The brief MMSE (15 items) was correlated with the full scale at r=0.92. On the FAQ, several items were locally dependent, leaving 5 items for the brief scale, which was correlated with the full scale at r=0.98. For the CDDS, 4 items had acceptable discriminations; the brief CDDS was correlated with the full scale at r=0.75. On the NPIQ-S, 4 of the items had discriminations ≥1.50, but one of these had content already covered in the brief CDDS (delusions), leaving a 3-item brief NPIQ-S that was correlated with the 12-item version at r=0.80. The brief scales had hazard ratios (HR) for time to mortality that were similar to the complete versions. (Table).

ObjectivesTo better capture the scope of caregiver burden by creating a composite of 3 existing measures that assess different health domains.DesignProspective follow‐up study.SettingUniversity‐based dementia care management program.ParticipantsCaregivers of persons with dementia (PWD) (N=1,091).MeasurementsThe composite measure (the Dementia Burden Scale—Caregiver (DBS‐CG)) was based on the Modified Caregiver Strain Index, Neuropsychiatric Inventory Questionnaire Distress Scale, and Patient Health Questionnaire (PHQ‐9). Alternative factor structures were evaluated using 2 confirmatory factor analysis (CFA) models: a bifactor model and a 3 correlated factors model. Good model fit was defined as a root mean square error of approximation (RMSEA) of less than 0.06 and comparative fit index (CFI) value greater than 0.95. Coefficient omega was used to estimate scale reliability. Minimally important differences (MIDs) were estimated by anchoring the magnitude of DBS‐CG change to change in caregiver self‐efficacy and functional ability of PWD.ResultsThe bifactor CFA model fit best (RMSEA = 0.04, CFI = 0.95). Based on this model, a DBS‐CG scale was created wherein all items were transformed to a possible range of 0 to 100 and then averaged. Higher scores indicate higher burden. Mean DBS‐CG score was 27.3. The reliability was excellent (coefficient omega=0.93). MID estimates ranged from 4 to 5 points (effect sizes: 0.20–0.49).ConclusionThis study provides support for the reliability and validity of the DBS‐CG. It can be used as an outcome measure to assess the effect of interventions to reduce dementia caregiver burden.

OBJECTIVE Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA1c, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA1c and incremental net cost. RESULTS Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA1c declined by 0.26% (95% CI 0.17–0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI −$612 to $843) per patient annually. Long-term ICERs were $100,000–$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000–$99,999/QALY in 1 RCT, $0–$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias. CONCLUSIONS Diverse multifaceted QI interventions that lower HbA1c appear to be a fair-to-good value relative to usual care, depending on society’s willingness to pay for improvements in health.

Context: Influenza vaccination rates remain below Healthy People 2020 goals. This project sought to systematically review economic evaluations of healthcare-based quality improvement interventions for improving influenza vaccination uptake among general populations and healthcare workers. Evidence acquisition: The databases MEDLINE, Econlit, Centre for Reviews & Dissemination, Greylit, and Worldcat were searched in July 2016 for papers published from January 2004 to July 2016. Eligible studies evaluated efforts by bodies within the healthcare system to encourage influenza vaccination by means of an organizational or structural change. For each study, program costs per enrollee and per additional enrollee vaccinated were derived (excluding vaccine costs, standardized to 2017 U.S. dollars). Complete economic evaluations were examined when available. Evidence synthesis: Of 2,350 records, 18 articles were eligible and described 29 unique interventions. Most interventions improved vaccine uptake. Among 23 interventions in general populations, the median program cost was $3.27 (interquartile range, $0.82-$11.53) per enrollee and $50.78 (interquartile range, $27.85-$124.84) per additional enrollee vaccinated. Among ten complete economic evaluations in general populations, three studies reported net cost savings, four reported costs <$50,000 per quality-adjusted life year, and three reported costs <$60,000 per life saved. Among six interventions in healthcare workers, the median program cost was $ 8.09 (interquartile range, $5.03-$10.31)per worker enrolled and $125.24 (interquartile range, $96.06-$171.38) per additional worker vaccinated (there were no complete economic analyses). Conclusions: Quality improvement interventions for influenza vaccination involve per-enrollee costs that are similar to the cost of the vaccine itself ($11.78-$-36.08/dose). Based on limited available evidence in general populations, quality improvement interventions may be cost saving to cost effective for the health system. (C) 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

OBJECTIVES: To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents.DESIGN: Randomized, controlled trial.SETTING: Five community NHs.PARTICIPANTS: Long-stay NH residents with an order for caloric supplementation (N = 122).INTERVENTION: Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care.MEASUREMENTS: Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake.RESULTS: Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P <.001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $ 1.27 per person per day higher than usual care (P <.001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance.CONCLUSION: It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake.

IMPORTANCE Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.OBJECTIVE To systematically review economic evaluations of QI interventions designed to reduce readmissions.DATA SOURCES Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).STUDY SELECTION Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.DATA EXTRACTION AND SYNTHESIS Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.MAIN OUTCOMES AND MEASURES Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.RESULTS Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P <.001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P <.001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P =.23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P =.90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714vs-$6568; P =.006).CONCLUSIONS AND RELEVANCE Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

Objective: Second-generation antipsychotics increase the risk of diabetes and other metabolic conditions among individuals with schizophrenia. Although metabolic testing is recommended to reduce this risk, low testing rates have prompted concerns about negative health consequences and downstream medical costs. This study simulated the effect of increasing metabolic testing rates on ten-year prevalence rates of prediabetes and diabetes (diabetes conditions) and their associated health care costs. Methods: A microsimulation model (N=21,491 beneficiaries) with a ten-year time horizon was used to quantify the impacts of policies that increased annual testing rates in a Medicaid population with schizophrenia. Data sources included California Medicaid data, National Health and Nutrition Examination Survey data, and the literature. In the model, metabolic testing increased diagnosis of diabetes conditions and diagnosis prompted prescribers to switch patients to lower-risk antipsychotics. Key inputs included observed diagnoses, prescribing rates, annual testing rates, imputed rates of undiagnosed diabetes conditions, and literature-based estimates of policy effectiveness. Results: Compared with 2009 annual testing rates, ten-year outcomes for policies that achieved universal testing reduced exposure to higher-risk antipsychotics by 14%, time to diabetes diagnosis by 57%, and diabetes prevalence by .6%. These policies were associated with higher spending because of testing and earlier treatment. Conclusions: The model showed that policies promoting metabolic testing provided an effective approach to improve the safety of second-generation antipsychotic prescribing in a Medicaid population with schizophrenia; however, the policies led to additional costs at ten years. Simulation studies are a useful source of information on the potential impacts of these policies.

Background. Since the recognition that human immunodeficiency virus is transmissible by blood transfusion there has been increasing public and professional support for autologous blood donations before elective surgery. Autologous blood donation is, however, a more expensive process than the donation of allogeneic blood by community volunteers. Furthermore, there have been recent improvements in the safety of the volunteer blood supply. Methods. We used a decision-analysis model to assess the cost effectiveness of donating autologous blood for four surgical procedures. Cost data were collected from the observation of transfusion practice at the University of California, Los Angeles, in 1992. Estimates of the risks of transfusion-associated diseases and the costs of treating them came from the medical literature. Cost effectiveness was expressed in dollars per quality-adjusted year of life saved. We performed sensitivity analyses of the variables in our model and examined the effect of strategies suggested to reduce costs. Results. Substituting autologous for allogeneic blood resulted in little expected health benefit (0.0002 to 0.00044 quality-adjusted year of life saved) at considerable additional cost ($68 to $4,783 per unit of blood). The additional cost of autologous blood was primarily a function of the discarding of units that were donated but not transfused and of a more labor-intensive donation process. The cost-effectiveness values ranged from $235,000 to over $23 million per quality-adjusted year of life saved. Conclusions. Given the improved safety of allogeneic transfusions today, the increased protection afforded by donating autologous blood is limited and may not justify the increased cost. (N Engl J Med 1995;332:719-24.) From the Division of General Internal Medicine, West Los Angeles Veterans Affairs Medical Center and the UCLA School of Medicine (J.E.); the Department of Pathology and Laboratory Medicine (L.P., L.C., S.K.) and the Departments of Medicine and Health Services (A.F., R.B.), UCLA Center for Health Sciences — all in Los Angeles; and RAND, Santa Monica, Calif. (J.E., E.K., C.S., R.B.). Address reprint requests to Dr. Etchason at the Division of General Internal Medicine, West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Blvd., Los Angeles, CA 90073. Supported in part by a grant from the Robert Wood Johnson Clinical Scholars Program (to Dr. Etchason) and by a Transfusion Medicine Academic Award (K07 HL02151, to Dr. Petz and Ms. Calhoun) from the National Heart, Lung, and Blood Institute. T HE epidemic of the acquired immunodeficiency syndrome (AIDS) has increased concern about the risk of transmitting infectious diseases through blood transfusion. In response to this concern, there has been a dramatic increase in preoperative autologous blood donations over the past decade. 1-4 Although sensationalized reports of the dangers of blood transfusion continue in the lay press, 5 there have been great improvements in the safety of the blood supply, primarily because of rigorous donor screening and sensitive serologic tests for the human immunodeficiency virus (HIV) and for hepatitis C virus. 6 Autologous blood is more costly than allogeneic blood. Its donation entails greater administrative expense and a longer, more labor-intensive process of collection. Moreover, the frequency of positive tests for infectious disease in autologous units 7,8 has raised questions about the safety of transfusing unused autologous units into patients other than the donor. Because of this concern, 85 percent of U.S. blood centers do not retain unused autologous units for other patients, but rather destroy them. 9 This practice has substantially raised the cost of autologous transfusion. The current national debate on health care reform makes this an appropriate time to analyze the cost effectiveness of autologous blood donation. In our study, we determined the costs of providing patients with autologous blood and used decision-analysis techniques to calculate the cost effectiveness of substituting autologous for allogeneic blood. We also analyzed the value of various strategies to minimize the costs of autologous-donation programs.

BACKGROUND:Identifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls. We developed a comprehensive four-step algorithm for identifying episodes of care for fall-related injuries and associated costs, using fee-for-service Medicare and Medicare Advantage health plan claims data for 2,011 patients from 5 medical groups between 2005 and 2009.METHODS:First, as a preparatory step, we identified care received in acute inpatient and skilled nursing facility settings, in addition to emergency department visits. Second, based on diagnosis and procedure codes, we identified all fall-related claim records. Third, with these records, we identified six types of encounters for fall-related injuries, with different levels of injury and care. In the final step, we used these encounters to identify episodes of care for fall-related injuries.RESULTS:To illustrate the algorithm, we present a representative example of a fall episode and examine descriptive statistics of injuries and costs for such episodes. Altogether, we found that the results support the use of our algorithm for identifying episodes of care for fall-related injuries. When we decomposed an episode, we found that the details present a realistic and coherent story of fall-related injuries and healthcare services. Variation of episode characteristics across medical groups supported the use of a complex algorithm approach, and descriptive statistics on the proportion, duration, and cost of episodes by healthcare services and injuries verified that our results are consistent with other studies.CONCLUSIONS:This algorithm can be used to identify and analyze various types of fall-related outcomes including episodes of care, injuries, and associated costs. Furthermore, the algorithm can be applied and adopted in other fall-related studies with relative ease.