Episode 1.36 Sub Download
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Recordings between all musicians are done via a live stream, and are available to the composer for download within 24 hours. However, I do have to wonder just how the startup is dealing with the dreaded latencey issue. I've participated, or tried to participate, in more than a few zoom-based jams, and the lack of, "we're all feeling the same beat here" has killed more sessions than I'd care to mention.
Administrative healthcare data collected over the period of April 1st 1997 to March 31st 2014 were analyzed to determine the healthcare system burden of HZ using direct medical costs. Episodes of HZ were identified using international classification of disease (ICD) codes. Trends in age-adjusted (AA) HZ-rates were analyzed by piecewise-regression. Total annual and per-episode costs were determined for drug treatment, medical care, and hospitalizations within each year.
The incidence of HZ increased by 49.5% from 1997/98 to 2013/14. Piecewise-regression of AA-rates revealed a steady AA-rate of 4.7 episodes/1000 person-years (PY) from 1997/98 to a breakpoint in 2008/09, after which rates began to increase reaching 5.7 episodes/1000 PY in 2013/14.
The large increase in incidence of HZ, with rising per episode medical and prescription costs were offset by dramatic drops in hospitalization rates, the net effect of which has been to hold the total costs relatively constant. However, the decrease in hospitalization rates slowed over the last half of the study, settling at 1.3% in the last 4 study years. The likely future of HZ burden is one of rising costs, primarily driven by the demographic shifts of an increasing and aging population.
Multiple episodes of HZ were allowed provided two conditions were met: 1) a minimum of 2 years had elapsed since the start, and 2) a minimum of 180 days had elapsed since the last HZ ICD code of the preceding episode. To avoid misclassification of prevalent episodes, episodes with start dates prior to April 1st 1997 were discarded. Episodes in individuals under 20 years of age were excluded from the analysis to avoid misclassification of potentially miscoded VZ cases. Furthermore, to avoid misclassification of physician visits regarding HZ vaccine as episodes, the MIMS database was searched for HZ vaccination records. As MIMS does not capture all HZ vaccinations we also used DPIN to search for vaccine prescriptions, and medical claims to find vaccination tariff codes, using these as surrogate markers of vaccination. Any HZ episode starting within 30 days of vaccination was excluded.
Pharmacotherapy was assessed using DPIN. Prescriptions for acyclovir, valacyclovir, and famciclovir dispensed in the first 30 days of an episode were classified as HZ antiviral treatment. DPIN was searched by Anatomical Therapeutic Chemical (ATC) class. Prescriptions for nabilone (ATC class A04AD), local anesthetics (D04A), systemic corticosteroids (H02A), NSAIDS (M01), opioids (N02A), ASA, acetaminophen (N02B), anticonvulsants (N03A), and antidepressants (N06A) were categorized as HZ pain prescriptions, provided that several conditions were met: 1) treatment of pain with any drug class began within 90 days following diagnosis; 2) use of a drug class was incident to diagnosis; and 3) use after the later of 90 days post-diagnosis and date of last ICD code for HZ was continuous. Use within a drug class was considered incident if less than 30 of the 90 days pre-diagnosis had prescription coverage from that class. Continuous use was defined as the ongoing dispensing of prescriptions of the above-named ATC classes, with no gaps between consecutive prescriptions greater than 200% of the duration of the earlier prescription.
HZ episodes were further stratified into two subcategories based on PHN status: HZ episodes with no diagnosis of PHN (HZ-only), and HZ episodes that converted to PHN (HZ-PHN). Costs were analyzed across all HZ episodes, and then within each stratum separately. The Manitoba Pharmacare fiscal year (April 1st to March 31st) was used for analysis over time. All costs and events were considered to have been incurred in the fiscal year of diagnosis.
Due to observation time required, two separate reporting periods are used. Epidemiology is reported from 1997/98-2013/14, as only a single observation is required to diagnose HZ, and no follow-up time is required. For burden analysis, two years of observable time is required to capture costs accruing over episodes, especially for HZ-PHN. Therefore, to capture all costs associated with each episode and allow for equal follow-up time we only report burden results of episodes initially diagnosed before the end of the 2011/12 fiscal year.
The number of episodes and incidence rate of HZ, and PHN conversion rates were calculated for each study year. We calculated annual incidence rates (per thousand person years) using population counts from the Manitoba Health registry for that particular year. The annual age-adjusted incidence rate was then determined by calculating age group-specific rates, and using them to directly standardize the overall incidence rate, with the 1997 Manitoba age-distribution as our reference structure. A segmented regression analysis was conducted to examine an apparent change in incidence of HZ. Ordinary least squares (OLS) regression analysis was used for trend analysis of costs and utilization. Due to non-linearity and high variance a t-test was used to compare annual hospital costs over the first (1997/98-2003/04) and last (2004/05-2011/12) halves of the study period.
A total of 73,886 episodes of HZ were diagnosed between 1997/98 and 2013/14, an overall crude incidence rate of 4.99 cases/1000 person-years (PY). As we have previously reported [33], a sustained upward trend in the annual numbers of HZ episodes was observed across the study period (Table 1). There were 5,746 episodes of HZ identified in 2013/14, a 49.5% increase from 1997/98.
Overall Burden of Herpes Zoster: 1997/98 to 2011/12. The total economic and epidemiologic burden of herpes zoster was determined for the period from 1997/98 to 2011/12 and are shown in the above figure. The inner circle shows the number of episodes broken down by post-herpetic neuralgia (PHN) status, with the orange portion representing episodes in which it occurred, while the outer ring breaks down the total costs in 2013 Canadian dollars. While PHN accounted for less than 10% of all episodes, it was responsible for 35% of total costs
There were 4984 diagnosed episodes of HZ in 2011/12, an incidence of 5.3 episodes/1000 PY. Of these, 497 went on to develop PHN, a conversion rate of 10.0%. Hospitalization accounted for 49% of total cost, medical services for 20%, and prescription drug costs for 32%. Although PHN occurred in only a tenth of all episodes, they were responsible for 41.6% of hospital costs, 21.3% of medical cost, and 49.7% of drug costs. Overall, HZ-PHN episodes accounted for 38.5% of total HZ-related costs.
The mean cost of an episode of HZ in 2011/12 was $401 (95% CI: $318, $484). The mean cost for HZ that converted to PHN (HZ-PHN), including the cost of treating PHN, was $1614 (95% CI: $1009, $2220). HZ episodes not associated with PHN (HZ-only) had a mean cost of $266 (95% CI: $204, $329), 16.5% of HZ-PHN episodes.
The mean cost of treating an episode of HZ with prescription drugs in 2011/12 was $127.34. Of this, 52.5% was from the treatment of pain with a mean cost of $66.81 (95% CI: $56.84, $76.78), the remainder arising from antiviral treatment at a mean of $60.53 (95% CI: $60.43, 59.92). For HZ-PHN episodes the mean drug cost was $635 (95% CI: $547, $723) with pain treatment accounting for 89% of this cost at $566/episode (95% CI: $478, $655). HZ-only episodes had a mean drug cost of $71.12 (95% CI: $69.18, $73.05), over 83% of which was due to antiviral prescriptions treatment.
The average HZ episode in 2011/12 resulted in 2.80 (95% CI: 2.67, 2.93) medical claims for a mean cost of $78.84 (95% CI: $74.08, $83.61). The average HZ-PHN episodes resulted in 5.57 claims (95% CI: 4.86, 6.29) with a mean cost of $168.30 (95% CI: $128.79, $207.81), while the average HZ- only episodes resulted in 2.49 claims (95% CI: 2.38, 2.60) with a mean cost of $68.93 (95% CI: $66.08, $71.79).
HZ-related hospitalization was uncommon, and occurred in 1.36% of episodes in 2011/12 with a mean cost per stay of $14,258/hospitalization (95% CI: $9,461, $19,056). HZ-PHN episodes were more frequently hospitalized at a rate of 5.0%, whereas HZ-only episodes had a hospitalization rate of 1.0%. There was no significant difference in the cost per hospitalization between HZ-PHN and HZ-only episodes so these results were combined. The cost of hospitalization averaged across all HZ episodes was $194.54 (95% CI: $115.90, $273.17).
This study explored the burden of HZ in terms of healthcare system costs. A significant increase in the incidence of HZ, independent of demographic shifts in the population, was found to begin in 2009/10. The medical cost per episode increased, as did total annual costs. There was an increase in the per episode cost of drug treatment over the first 3 years of study period, after which costs stabilized and remained relatively constant. The combination of these trends in per episode costs arising from medical care and drug treatment were multiplied by the increase in the annual incidence of HZ, causing total outpatient costs to increase. However, this increase was offset by the dramatic drop in rates of hospitalization and the resulting decrease in hospital costs. 2b1af7f3a8