Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality

Houston, TX, United States

Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality

Houston, TX, United States
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Balentine C.J.,University of Wisconsin - Madison | Richardson P.A.,Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality | Mason M.C.,Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality | Mason M.C.,Baylor College of Medicine | And 6 more authors.
Annals of Surgery | Year: 2017

Objective: To determine whether postacute care (PAC) facilities can compensate for increased mortality stemming from a complicated postoperative recovery (complications or deconditioning). Background: An increasing number of patients having cancer surgery rely on PAC facilities including skilled nursing and rehabilitation centers to help them recover from postoperative complications and the physical demands of surgery. It is currently unclear whether PAC can successfully compensate for the adverse consequences of a complicated postoperative recovery. Methods: We combined data from the Veterans Affairs Cancer Registry with the Surgical Quality Improvement Program to identify veterans having surgery for stage I-III colorectal cancer from 1999 to 2010. We used propensity matching to control for comorbidity, functional status, postoperative complications, and stage. Results: We evaluated 10,583 veterans having colorectal cancer surgery, and 765 veterans (7%) were discharged to PAC facilities whereas 9818 veterans (93%) were discharged home. Five-year overall survival after discharge to PAC facilities was 36% compared with 51% after discharge home. Stage I patients discharged to PAC facilities had similar survival (45%) as stage III patients who were discharged home (44%). Patients discharged to PAC facilities had worse survival in the first year after surgery (hazard ratio 2.0, 95% confidence interval 1.7-2.4) and after the first year (hazard ratio 1.4, 95% confidence interval 1.2-1.5). Conclusions: Discharge to PAC facilities after cancer surgery is not sufficient to overcome the adverse survival effects of a complicated postoperative recovery. Improvement of perioperative care outside the acute hospital setting and development of better postoperative recovery programs for cancer patients are needed to enhance survival after surgery. © Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.


Chhatwal J.,University of Houston | Kanwal F.,Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality | Roberts M.S.,University of Pittsburgh | Dunn M.A.,University of Pittsburgh
Annals of Internal Medicine | Year: 2015

Background: Sofosbuvir and ledipasvir, which have recently been approved for treatment of chronic hepatitis C virus (HCV) infection, are more efficacious and safer than the old standard of care (oSOC) but are substantially more expensive. Whether and in which patients their improved efficacy justifies their increased cost is unclear. Objective: To evaluate the cost-effectiveness and budget impact of sofosbuvir and ledipasvir. Design: Microsimulation model of the natural history of HCV infection. Data Sources: Published literature. Target Population: Treatment-naive and treatment-experienced HCV population defined on the basis of HCV genotype, age, and fibrosis distribution in the United States. Time Horizon: Lifetime. Perspective: Third-party payer. Intervention: Simulation of sofosbuvir-ledipasvir compared with the oSOC (interferon-based therapies). Outcome Measures: Quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and 5-year spending on antiviral drugs. Results of Base-Case Analysis: Sofosbuvir-based therapies added 0.56 QALY relative to the oSOC at an ICER of $55 400 per additional QALY. The ICERs ranged from $9700 to $284 300 per QALY depending on the patient's status with respect to treatment history, HCV genotype, and presence of cirrhosis. At a willingness-to-pay threshold of $100 000 per QALY, sofosbuvirbased therapies were cost-effective in 83% of treatment-naive and 81% of treatment-experienced patients. Compared with the oSOC, treating eligible HCV-infected persons in the United States with the new drugs would cost an additional $65 billion in the next 5 years, whereas the resulting cost offsets would be $16 billion. Results of Sensitivity Analysis: Results were sensitive to drug price, drug efficacy, and quality of life after successful treatment. Limitation: Data on real-world effectiveness of new antivirals are lacking. Conclusion: Treatment of HCV is cost-effective in most patients, but additional resources and value-based patient prioritization are needed to manage patients with HCV. © 2015 American College of Physicians.

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