The document summarizes a presentation on opportunities for improving quality, value and population health in pediatric endocrinology through understanding costs and cost-effectiveness. It provides examples of studies analyzing the cost and cost-effectiveness of growth hormone therapy for short stature and different screening strategies for prediabetes and diabetes in children. The results suggest current guidelines may not optimize value and new models of care are needed to improve outcomes and reduce costs.
Delivery of eQIPP through a seven day working physiotherapy service for cardi...NHS Improving Quality
Delivery of eQIPP through a seven day working physiotherapy service for cardio-thoracic surgery patients
South Tees Hospitals NHS Foundation Trust
Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013
More information about this event can be found at
http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx
Quality Lowers Cost: The Cost Effectiveness of a Multicenter Treatment Bundle for Severe Sepsis and Septic Shock By: Lydia Dong MD, MS; Intermountain Healthcare - Intensive Medicine Clinical Programs
Presented at the 11th Annual HSR/ PCOR Conference: Partnering for Better Health: Bringing Utah's Patient Voices to Research 2016
Delivery of eQIPP through a seven day working physiotherapy service for cardi...NHS Improving Quality
Delivery of eQIPP through a seven day working physiotherapy service for cardio-thoracic surgery patients
South Tees Hospitals NHS Foundation Trust
Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013
More information about this event can be found at
http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx
Quality Lowers Cost: The Cost Effectiveness of a Multicenter Treatment Bundle for Severe Sepsis and Septic Shock By: Lydia Dong MD, MS; Intermountain Healthcare - Intensive Medicine Clinical Programs
Presented at the 11th Annual HSR/ PCOR Conference: Partnering for Better Health: Bringing Utah's Patient Voices to Research 2016
DASH - does arthritis self-management help?epicyclops
This lecture was given by Dr Marta Buszewicz, General Practitioner from North London and Senior Lecturer in Community Based Teaching & Research at UCL, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Guidelines - what difference do they make? A Dutch perspectiveepicyclops
This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. His lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Expositor: Juan Ponce -Director FLACSO Ecuador
Seminario Internacional sobre Experiencia exitosas en Nutrición, organizado por el Programa Mundial de Alimentos de las Naciones Unidas (PMA) en Colombia y DSM.
14 y el 15 de mayo de 2015.
Bogotá, Colombia.
The BATH-OUT study is a feasibility randomised controlled trial with nested qualitative interview study. It involves adults aged 65 or over, and their carers, who have been assessed by a social care occupational therapist and referred for an accessible showering facility. We want to investigate the impact of the accessible showering facility on disabled older adults and their carers.
The researchers' long term aim is to evaluate the effect of these adaptations on quality of life, health and wellbeing and functional ability.
American Public Health Association- Annual Meeting 2014 Presentation scherala
Title: Using Quantitative Data to focus Medical Home Facilitation Interventions in the Massachusetts Patient Centered Medical Home Initiative (MA PCMHI)
Personalised medicine holds great promised for both improving patients’ outcomes and enhancing the efficiency of treatment. Medicines paired with diagnostics are the backbone of personalised medicine, presenting new challenges in for health technology assessment. The situation in England, particularly how NICE might respond to this challenge, was the focus of the third networking event co-sponsored by the Association of the British Pharmaceutical Industry association (ABPI) and the British In Vitro Diagnostics Association. At this one-day event, speakers set the stage for discussion by presenting defining the context of this challenge for England.
OHE’s Adrian Towse presented on the economics. He discussed the elements of value of a diagnostics test (see our earlier blog post) and described the context necessary to produce useful assessments and to ensure subsequent use in the marketplace. His topics included issues of evidence generation, incentives for innovation, flexible approaches to access coincident with evidence development, and encouraging uptake and use.
In responding to an Ethiopian library's challenge of providing content to medical students, MSIS technologist Bob Riddle discusses affordable network solutions that were easily deployed.
DASH - does arthritis self-management help?epicyclops
This lecture was given by Dr Marta Buszewicz, General Practitioner from North London and Senior Lecturer in Community Based Teaching & Research at UCL, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Guidelines - what difference do they make? A Dutch perspectiveepicyclops
This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. His lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Expositor: Juan Ponce -Director FLACSO Ecuador
Seminario Internacional sobre Experiencia exitosas en Nutrición, organizado por el Programa Mundial de Alimentos de las Naciones Unidas (PMA) en Colombia y DSM.
14 y el 15 de mayo de 2015.
Bogotá, Colombia.
The BATH-OUT study is a feasibility randomised controlled trial with nested qualitative interview study. It involves adults aged 65 or over, and their carers, who have been assessed by a social care occupational therapist and referred for an accessible showering facility. We want to investigate the impact of the accessible showering facility on disabled older adults and their carers.
The researchers' long term aim is to evaluate the effect of these adaptations on quality of life, health and wellbeing and functional ability.
American Public Health Association- Annual Meeting 2014 Presentation scherala
Title: Using Quantitative Data to focus Medical Home Facilitation Interventions in the Massachusetts Patient Centered Medical Home Initiative (MA PCMHI)
Personalised medicine holds great promised for both improving patients’ outcomes and enhancing the efficiency of treatment. Medicines paired with diagnostics are the backbone of personalised medicine, presenting new challenges in for health technology assessment. The situation in England, particularly how NICE might respond to this challenge, was the focus of the third networking event co-sponsored by the Association of the British Pharmaceutical Industry association (ABPI) and the British In Vitro Diagnostics Association. At this one-day event, speakers set the stage for discussion by presenting defining the context of this challenge for England.
OHE’s Adrian Towse presented on the economics. He discussed the elements of value of a diagnostics test (see our earlier blog post) and described the context necessary to produce useful assessments and to ensure subsequent use in the marketplace. His topics included issues of evidence generation, incentives for innovation, flexible approaches to access coincident with evidence development, and encouraging uptake and use.
In responding to an Ethiopian library's challenge of providing content to medical students, MSIS technologist Bob Riddle discusses affordable network solutions that were easily deployed.
Social Media and Academic Medicine: Dangerous Liaisons?Joyce Lee
Why I think it's important for academic physicians and researchers to have a presence on Social Media. This is a compilation of talks that I have given while on sabbatical in the Bay Area and Grand Rounds at University of Michigan http://joycelee.me/
Noun Project citations: Jerry Wang
Tall boys and short girls: Pursuit of the American Dream Joyce Lee
This is the story of growth hormone prescribing for idiopathic short stature, and its historical counterpart (estrogen treatment for tall girls). Check out http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/archpedi.160.10.1035
These slides are adapted from a talk that I gave this year at the 2013 Cusp Conference, which is a conference about the design of everything. It's about my personal journey from medical doctor to medical "designer" and why we as medical professionals must become design thinkers. I was honored to be presenting at the event and it literally was the most amazing conference I have ever attended in my life! Thank you to Dave Mason and the folks at Multiple. http://joycelee.me
Development of the Gestational Diabetes Registry at CMDHB (New Zealand) using...Koray Atalag
This is the prezo I have at the Australasian Long-Term Conditions Conference in Auckland on 30 Jul 2014. Focus was on prevention and management of long term conditions and use of clinical registries has proven to be effective. This is a pilot project at a large healthcare provider organisation in Auckland (Counties Manukau District Health Board) where we used the full openEHR stack to build web based front end with the OceanEHR backend.
Best Practices for a Data-driven Approach to Test UtilizationViewics
Would you like to learn how data-driven interventions can improve laboratory test utilization in your organization? Would you like to hear about the impact that leading hospitals/health systems and managed care organizations have made through these interventions?
If so, you might be interested in this presentation by utilization management expert Dr. Michael Astion, Medical Director at the Department of Laboratories at Seattle Children’s Hospital and Clinical Professor of Laboratory Medicine at the University of Washington.
In this presentation, Dr. Astion discusses the current state of the misuse of laboratory testing in the United States and some of the interventions that are being implemented to improve it. He covers a number of common areas of unnecessary testing — from pure abuse to tests that could be useful but are ordered inappropriately.
You'll learn about:
• Two areas of laboratory testing where misordering of tests occur frequently
• Three interventions to improve the value of testing for patients
• The role of genetic counselors and other laboratory professionals in improving lab test ordering
• The national endeavor known as PLUGS, the Pediatric Laboratory Utilization Guidance Service
Introduction of the NZ Health IT Plan enables better gout management - Reflections of an early adopter. Presented by Peter Gow, Counties Manukau DHB, at HINZ 2014, 12 November 2014, 11.37am, Plenary Room
Behaviour change techniques targeting diet and physical activity in type 2 di...Health Evidence™
Health Evidence hosted a 60 minute webinar examining the behaviour change techniques (BCTs) and features of dietary and physical activity interventions associated with reducing HbA1c in people with type 2 diabetes. Click here for access to the audio recording for this webinar: https://youtu.be/Fb6_t7_TGxw
Kevin Cradock, PhD student, National University of Ireland, Galway led the session and presented findings from his recent systematic review:
Cradock K, OLaighin G, Finucane F, Gainforth H, Quinlan L, & Ginis K. (2017). Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 18.
Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging. The objective of this study was to identify behaviour change techniques (BCTs) and intervention features of dietary and physical activity interventions for patients with type 2 diabetes that are associated with changes in HbA1c. Thirteen RCTs were identified. Diet and physical activity interventions achieved clinically significant reductions in HbA1c at three and six months, but not at 12 and 24 months. Specific BCTs and intervention features identified may inform more effective structured lifestyle intervention treatment strategies for type 2 diabetes.
Alive pd protocol and descriptive paperGladys Block
Alive-PD is a fully automated tailored diabetes prevention program. This journal article describes its features, and describes the protocol of the randomized controlled trial.
The Value of Targeted Sequencing in Advanced Cancer: DCE to Elicit the Public...Office of Health Economics
This project seeks to elicit the public’s preferences for different features of a genomic test to sequence advanced solid cancer tumours. Understanding the relative preferences for various attributes of targeted testing are useful for determining the value of sequencing approaches, and informing technology adoption decisions. A discrete choice experiment (DCE) survey was designed to assess the preferences of members of the Australian general public for targeted sequencing in advanced cancer. The survey presented respondents with 12 questions in which they had to choose between two unlabelled tests (Test A and Test B). Tests were specified in terms of five attributes: time to receive the test result; cost of the test; likelihood that the test result will lead to a change in treatment; length of time health care professionals spend describing the test; and type of health care team who explains the test result. Respondents were sampled from an online panel and also completed questions related to demographic and socio-economic factors, experiences of cancer and familial history. We found that cost, timeliness, expertise/location and likeliness of changing treatment regimes were identified as attributes of genomic sequencing that are most valuable to a sample of the public. These results will ultimately be compared with the results of an ongoing DCE being conducted with patients with advanced cancer who are undergoing sequencing.
Author(s) and affiliation(s): Paula Lorgelly (OHE), Grace Hampson (OHE), James Buchanan (Oxford), Melissa Martyn (MGHA), Jayesh Desai (PeterMac), Clara Gaff (MGHA), and iPREDICT MGHA Flagship collaborators
Conference/meeting: EuHEA 2018
Location: Maastricht, the Netherlands
Date: 12/07/2018
Medical Doctor as Maker Designer: Participatory Design for HealthcareJoyce Lee
Slides from my Vanderbilt University Tech Talk on June 1, 2015. Video available here: http://mediasite.vanderbilt.edu/Mediasite/Play/36ef6c8ea30049d498201313ea925c711d
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Health Outcomes, Quality, and Cost: Opportunities for Pediatric Endocrinology
1. Joyce Lee, MD, MPH
Associate Professor
Pediatric Endocrinology
Child Health Evaluation and Research Unit
University of Michigan
Twitter: @joyclee
Health Outcomes, Quality, and Cost:
Opportunities for Pediatric
Endocrinology
Paul Kaplowitz Endowed Lectureship for
contributions to quality and cost-effective
care in Pediatric Endocrinology
11. “Intensive therapy effectively delays the onset
and slows the progression of diabetic
retinopathy, nephropathy, and neuropathy in
patients with IDDM”
1983-1993
Diabetes Control and
Complications Trial
13. “If I publish it, it will be done”
There is a translational gap in
Pediatric Endocrinology,
which is why we need the Science
of Health Services Research and
the Science of Health Services
Delivery to achieve the goal of
providing the best possible medical
care for our patients
14. Disclaimer: Measuring costs and cost-
effectiveness are just one aspect of the
science of health services research and
health services delivery
Focus of this talk:
Cost & Cost-effectiveness (CE)
15. Takeaways
Costs/CE affects access to therapies for our
patients
Understanding Costs/CE helps us optimize our
use of health care resources by identifying
which clinical strategies may lead to greater
value for cost
Understanding Costs can help us think about
opportunities for developing new models of care
16. Takeaways
Costs/CE affects access to therapies for our
patients
Understanding Costs/CE helps us optimize our
use of health care resources by identifying
which clinical strategies may lead to greater
value for cost
Understanding Costs can help us think about
opportunities for developing new models of care
17.
18. We built a model based on efficacy results from the
pivotal trial used for the ISS FDA approval &
studies from the literature
Hypothetical cohort of 10 year old boys treated w/
GH compared with an untreated control cohort
5 year duration of tx
GH dosing 0.37 mg/kg/week
5th% weight
30% discontinuation rate in 1st year of tx
Yearly visits with Endo, bone age, TFTs, IGF-1
22. Incremental
Cost per
Child, $
Incremental
Growth per
Child, in
Cost
per
Inch, $
Lower Efficacy (1.8 in)
Higher Efficacy (3.9 in)
99,959
99,959
1.2
2.6
81,875
38,783
Age at initiation ages 8-13y
Age at initiation ages 12-16y
81,268
126,123
1.9
1.9
42,792
66,411
Discontinuation rate, 0%
Discontinuation rate, 40%
137,779
87,352
2.6
1.7
53,531
52,174
Treatment Duration, 7y (Ages 8-15y)
Treatment Duration, 10y (Ages 5-15)
122,513
145,550
2.5
3.2
49,396
45,156
Dosing Regimens
Low-dosage GH (0.24 mg/kg per wk)
Standard-dosage GH (0.37 mg/kg per
wk x 2y followed by high-dosage
GH at puberty (0.7 mg/kg per wk) x
3y
Standard-dosage GH (0.37 mg/kg per
wk) x 1y followed by high-dosage
GH at puberty (0.7 mg/kg per wk) x
4y
65,092
155,440
170,866
1.4
3.1
3.4
45,700
49,821
50,384
Sensitivity Analyses
23. Conclusions
Estimate of $52,000 was substantially higher
than a previous cited cost estimate of $35,000
No alternative GH treatment strategies change
the cost-effectiveness of the therapy
The cost of the drug drives CE
24. Takeaways
Cost and CE affects access to therapies for our
patients
Understanding Costs/CE helps us optimize our
use of health care resources by identifying
which clinical strategies may lead to greater
value for cost
Understanding Costs/CE can help us think
about opportunities for developing new models
of care
25. 2010 ADA guidelines
Prediabetes
HbA1c ≥ 5.7% & <6.5%
Diabetes
HbA1c ≥ 6.5%
2010 ADA Guidelines
The guideline was based exclusively on
data from adults. No pediatric data about
test efficacy/effectiveness or cost-
effectiveness.
26. Study Design: Cross-sectional cohort of 254 children
10-17 years with a BMI ≥ 85th%
2-hour OGTT (Gold standard)
Nonfasting HbA1c
Nonfasting 50 gm 1 hour glucose challenge test
Nonfasting Random glucose
Outcome was Dysglycemia (2-hr Glu≥140) as defined 2-
hour OGTT (Prediabetes n=99, Diabetes n=3)
Receiver Operator Characteristic Curves and
Compared Area Under the Curve
27. 0%
25%
50%
75%
100%
0%
25%
50%
75%
100%
Sensitivity(Truepositive)
1-Specificity (False )
Sensitivity(Truepositive)
1-Specificity (False Positive) *p=0.02
1-hr 50 gm
Glucose Challenge
Test (GCT)
Random Glucose
HbA1c
Test performance of nonfasting glucose
tests of glycemia was better than HbA1c
5.7%
110
100
110
120
6.0%
AUC
Random
Glucose
0.68 (0.61-0.76)*
1 hour
GCT
0.70 (0.62-0.78)*
HbA1c
0.55 (0.47-0.64)
30. Model of a hypothetical cohort of the 2.5
million overweight or obese adolescents 10-19
years of age eligible for screening
Modeled a one-time screening program for
diabetes and dysglycemia from the societal
perspective
31. Screening Strategies Evaluated
2-hour oral glucose tolerance test
Hemoglobin A1c (HbA1c)
Random Glucose
1-hr 50gm Glucose Challenge Test
If positive,
2-hr OGTT
32. Base Case Assumptions
16% prevalence of dysglycemia (n=400,000)
0.02% prevalence of diabetes (n=500)
100% adherence
2-hr OGTT has 100% sensitivity and
specificity
Liese et al, Pediatrics, 2006
Li et al, Diabetes Care, 2009
33. Cost Assumptions
Screening
Strategy
Cost per Screen
($ 2010)*
Patient time
for Testing**
2-hr OGTT
$18.44
135 min
HbA1c
$13.90
15 min
1-hr GCT
$6.80
75 min
Random
Glucose
$5.62
15 min
½ Mean Hourly Wage
(All Occupations)
$10.68/hour
Physician Time
1/5th visit=$20
Direct and Indirect Costs
*Medicare reimbursement rates **Wage data (Bureau of Labor Statistics)
34. Study Outcomes
Proportion of cases (diabetes/dysglycemia)
identified
Total costs (direct & indirect)
Cost per case identified (direct & indirect)
35. Sensitivity Analyses
Alternative estimates of HbA1c test performance
Higher or lower prevalence (±25%)
Differing levels of adherence (75% for nonfasting
and 50% for 2-hr OGTT)
Doubled provider time
Halved HbA1c costs
36. $831,166 (33%)
2 hr OGTT
$312,224 (100%)
HbA1c 5.7%
HbA1c 5.5%
$731,822
(33%)
HbA1c 6.5%
$571,344
(33%)
Cost per Diabetes Case Identified ($)
%ofCasesIdentified
Base Case (100% adherence)
High Effectiveness
Low Cost per case
Low Effectiveness
High Cost Per Case
37. $831,166 (33%)
2 hr OGTT
$312,224 (100%)
HbA1c 5.7%
HbA1c 5.5%
$731,822
(33%)
HbA1c 6.5%
$571,344
(33%)
Cost per Diabetes Case Identified ($)
%ofCasesIdentified
Base Case (100% adherence)
40. Sensitivity Analyses did not change the
Overall Rankings
Alternative estimates of HbA1c test performance
Higher or lower prevalence (±25%)
Differing levels of adherence (75% for nonfasting
and 50% for 2-hr OGTT)
Doubled provider time
Halved HbA1c costs
41. Conclusions/Implications
HbA1c had lower effectiveness and higher costs
Why would we prioritize a screening test that
performs worse and costs more?
A1c is still useful at diagnosis of diabetes, but
random or 1-hour GCT may be more promising
screening tests
Should the ADA change its policy on HbA1c for
children? What should the AAP recommend?
42. Takeaways
Cost and CE affects access to therapies for our
patients
Understanding Costs/CE helps us optimize our
use of health care resources by identifying
which clinical strategies may lead to greater
value for cost
Understanding Costs/CE can help us think
about opportunities for developing new models
of care
43. Most studies of cost in adults, non-US populations,
privately insured kids, so we studied kids covered
under California Children’s Services
Outcomes: We measured health utilization and
costs for 652 children with presumed T1D enrolled
for the period July 1, 2009, to June 30, 2012.
Aged 0-21 years
Continuously enrolled for at least 365 days
Had an outpt visit for T1D in the year
Were taking insulin
45. S/P DKA Episode #3
Flat affect
Lives 2 ½ hours away
3 hour clinic visit
Does not bring meter
HbA1c = 14%
46. Clinical
Effectiveness
Knowledge
Improved
Quality, Value,
& Population
Health
Basic
Biomedical
Science
T1 T2 T3
Dougherty JAMA 2008
Translational Research
Health Services Delivery
• Systems Design
• Quality Improvement Science
• Human-centered Design/
Participatory Design
Health Services Research
• Health Utilization
• Health Outcomes
• Costs/Cost-effectiveness
• Access/Quality
Clinical
Efficacy
Knowledge
47. Design of a Learning Health System
for Type 1 Diabetes
48. Healthcare delivery system as scientific
laboratory
Clinical Care, Research, and Quality
Improvement are no longer separate efforts
but are deliberately designed to be integrated
Research informs practice and practice
informs research
Learning Health System
49. Technology Tools
Focus on Outcomes/Quality Improvement
Collaborative Network
What does a Learning Health System
Consist Of?
58. Technology Tools
Focus on Outcomes/Quality Improvement
Collaborative Network
What does a Learning Health System
Consist Of?
59. Collaborative Network of Patients &
Caregivers, Clinicians, Researchers
Sharing Virtual/In Person
“Stealing Shamelessly & Sharing
Seamlessly”
Resources, QI Interventions, Innovations
One Patient è Many Patients
One Provider è Many Providers
One Visit è Many Visits
60. Identify her as a high risk patient &
provide clinical support between visits
Depression Screening (QI Intervention)
Diabetes coach (self-management skills)
Peer support (Group Classes)
Diabetes education for millennials
What can a Learning Health System do
for Kayla?
62. Alternative Payment Models (accountable care
organizations (ACOs), bundled payments, and
advanced primary care medical homes)
Currently at 20% of Medicare
Goal of 30% by 2016
Goals of 50% by 2018
63. “Wilkins demonstrated his organized
approach to patient care. Impressed by the
poor care of children with congenital syphilis
and their lack of follow-up care, he started a
dedicated clinic, organized the care, and
obtained a special social worker to develop a
follow-up system.”
64. Health Outcomes, Cost, Quality,
and Learning Health Systems of Care:
Our opportunity to fulfill
Wilkins’ vision of care
for Pediatric Endocrinology!
65. Valerie Castle, MD
Ram Menon, MD
Gary Freed, MD, MPH
Sarah Clark, MPH
Matthew Davis, MD, MAPP
UM Pediatric Endocrinology
Twitter: @joyclee
Email: joyclee@med.umich.edu
http://www.doctorasdesigner.com/
Acknowledgements
Emily Hirschfeld
Ashley Garrity
Nayla Kazzi
En-Ling Wu
Beth Tarini
Esther Yoon
Jim Gurney
Acham Gebremariam