1.
6.11.2019 1
Anticoagulation management in Siun sote region:
Modeling travel and time costs of warfarin therapy and
optimizing least-cost market areas for alternative
medication
Aapeli Leminen | Mikko Pyykönen
Department of Geographical and Historical Studies
Geospatial Health Research Group
University of Eastern Finland, Joensuu
6.11.2019 IMPRO Work Package 4 // Efficient Allocation of Health and Social Care Service Delivery 1
Paikkatieto sote-uudistuksen tukena –seminaari
Helsinki, October 8, 2019

2.
Atrial Fibrillation (AF) and Anticoagulation Management
6.11.2019 IMPRO Work Package 4 2
♦ Warfarin has been the primary recommended anticoagulant drug for
reducing the risk of stroke, but for safety reasons the dosage must be
monitored regularly
♦ This INR (international normalized ratio) monitoring is a major burden for
patients, as they must travel to a laboratory for blood tests
 In Finland an average of 15 trips per year
♦ Warfarin could be replaced with direct
oral anticoagulants (DOAC), which are
more expensive but do not require INR
monitoring
Irregular and rapid heart rate that increases the risk of
stroke, heart failure and other heart-related complications

3.
6.11.2019 3
Study 1:
Modeling patients’ time, travel and monitoring costs
in anticoagulation management: societal cost
comparison of two medications
6.11.2019 aapeli.leminen@uef.fi 3
A. Leminen, M. Pyykönen, J. Tynkkynen, M. Tykkyläinen & T. Laatikainen,
Modeling patients' time, travel, and monitoring costs in anticoagulation
management: societal savings achievable with the shift from warfarin to
direct oral anticoagulants. [submitted article]

4.
6.11.2019 aapeli.leminen@uef.fi 4
Time and travel costs associated with receiving health care services are
often ignored in economic assessments, even though they are critical to
both society and patients
Illness which requires regular monitoring
- Type 2 diabetes
- Atrial fibrillation
+ Others

5.
1) We measured time, travel and monitoring costs of warfarin therapy
in Siun sote healthcare district in 2017
2) We compared the societal total cost of this patient group to the
situation, in which most of these patients would have used DOACs
 In short: which costs more?
DOAC therapy (high drug price)
Warfarin therapy (low drug price, but
substantial monitoring, travel and time costs)
6.11.2019 aapeli.leminen@uef.fi 5
Aims of the Study
The effectiveness of both therapies
was assumed to be equally good,
and only the costs were compared
What was done?

6.
Data in Siun Sote Area
6.11.2019 aapeli.leminen@uef.fi 6
Patient register data (Mediatri) GIS data
AF patients at the end of 2016 (n=6,594)  Patient locations (n=6,519)
- Gender and age Laboratory locations
- Home address Digital road network (Esri STK)
- Diagnoses and laboratory results Zip code area income data (Paavo)
- Prescriptions
- Health care visits (location, number, type)
Etc.
Geocoding of addresses
using Digitransit geocoding
API in QGIS-software
4,550 using warfarin
1,250 using DOAC
700 without medication
Data for
2017

7.
6.11.2019 aapeli.leminen@uef.fi 7
Laboratory
Locations
(Destination)
Patient
Locations
(Origin)
Travel Modes
OD Cost Matrix
Travel Distance
Travel Time
Network Analysis
♦ Origin-Destination (OD) Cost Matrix in
ArcGIS Pro
 Travel time and distance between
patient home addresses and
laboratories based on the fastest
routes along road network
 Revealed spatial accessibility

8.
Cost Model
6.11.2019 aapeli.leminen@uef.fi 8
Travel Distance
Travel Time
Zip Code Area
Income Data
Medication
Costs
INR
Monitoring
Costs
Number of
Annual INR
Measurements
Cost Model
Direct Travel
Costs
Travel Time
Costs
Direct Anticoagulation
Management Costs
Anticoagulation
Management
Time Costs
♦ Microsoft Excel based model
where travel distance and
travel time are converted as
monetary costs
♦ Time is valued based on
hourly income (100% for
working age patients and
35% for the leisure time of
retired patients)
Total Societal Cost

9.
Results
6.11.2019 aapeli.leminen@uef.fi 9
The Distribution of Costs in Warfarin
Therapy in the Area of Siun Sote
♦ Total societal cost of warfarin therapy was 3.8 mill. EUR in 2017
♦ Time and travel costs constituted over 25 % of these costs
If warfarin would be replaced with DOACs for as many patients as possible:
Drug retail prices Drug wholesale prices
3 % increase
14 % decrease
Total
Societal
Cost (EUR)

10.
Conclusions
1) Patients’ time and travel costs can critically increase the societal cost of
an intervention such as warfarin therapy
♦ In this case, the inclusion of these costs makes DOAC therapy a cost-efficient
alternative to warfarin in the area of Siun sote
2) Revealed spatial accessibility of health care can be measured with GIS
and electronic health records (EHRs)
♦ Useful information for assessing the equity in social welfare and health care
3) In the future, time and travel costs could be included in a wide range of
cost-effectiveness studies
Cooperation possibility for geography and health sciences
6.11.2019 aapeli.leminen@uef.fi 10

11.
6.11.2019 11
Study 2:
A geospatial model to determine the spatial
cost-efficiency of anticoagulation drug
therapy; patients’ perspective
6.11.2019 mikko.pyykonen@uef.fi 11
M. Pyykönen, A. Leminen, J. Tynkkynen, M. Tykkyläinen & T. Laatikainen, A
geospatial model to determine the spatial cost-efficiency of anticoagulation
drug therapy; patients’ perspective. [article submitted and revised]

12.
Costs of Anticoagulant Therapy from Patients’ Perspective
Background:
• Two different therapy options are available for patient:
1) Warfarin therapy:
• Medication, regular monitoring of INR, dose adjustment
2) Direct oral anticoagulant (DOAC) therapy:
• Medication
Research Questions:
1) How to set the least-cost market areas for anticoagulation therapies from patient’s perspective?
2) How cost-efficiency of therapies varies between travel modes and age groups?
6.11.2019 mikko.pyykonen@uef.fi 12
Warfarin therapy DOAC therapy
Out-of-pocket cost of drugs (annual) ~ 25 € 340-370 €
Therapy-related visits in healthcare
(annual)
min=6, mean=15 0
Time and travel costs Yes No
Fixed annual cost, (yearly cost) No, (?) Yes, (~340-370€)

13.
Geospatial Model to Determine Cost-efficiency of Therapies
• Theoretical background:
- Theory of industrial location is applied in model
- Principles of Palander’s market area theory
• Data:
- Cost parameters (time and travel costs by travel modes,
drugs costs)
- Locations of sample collection points
- Digital road network
• Methods & Software:
- Model is built using ArcGIS and Python
- Cost model
- Spatial analyses (Network analysis)
6.11.2019 mikko.pyykonen@uef.fi 13

14.
Market Areas of Therapies
• Market areas can be visualized using the output of network
analysis
- Model produces market areas at the level of healthcare district
• Map shows primarily market areas for warfarin therapy by
travel modes
 The least-cost market area for DOAC therapy is located outside
of particular market area of warfarin therapy
6.11.2019 mikko.pyykonen@uef.fi 14
Market areas of warfarin therapy by car,
walk, and taxi (freq=15):
Considered in Network Analyses:
 Travel cost is the combination of time and vehicle
operating cost
 Speed limits of road network
 Travel delays (intersections, traffic lights)

15.
Cutoff Distances of Market Areas
• Figure shows potential travelling distances to INR monitoring
when the total cost of warfarin therapy is equal to the cost of
DOAC therapy in the annual-level
6.11.2019 mikko.pyykonen@uef.fi 15
0
4
8
12
16
20
24
28
6 9 12 15 18 21 24 27 30
CUTOFFDISTANCE(km)
ANNUAL INR MONITORING FREQUENCY
FOR RETIREES
0
4
8
12
16
20
24
28
6 9 12 15 18 21 24 27 30
CUTOFFDISTANCE(km)
ANNUAL INR MONITORING FREQUENCY
FOR WORKING PERSONS
AV.INRMON.AV.INRMON.
For Retirees:
- Car, walk or public transport cost-efficient travel mode in many cases
 DOAC therapy is the least-cost option further for sample collection points
- Travelling by taxi is cost-efficient from short distances and < 20 times
per year
 If patient has > 20 visit, the total cost of DOAC is lower despite patient’s
location
For Working Persons:
- The longest cutoff distance is reached by car (~11 km, freq= 15)
- Taxi or public transport isn’t cost-efficient from anywhere if patient has
>16 visits by taxi or >18 visit by public transport

16.
Sensitivity Analyses
• The cost of DOAC therapy will drop down when generics
come onto markets
- In sensitivity analysis, the cost of DOACs have reduced 25 %
• For Retirees:
- Car, walk, and public transport are still cost-efficient travel modes in
most urban areas
- Regular use of taxi is not cost-efficient anymore
• For Working Persons:
- DOAC therapy will be more affordable than warfarin therapy by taxi
- If patient visits 15 times at INR monitoring, the cutoff distance is 7 km
by car, 5 km by public transport and 2 km by walking
6.11.2019 mikko.pyykonen@uef.fi 16
0
4
8
12
16
20
24
28
6 9 12 15 18 21 24 27 30
CUTOFFDISTANCE(km)
ANNUAL INR MONITORING FREQUENCY
FOR RETIREES
0
4
8
12
16
20
24
28
6 9 12 15 18 21 24 27 30
CUTOFFDISTANCE(km)
ANNUAL INR MONITORING FREQUENCY
FOR WORKING PERSONS
AV.INRMON.AV.INRMON.

17.
Conclusion
Evaluation of the Cost-efficiency of Anticoagulant Therapies:
• Geospatial model shows the spatial distribution of the anticoagulant therapies
- Market areas and cutoff distances bring out differences in the cost-efficiency
• The least-cost therapy should be estimated individually for patients
- Total costs of warfarin therapy varies within patients
 INR monitoring frequency, travel mode, travel path (Home-INR-Home or Home-INR-Work)
Further development:
• Web application to calculate personalized therapy costs for patient
- More accurate way to estimate the least-cost therapy
6.11.2019 mikko.pyykonen@uef.fi 17

18.
6.11.2019 18
Thank you!
IMPRO Work Package 4 // Efficient Allocation of Health and Social Care Service Delivery