Despite the ubiquity of electricity in many parts of the world, there are still over a billion people who do not have access to a reliable electric grid. Distributed solar energy has emerged as a low-cost solution for these off-grid communities to gain access to electricity. These communities tend to be in rural, remote, or agricultural regions where it can be expensive to extend existing electrical infrastructure. Such regions have also been shown to be the slowest to recover in post-disaster situations, where electrical infrastructure has been damaged. Addressing this need, our group installed small-scale solar kits (100-400 W) in different regions of non-electrified Guatemala and post-Hurricane Maria Puerto Rico. To improve the efficacy of our installations and future efforts, we surveyed households about their current circumstances, energy consumption, and energy needs. Our results show that despite different circumstances impacting energy access (non-electrified Guatemala versus for disaster recovery in Puerto Rico), there were similarities in their socio-economic statuses and their energy needs. We found that the small-scale solar kits enabled the usage of basic devices such as in-home medical equipment, lighting, phone-charging, and other small devices of interest to the families. Herein, we address the link between energy poverty, solar electrification for powering small devices, and the quality of life of households in both communities.

Objectives: To determine if solar-powered battery systems could be successfully used for electricity-dependent medical devices by families during a power outage. Methods: We assessed the use of and satisfaction with solar-powered battery systems distributed to 15 families following Hurricane Maria in rural Puerto Rico. Interviews were conducted in July 2018, 3 mo following distribution of the systems. Results: The solar-powered battery systems powered refrigeration for medications and prescribed diets, asthma therapy, inflatable mattresses to prevent bedsores, and continuous positive airway pressure machines for sleep apnea. Despite some system problems, such as inadequate power, defective cables, and blown fuses, families successfully dealt with these issues with some outside help. Almost all families were pleased with the systems and a majority would recommend solar-powered battery systems to a neighbor. Conclusions: Families accepted and successfully used solar-powered battery systems to power medical devices. Solar-powered battery systems should be considered as alternatives to generators for power outages after hurricanes and other disasters. Additional research and analysis are needed to inform policy on increasing access to such systems.

BACKGROUND:Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis.METHODS:We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario.RESULTS:In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence.CONCLUSIONS:HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available.

Approximately 233,898 individuals in the Veterans Affairs healthcare network are hepatitis C virus (HCV)-infected, making the Veterans Affairs the single largest provider of HCV care in the USA. Direct-acting antiviral treatment regimens for HCV offer high cure rates. However, these medications pose an enormous financial burden, and whether HCV cure is associated with decreased healthcare costs is poorly defined.

BACKGROUND & AIMS:It is important to quantify medical costs associated with hepatocellular carcinoma (HCC), the incidence of which is rapidly increasing in the United States, for development of rational healthcare policies related to liver cancer surveillance and treatment of chronic liver disease. We aimed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system and develop a model for predicting costs that is based on clinically relevant variables. METHODS:Three years subsequent to liver cancer diagnosis, costs accrued by patients included in the Veteran's Outcome and Cost Associated with Liver disease cohort were compiled by using the Department of Veterans Affairs Corporate Data Warehouse. The cohort includes all patients with HCC diagnosed in 2008-2010 within the VA with 100% chart confirmation as well as chart abstraction of tumor and clinical characteristics. Cancer cases were matched 1:4 with non-cancer cirrhosis controls on the basis of severity of liver disease, age, and comorbidities to estimate background cirrhosis-related costs. Univariable and multivariable generalized linear models were developed and used to predict cancer-related overall cost. RESULTS:Our analysis included 3188 cases of HCC and 12,722 controls. The mean 3-year total cost of care in HCC patients was $154,688 (standard error, $150,953-$158,422) compared with $69,010 (standard error, $67,344-$70,675) in matched cirrhotic controls, yielding an incremental cost of $85,679; 64.9% of this value reflected increased inpatient costs. In univariable analyses, receipt of transplantation, Barcelona Clinic Liver Cancer (BCLC) stage, liver disease etiology, hospital academic affiliation, use of multidisciplinary tumor board, and identification through surveillance were associated with cancer-related costs. Multivariable generalized linear models incorporating transplantation status, BCLC stage, and multidisciplinary tumor board presentation accurately predicted liver cancer-related costs (Hosmer-Lemeshow goodness of fit; P value ≅ 1.0). CONCLUSIONS:In a model developed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system, we associated receipt of liver transplantation, BCLC stage, and multidisciplinary tumor board with higher costs. Models that predict total costs on the basis of receipt of liver transplantation were constructed and can be used to model cost-effectiveness of therapies focused on HCC prevention.

Hepatitis C virus (HCV) treatment has the potential to cure the leading cause of cirrhosis and hepatocellular carcinoma. However, only those deemed eligible for treatment have the possibility of this cure. Therefore, understanding the determinants of HCV treatment eligibility is critical. Given that effective communication with and trust in healthcare providers significantly influences treatment eligibility decisions in other diseases, we aimed to understand patient-provider interactions in the HCV treatment eligibility process. This prospective cohort study was conducted in the VA Pittsburgh Healthcare System. Patients were recruited after referral for gastroenterology consultation for HCV treatment with interferon and ribavirin. Consented patients completed semi-structured interviews and validated measures of depression, substance and alcohol use, and HCV knowledge. Two coders analyzed the semi-structured interviews. Factors associated with patient eligibility for interferon-based therapy were assessed using multivariate logistic regression. Of 339 subjects included in this analysis, only 56 (16.5%) were deemed eligible for HCV therapy by gastroenterology (GI) providers. In the multivariate logistic regression, patients who were older (OR = 0.96, 95% CI = 0.92-0.99, p = .049), reported concerns about the GI provider (OR = 0.40, 95% CI = 0.10-0.87, p = 0.02) and had depression symptoms (OR = 0.32, 95% CI = 0.17-0.63, p = 0.001) were less likely to be eligible. Patients described barriers that included feeling stigmatized and poor provider interpersonal or communication skills. In conclusion, we found that patients' perceptions of the relationship with their GI providers were associated with treatment eligibility. Establishing trust and effective communication channels between patients and providers may lower barriers to potential HCV cure.

Six strategies for identifying hepatitis C virus (HCV) viremia, involving testing for HCV antibody (HCVAb) followed by a nucleic acid test (NAT) for HCV RNA when the antibody test is positive, are compared. Decision analysis was used to determine mean relative cost per person tested and outcomes of HCV viremia detection. Parameters included proportions of test population with HCVAb and viremia plus specificity, sensitivity, and cost of individual tests. For testing a population with an HCVAb seroprevalence of 3.25%, all strategies when adopting quantitative NAT vary little in cost (range, $29.50‐$30.70) and are highly viremia specific (≥0.9997). Four of the strategies using venipuncture blood for HCVAb testing (whether laboratory conducted or employing a rapid, point‐of‐care assay) and for NAT (whether done by reflex or using separately drawn blood) achieve the highest viremia sensitivities (range, 0.9950‐0.9954). Point‐of‐care HCVAb testing in fingerstick blood followed by NAT in venipuncture blood yields relatively lower viremia sensitivity (0.9301). The strategy that requires returning for NAT is even less viremia sensitive (<0.9000) because of follow‐up loss. Strategies adopting qualitative rather than quantitative NAT are slightly cheaper (range, $28.90‐$29.99), similarly viremia specific (≥0.9997), but less viremia sensitive (≤0.9456). Viremia sensitivity and specificity remain the same regardless of the proportion of HCVAb‐seropositive persons in the cohort being tested. Conclusions: Strategies involving HCVAb testing in venipuncture blood, whether laboratory conducted or using a point‐of‐care assay, when followed by quantitative NAT done reflexively or in separately drawn blood, are comparably economical and suitably viremia sensitive. Less cost‐effective is point‐of‐care HCVAb testing in fingerstick blood followed by NAT in venipuncture blood. Least cost‐effective is the strategy requiring the tested person to return for NAT. (Hepatology 2015;62:1396–1404)

BACKGROUND There is significant interest in measuring health care value, but this concept has not been operationalized in specific patient cohorts. The longitudinal outcomes and costs for patients after percutaneous coronary intervention (PCI) provide an opportunity to measure an aspect of health care value.OBJECTIVES This study evaluated variations in 1-year outcomes (risk-adjusted mortality) and risk-standardized costs of care for all patients undergoing PCI in the Veterans Affairs (VA) system from 2007 to 2010.METHODS This retrospective cohort study evaluated all veterans undergoing PCI at any of 60 hospitals in the VA health care system, using data from the national VA Clinical Assessment, Reporting, and Tracking (CART) program. Primary outcomes were 1-year mortality and costs following PCI. Risk-standardized mortality and cost ratios were calculated, adjusting for cardiac and noncardiac comorbidities.RESULTS A median of 261 PCIs were performed in the 60 hospitals during the study period. Median 1-year unadjusted hospital mortality rate was 6.13%. Four hospitals were significantly above the 1-year risk-standardized median mortality rate, with median mortality ratios ranging from 1.23 to 1.28. No hospitals were significantly below median mortality. Median 1-year total unadjusted hospital costs were $46,302 per patient. There were 16 hospitals above and 19 hospitals below the risk-standardized median cost, with risk-standardized ratios ranging from 0.45 to 2.09, reflecting a much larger magnitude of variability in costs than in mortality.CONCLUSIONS There is much smaller variation in 1-year risk adjusted mortality than in risk-standardized costs after PCI in the VA. These findings suggest that there are opportunities to improve PCI value by reducing costs without compromising outcomes. This approach to evaluating outcomes and costs together may be a model for other health systems and accountable care organizations interested in operationalizing value measurement. (C) 2015 by the American College of Cardiology Foundation.

Background: Health care providers recommend an annual visit to a multiple sclerosis specialty care provider.Objective: To examine potential barriers to the implementation of this recommendation in the Veterans Health Administration.Design: Observational cohort study.Setting: Veterans Health Administration.Participants: Participants were drawn from the Veterans Affairs Multiple Sclerosis National Data Repository and were included if they had an outpatient visit in 2007 and were alive in 2008 (N = 14,723).Main Outcome Measurements: Specialty care visit, receipt of medical services.Results: A total of 9643 (65.5%) participants had a specialty care visit in 2007. Veterans who were service connected, had greater medical comorbidity, and who lived in urban settings were more likely to have received a specialty care visit. Veterans who were older and had to travel greater distances to a center were less likely to have a specialty care visit.Conclusions: Access to care in rural areas and areas at a greater distance from a major medical center represent notable barriers to rehabilitation and other multiple sclerosis-related care.

PURPOSE:To assess the feasibility of using a multimedia program to teach caregivers of Veterans with cancer how to offer basic massage for supportive care at home.METHODS:Feasibility was assessed according to partner availability, compliance with watching training materials and practicing massage regularly, compliance with data collection; perceived study materials burden; clarity of instructional and other study materials. Pre- and post-massage changes in patients' symptom scores were measured using a numerical rate scale. A semistructured exit interview was answered by patient and caregiver at the end of the study.RESULTS:A total of 27 dyads were recruited. Veterans were 78% male. Forty-eight percent were diagnosed with hematologic malignancies (85%, advanced stage); 52% were diagnosed with solid tumors (64% advanced stage). Caregivers were 78% female; 81% were spouses. Out of the 27 pairs, 11 completed 8 weeks of data and practiced massage weekly. The majority of attrition (69%) was due to caregivers' burden. Caregivers reported instructional materials were clear, high quality, and easy to use. Patients were highly satisfied with receiving touch from their partners regularly. Post-massage symptom scores showed statistically significant decreases in pain, stress/anxiety, and fatigue. Perceived burden of data collection instruments was high, particularly for patients.CONCLUSION:It is feasible to use the TCC program to train caregivers of Veterans with cancer to offer massage for supportive care at home. Future studies should evaluate ways of providing support to caregivers, including offering massage to them, and easing the burden of data collection for patients.

Background: Value in health care has been defined as outcomes achieved relative to costs for the full cycle of care. To date, it has not been operationalized and applied to specific patients. Percutaneous coronary intervention (PCI) is one important aspect of the care of patients with ischemic heart disease. PCI and the longitudinal care provided to patients following the procedure provides an opportunity to measure health care value. Methods: We analyzed data from the VA National CART Program that includes all 76 cardiac catheterization laboratories and all patients undergoing PCI along with longitudinal follow-up and cost data from 2008 to 2010. Costs were obtained from the VA’s Decision Support System, a cost accounting system that tracks costs for each patient. To assess 1-year value following each PCI procedure, patient costs and mortality were attributed to the index hospital in which PCI occurred. Risk standardized outcomes of mortality and log cost ratios were calculated using standardized covariates and adjusting for cardiac and non-cardiac co-morbidities. Results: There were 59 hospitals (n=19,139 patients) that performed more than 20 PCIs during the study period with mean of 324 and median of 258 PCIs. One-year unadjusted mean mortality rate was 6.1% and median of 6.4%. There were 3 sites above and no sites below the 1-year risk standardized median mortality rate (Figure; red bars). Mean and median total costs at 1-year were $62,142 and $59,262 (IQR $42,438 to $131,526) per patient, respectively. Risk standardized 1 year total costs demonstrated 17 hospitals above and 18 hospitals below the risk standardized average (Figure; green bars). Cardiac costs accounted for slightly more than half of the total costs at the hospital level, 51.4% of the mean and 50.4% of the median total costs. Conclusion: There were overall low 1 year mortality rates following PCI and small variation across sites. In contrast, there was significantly greater variability in 1 year costs following PCI, suggesting opportunities to reduce the costs of longitudinal PCI care without compromising outcomes.

Background. A second allogeneic transplantation after a prior allogeneic (allo-allo) or autologous (auto-allo) hematopoietic cell transplantation (HCT) is usually performed for graft failure, disease recurrence, secondary malignancy, and, as planned, auto-allo transplantation for some diseases.Methods. We sought to describe the costs of second allogeneic HCT and evaluate their relationship with patient characteristics and posttransplantation complications. Clinical information and medical costs for the first 100 days after transplantation of 245 patients (allo-allo, 55; auto-allo, 190) who underwent a second HCT between 2004 and 2010 were collected.Results. Median costs of the second allogeneic HCT were U.S. $151,000 (range, U.S. $62,000-405,000) for the allo-allo group and U.S. $109,000 (range, U.S. $26,000-490,000) for the auto-allo group. Median length of hospital stay was 23 days (range, 0-76) for the allo-allo group and 9 days (range, 0-96) for the auto-allo group. Only the year of transplantation and posttransplantation complications were significantly associated with costs in both groups when both pre- and posttransplantation variables were considered. The overall costs of the second HCT were higher than the first in the allo-allo group. For the auto-allo group, there was no difference between the costs whether preformed as a planned tandem or as salvage for relapse.Conclusions. Our results suggest that second allogeneic HCT is costly, particularly if it follows a prior allogeneic transplantation, and is driven by the costs of complications.

In this era of growing health care costs, the decision to proceed with a second allogeneic transplant has financial as well as clinical implications. We analyzed all medical costs for the transplant process from the beginning of conditioning to 100 days after the transplant for 55 patients who underwent second allogeneic transplants from 1/19/05 to 4/9/10 at the University of Washington/Seattle Cancer Care Alliance. Clinical information was obtained from the institutional database. Multiple linear regression was used to analyze the patient and transplant characteristics that are associated with total costs. Median age was 50 years (range 21 to 69 years), and 62% patients were male. Seventy eight percent transplants were for acute leukemia/MDS. Reasons for second transplant were graft failure (25%), relapse of original disease (65%) and other causes e.g. secondary MDS/aplasia (10%). 73% of relapsed patients were in remission at the time of the second transplant. Non-myeloablative conditioning was more common in the second allografts (75%) than in first allografts (30%) and a higher proportion of second allografts were from unrelated donors (76% vs. 43%). In the first 100 days, relapse occurred in 25% patients and 64% experienced ≥ grade II acute GVHD. Survival was 78% at 100 days and 49% at one year after transplant. Regimen related toxicity accounted for 75% of deaths within the first 100 days. The median total cost in 2010 dollars was $137,600 ($4,500 - $434,200) for the first 100 days, with approximately $135,600 (0 - $432,200) for inpatient and $4,100 (0 - $17,200) for outpatient costs. The median length of hospital stay was 22 days (range 0 to 77 days). Myeloablative conditioning, unrelated donors and pulmonary complications post-transplant were significant predictors of higher costs for the second transplants.Table 1Predictors of costs for second allogeneic transplantVariableCost multiplier95%CIp valuePre-transplant factorsAge <501 >500.890.53-1.470.64Disease Acute leukemia/MDS1 Lymphoma0.650.28-1.480.31 Others3.180.90-11.20.08Diseases status Remission1 Relapse0.760.38-1.490.43Graft source PBSC1 BM0.970.26-3.660.97 cord blood0.830.35-1.940.67Conditioning myeloablative1 Non-myeloablative0.450.23-0.860.02Year of transplant Per year0.880.73-1.060.18Reason for transplant Relapse1 Graft rejection1.180.64-2.190.6 Others1.480.45-4.950.52Donor type Related1 Unrelated2.391.34-4.250.006CMV serostatus negative1 positive0.830.50-1.370.48Post-transplant complications within 100 days Death (n = 12)0.90.37-2.200.82 Relapse (n = 14)1.150.64-2.070.65 GVHD (II-IV) (n = 35)1.590.96-2.640.08 VOD (n = 10)∗Veno-occlusive disease1.160.52-2.580.72 Pulmonary (n = 5)2.081.05-4.120.04 Renal (n = 9)1.580.59-4.180.37 Infection (n = 29)1.620.96-2.730.08∗ Veno-occlusive disease Open table in a new tab Short-term costs of second transplants appear comparable to those of first transplants especially since a majority of them are non-myeloablative/reduced intensity regimens. Additional work is needed with larger numbers of patients to confirm these results and identify additional characteristics that would predict the group with the best clinical and economic outcomes.

Methods Dyads received a training program including DVD and manual, and were instructed to watch and practice at least 20 minutes/day over 8 weeks. The training program was specially developed for caregivers of cancer patients and previously tested in a randomized trial with non-veteran population. Feasibility assessed partner availability, perceived burden, clarity of instructional materials and compliance with training materials, weekly massage practice, and returning of data collection instruments.

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations. Published in 2010 by John Wiley & Sons, Ltd.

BACKGROUND & AIMS A significant proportion of patients with hepatitis C virus (HCV) infection discontinue anti viral treatment prematurely Risk factors for discontinuation before 48 weeks among patients with genotype 1 HCV vary over the course of therapy We investigated the rates and risk factors for treatment discontinuation within 12 weeks, 12-24 weeks, and 24-48 weeks METHODS We retrospectively evaluated data from all Veterans Affairs (VA) patients with genotype 1 HCV who initiated pegylated interferon and ribavirin therapy from 2002-2007 (n = 11,019) We accounted for appropriate discontinuation because of viral nonresponse RESULTS Overall, 53% of patients completed at least 38 4 weeks of therapy (80% of the projected 48 weeks), 16 5% discontinued early in the setting of viral nonresponse, and 30 9% discontinued de spite viral response or in the absence of virologic data Cirrhosis, diabetes, pretreatment substance use disorder, hemoglobin, and lack of hematopoietic growth factor use independently predicted discontinuation before 12 weeks (P < 05 for all) Among patients with documented early virologic responses, higher baseline levels of creatinine, depression, and lack of growth factor use predicted discontinuation from 12-24 weeks No factors independently predicted discontinuation from 24-48 weeks among patients responding to treatment at 24 weeks CONCLUSIONS Early discontinuation of antiviral therapy is common Use of growth factors was the strongest independent predictor of treatment retention be fore 24 weeks and should be evaluated prospectively Early interventions may also be warranted for other risk factors for early discontinuation, such as pre-existing substance use, depression, cirrhosis, or diabetes

See related article, Swain MG et al, on page 1593 in Gastroenterology. BACKGROUND & AIMS: A significant proportion of patients with hepatitis C virus (HCV) infection discontinue antiviral treatment prematurely. Risk factors for discontinuation before 48 weeks among patients with genotype 1 HCV vary over the course of therapy. We investigated the rates and risk factors for treatment discontinuation within 12 weeks, 12‐24 weeks, and 24‐48 weeks. METHODS: We retrospectively evaluated data from all Veterans Affairs (VA) patients with genotype 1 HCV who initiated pegylated interferon and ribavirin therapy from 2002‐2007 (n 11,019). We accounted for appropriate discontinuation because of viral nonresponse. RESULTS: Overall, 53% of patients completed at least 38.4 weeks of therapy (80% of the projected 48 weeks), 16.5% discontinued early in the setting of viral nonresponse, and 30.9% discontinued despite viral response or in the absence of virologic data. Cirrhosis, diabetes, pretreatment substance use disorder, hemoglobin, and lack of hematopoietic growth factor use independently predicted discontinuation before 12 weeks (P .05 for all). Among patients with documented early virologic responses, higher baseline levels of creatinine, depression, and lack of growth factor use predicted discontinuation from 12‐24 weeks. No factors independently predicted discontinuation from 24‐48 weeks among patients responding to treatment at 24 weeks. CONCLUSIONS: Early discontinuation of antiviral therapy is common. Use of growth factors was the strongest independent predictor of treatment retention before 24 weeks and should be evaluated prospectively. Early interventions may also be warranted for other risk factors for early discontinuation, such as pre-existing substance use, depression, cirrhosis, or diabetes.