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6.11.2019 1
Anticoagulation management in Siun sote region:
Modeling travel and time costs of warfarin therapy and
optimiz...
Atrial Fibrillation (AF) and Anticoagulation Management
6.11.2019 IMPRO Work Package 4 2
♦ Warfarin has been the primary r...
6.11.2019 3
Study 1:
Modeling patients’ time, travel and monitoring costs
in anticoagulation management: societal cost
com...
6.11.2019 aapeli.leminen@uef.fi 4
Time and travel costs associated with receiving health care services are
often ignored i...
1) We measured time, travel and monitoring costs of warfarin therapy
in Siun sote healthcare district in 2017
2) We compar...
Data in Siun Sote Area
6.11.2019 aapeli.leminen@uef.fi 6
Patient register data (Mediatri) GIS data
AF patients at the end ...
6.11.2019 aapeli.leminen@uef.fi 7
Laboratory
Locations
(Destination)
Patient
Locations
(Origin)
Travel Modes
OD Cost Matri...
Cost Model
6.11.2019 aapeli.leminen@uef.fi 8
Travel Distance
Travel Time
Zip Code Area
Income Data
Medication
Costs
INR
Mo...
Results
6.11.2019 aapeli.leminen@uef.fi 9
The Distribution of Costs in Warfarin
Therapy in the Area of Siun Sote
♦ Total s...
Conclusions
1) Patients’ time and travel costs can critically increase the societal cost of
an intervention such as warfar...
6.11.2019 11
Study 2:
A geospatial model to determine the spatial
cost-efficiency of anticoagulation drug
therapy; patient...
Costs of Anticoagulant Therapy from Patients’ Perspective
Background:
• Two different therapy options are available for pa...
Geospatial Model to Determine Cost-efficiency of Therapies
• Theoretical background:
- Theory of industrial location is ap...
Market Areas of Therapies
• Market areas can be visualized using the output of network
analysis
- Model produces market ar...
Cutoff Distances of Market Areas
• Figure shows potential travelling distances to INR monitoring
when the total cost of wa...
Sensitivity Analyses
• The cost of DOAC therapy will drop down when generics
come onto markets
- In sensitivity analysis, ...
Conclusion
Evaluation of the Cost-efficiency of Anticoagulant Therapies:
• Geospatial model shows the spatial distribution...
6.11.2019 18
Thank you!
IMPRO Work Package 4 // Efficient Allocation of Health and Social Care Service Delivery
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Anticoagulation management in siun sote region modeling travel and time costs of warfarin therapy and optimizing least-cost market areas for alternative medication

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IMPROn järjestämässä Paikkatieto sote-uudistuksen tukena seminaarissa 8.10.2019 Itä-Suomen yliopiston Mikko Pyykönen ja Aapeli Leminen esittelivät paikkatiedon hyödyntämistä hoidon ja lääkityksen kustannustehokkuuden näkökumasta.

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Anticoagulation management in siun sote region modeling travel and time costs of warfarin therapy and optimizing least-cost market areas for alternative medication

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 18. 6.11.2019 18 Thank you! IMPRO Work Package 4 // Efficient Allocation of Health and Social Care Service Delivery

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