Understanding the costs of asthma: the next step.
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Adult↗
Biomedical subjects
S D Sullivan
Publications and source records attributed to S D Sullivan.
Home care reimbursement for intravenous ganciclovir therapy.
Variability in reimbursement for home i.v. ganciclovir therapy among three types of payers was investigated. A survey was developed to estimate reimbursement for drug and medical supplies and nursing services associated with preparing i.v. ganciclovir and administering it to persons with cytomegalovirus (CMV)-associated retinitis in the home care setting. The questionnaire was mailed to 45 home health care agencies and 11 nursing agencies. Of the 56 surveys mailed, 26 (46%) were returned and considered usable. Of the 26 respondents, 22 were home health care companies, 4 were nursing agencies, 22 served patients covered by managed care or state assistance that reimbursed on a per diem basis, and 9 did not provide care to fee-for-service patients. The mean total daily reimbursement rate (for ganciclovir, supplies, and nursing services) from managed care per diem plans was $137.69 per patient, compared with $129.18 from fee-for-service plans and $72.68 from state assistance per diem plans. The dissimilarity may have been due to geographic variations in reimbursement and different mechanisms of reimbursement. Providers of home i.v. ganciclovir therapy for persons with CMV retinitis received the highest mean total daily reimbursement from managed care per diem plans, followed by fee-for-service plans and state assistance per diem plans.
Antiviral Agents↗
A utility assessment of oral and intravenous ganciclovir for the maintenance treatment of AIDS-related cytomegalovirus retinitis.
The purpose of this study was to determine the magnitude of the difference in patient preference/utility for intravenous (i.v.) ganciclovir compared with oral ganciclovir for maintenance treatment of cytomegalovirus (CMV) retinitis. We used a cross-sectional, interviewer-administered time trade-off (TTO) exercise with hypothetical health state descriptions, based upon data from clinical trials and the published literature. The study was conducted in a private clinic in Sydney Australia, specialising in the care of people with HIV. A total of 80 individuals with HIV infection who had not developed AIDS were administered the TTO instrument. The main outcome measure was the difference between each respondent's utility score for oral and i.v. ganciclovir maintenance therapy. When the 80 HIV-positive patients were presented with information on drug efficacy, adverse effects and mode of administration, 60 (75%) preferred oral ganciclovir, 4 patients preferred i.v. ganciclovir, and 16 were indifferent. The median utilities were 0.837 (oral ganciclovir) and 0.475 (i.v. ganciclovir). The difference in rankings was statistically significant by Wilcoxon's signed-ranks test (Z = -6.69, p < 0.00005). The median utility scores suggest that, all other things being equal, individuals with HIV infection would prefer an oral formulation of ganciclovir to i.v. administration in the event of CMV retinitis infection.
Acquired Immunodeficiency Syndrome↗
Accuracy of technicians and pharmacists in identifying dispensing errors.
The accuracies with which pharmacists and technicians checked medications in a unit dose distribution system were compared. The study was conducted at three large hospitals in Washington State. From August through October 1991, technicians filled unit dose medication drawers and pharmacists verified the accuracy of each fill (pharmacist verification period). From November 1991 through January 1992, technicians who had undergone special training verified the accuracy with which medication drawers were filled by other technicians (technician verification period). For each study period, two error rates were estimated: the frequency with which the pharmacists or technicians identified dispensing errors and the frequency of verification errors identified by the investigators in a final independent check. A total of 143,952 unit doses were dispensed during the pharmacist verification period, of which 49,718 were randomly analyzed for accuracy. A total of 151,721 doses were dispensed during the technician intervention period, of which 55,470 were assessed. The mean +/- S.E. daily rates of dispensing-error identification by pharmacists (0.0125 +/- 0.0069%) and technicians (0.0119 +/- 0.0001) did not differ significantly. While pharmacists overlooked more errors (107) than technicians (50), the percentage of such missed errors classified as potentially serious did not differ significantly between the groups (25.2% versus 32.0%, respectively). Pharmacy technicians who underwent special training were able to verify medications in a unit dose distribution system without compromising the accuracy of dispensing.
Education, Pharmacy↗
Firm behavior in the U.S. market for factor VIII: a need for policy?
In this paper, we historically examine the market for Factor VIII concentrate, a collection of blood products used in the treatment of hemophilia A. With the introduction of HIV-1 into the U.S. blood supply, a majority of American hemophiliacs became infected with the virus. In response to contamination, the pharmaceutical manufacturers producing Factor VIII concentrate developed highly purified products which were introduced in the late 1980s at four to five times the price of the older, intermediate purity products. These new products are highly valuable in protecting the 30% of hemophiliacs who are HIV-1 seronegative; however, for those individuals previously infected by the virus, the extra benefit of the more costly products was questionable at the time they were first introduced. We postulate that there has been some level of industry coordination among the producers of Factor VIII concentrates to supply only the more expensive, highly purified products even though there appeared to be significant demand for the intermediate purity products by HIV-1 infected hemophiliacs. We develop and present a model that is useful for testing an inter-product collusion hypothesis. Further, we hypothetically discuss the model's implications and develop some public health policy options that might improve the competitive performance of the market.
Cost Control↗
Professional organizations and healthcare industry support: ethical conflict?
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Advertising↗
The hospital response to Medicare's Prospective Payment System: an econometric model of Blue Cross and Blue Shield plans.
This paper presents an empirical analysis of the impact that resulted from phase-in of Medicare's Prospective Payment System (PPS) on hospital utilization and payments for the Blue Cross and Blue Shield (BCBS) plans. A pooled cross-sectional time series econometric model was specified and estimated using quarterly hospital utilization and payments of the BCBS plans over the period 1980 to 1987. The results indicate that the implementation of PPS was significantly associated with a lower rate of hospital admissions, days and deflated inpatient payments for the BCBS plan members under age 65. A 1% increase in the proportion of hospital days reimbursed under PPS resulted in a .032% decrease in BCBS plan admissions per 1,000 members, a 0.017% decline in days per 1,000 members and a 0.016% decline in deflated inpatient payment per 1,000 members. The reductions in hospital utilization resulted in lower payments by BCBS plans to participating hospitals suggesting a positive spill-over effect of PPS for private insurers. This research underscores the importance of interaction between federal health policy and the private health insurance market.
Blue Cross Blue Shield Insurance Plans↗
Socio-economic burden of asthma, allergy, and other atopic illnesses.
Asthma and atopic illness account for a substantial burden of social morbidity. The purpose of this brief report will be to provide an overview of the different dimensions to the socio-economic burden of asthma and other atopic diseases and suggest areas where future research in this area may advance our understanding of the impact of various treatment strategies of these diseases. While there are occasional studies which describe the full dimensions of this social and economic burden, more studies are needed to complete our understanding of this burden especially studies that investigate the relative cost-effectiveness of medical and non-medical interventions. These studies will provide the infrastructure to rationally examine the optimal cost-effective strategies for these illnesses. In particular economic studies are needed to examine how best to balance resource expenditures for preventive versus pharmacologic control. Use of health economic methods will provide insights into the most efficient design and implementation of current disease control, with potentially concomitant reductions in costs and social burden for atopic illnesses, including asthma.
Asthma↗
Cost-effectiveness of unenhanced MR imaging vs contrast-enhanced CT of the abdomen or pelvis.
OBJECTIVE: The purpose of this study was to compare the cost of unenhanced MR imaging with that of CT with high- or low-osmolality contrast agents for abdominal or pelvic imaging in patients at risk for nephrotoxic effects induced by contrast material. MATERIALS AND METHODS: Using decision analysis, we evaluated direct medical care costs associated with the use of CT with high- or low-osmolality contrast agents vs MR imaging. We used data from a variety of sources and assumed that the three imaging techniques provide nearly equivalent diagnostic information. The base-case analysis assumed that patients were at low risk (i.e., 2%) for development of nephrotoxic effects. Nephrotoxic effects were defined as increases in the serum level of creatinine of 50% or more above baseline. Our analysis took the perspective of the hospital and used estimated hospital costs, not charges. Sensitivity analyses were performed on risk estimates for development of nephrotoxic effects and for the estimates of medical care costs. RESULTS: For the base case, CT with a high-osmolality contrast agent is the least costly imaging strategy. When the risk of nephrotoxic effects exceeds 5% for high-osmolality contrast agents or 2.6% for low-osmolality contrast agents, then MR imaging is the preferred strategy. The model is relatively insensitive to treatment costs. CONCLUSION: From a hospital's perspective, MR imaging of the abdomen or pelvis is cost minimizing in patients at high risk for nephrotoxic effects induced by contrast agents. Use of low-osmolality contrast agents must reduce the frequency of nephrotoxic effects in high-risk patients by at least 50% to be less costly than MR imaging.
Abdomen↗
Trends in cesarean section use in California, 1983 to 1990.
OBJECTIVE: Our aim was to assess recent trends in cesarean section use in California. STUDY DESIGN: California discharge abstract data on hospital deliveries in 1983 through 1990 (379,759 to 587,508 annual deliveries) were used to analyze time trends by indication, age, race, and payment source. RESULTS: California cesarean section rates increased annually from 21.8% in 1983 to 25.0% in 1987 and then decreased to 22.7% by 1990. Similar patterns were noted for all age and race or ethnicity groups. Primary cesarean section rates increased from 15.2% in 1983 to 17.9% in 1987, then decreased to 16.2% by 1990. Declines in repeat cesarean section rates continued throughout 1983 through 1990, accelerating after 1987. For both primary and repeat cesarean section rates, time trends after mid-1987 were significantly different than those for 1983 to 1987. CONCLUSION: After increasing from 1983 to 1987, California cesarean section rates declined from 1988 to 1990. Existing payment source differences in cesarean section use increased in magnitude from 1983 to 1990, with privately insured women consistently having the highest cesarean section rates.
California↗
Assessing cost-effectiveness in asthma care: building an economic model to study the impact of alternative intervention strategies.
Expenditures for medical care services continue to rise as a proportion of the total Gross Domestic Product (GDP) in most countries. Because a large share of resources are increasingly being spent on medical care services, there is a need to more closely examine the quality, cost and efficiency of all aspects of health care delivery. One method for assessing efficiency is cost-effectiveness analysis. Many of the elements of a basic cost-effectiveness model for asthma care are available, including accepted relevant studies on societal cost-of-illness, accepted health outcomes relevant to good clinical care, and a selection of potential intervention strategies, both for prevention and control. The purpose of this paper is to illustrate how an economic approach to decision-making can be used to assess the potential impact of alternative intervention strategies for asthma care. Two case studies are developed including a new management strategy for the chronic care of stable moderate asthma and a management strategy for the early detection and prevention of childhood asthma. It is proposed that economic modeling of possible intervention strategies can serve as a useful method for determining the potential impact (in terms of cost-effectiveness) of a proposed intervention strategy well in advance of any empiric clinical trials. Analysis such as these may prove valuable in protecting researchers from developing intervention strategies that are clinically efficacious but cost-ineffective and, therefore, are unlikely to be adopted by providers/payers of medical care services for asthmatics.
Asthma↗
The economic costs of asthma: a review and conceptual model.
There is a growing international concern about increasing asthma morbidity. While much is known about asthma morbidity, there are few available data on the economic burden of this condition, particularly in underdeveloped countries. In the absence of data on social costs, it is not possible to develop rational approaches to policies regarding resource allocation to reduce morbidity. The purpose of this article is to provide a review of the available literature on the social costs of illness for asthma. In light of this literature, we propose a conceptual model that links asthma morbidity to the social opportunity costs of the disease. We then delineate a framework, based on the proposed model, that can be used to conceptualise and evaluate the relative impact of alternative asthma intervention strategies. Based upon proposed analyses using this model, we believe that it would be possible to compare how various intervention strategies are likely to affect asthma costs and morbidity, thus providing a means for a more rational approach to healthcare policies regarding societal resource allocation for asthma.
Asthma↗
HMO and PPO growth and hospital utilization and payment: a recursive model.
A recursive model of growth of Blue Cross and Blue Shield Plan Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) membership share is used to analyze total hospital utilization and payments per thousand insured members over an eight year study period, 1980 through 1987. Results indicate a strong, significant relationship between previous year Plan payments and current year growth in HMO membership share. Additional results suggest that Blue Cross and Blue Shield Plans experienced significant reductions in utilization and payments rates resulting from PPO membership share gains and not from HMO membership share gains.
Blue Cross Blue Shield Insurance Plans↗
The impact of Blue Cross and Blue Shield Plan utilization management programs, 1980-1988.
This study evaluates the aggregate and temporal impact seven Blue Cross and Blue Shield Plan utilization management (UM) programs have on hospital utilization and payments over a nine-year period, 1980 through 1988. The impact of these programs is determined using a statistical model that controls for variations in organizational characteristics of 56 Blue Cross and Blue Shield Plans, the health care market of the individual Plan, and several state and federal health care regulations. The statistical results indicate that over the entire period 1980 to 1988, preadmission certification, concurrent review, and denial of payment (as a part of the retrospective review program) programs were associated with lower hospital admissions, and fewer inpatient days and payments per 1,000 members. Mandatory second surgical opinion did not have a statistical impact on hospital utilization and payments. The aggregate reduction in hospital payments for all Blue Cross and Blue Shield Plans with both a preadmission certification and concurrent review program was estimated at $2.55 billion in 1988 dollars. For those Plans conducting preadmission certification, concurrent review, denial of payment, and case management programs in 1988, the total per enrollee reduction of inpatient payments was $52.94.
Blue Cross Blue Shield Insurance Plans↗
Use of a path model to analyze factors that influence hospital pharmacists' salaries.
The direct and indirect effects of eight factors on Texas hospital pharmacists' salaries are described. Data for a path analysis (a method of examining relationships among specific variables while controlling for the effects of other variables) were collected by mail survey during the fall of 1985 from randomly selected hospital pharmacists residing in Texas. A path model was constructed to examine the effects of the following variables on the annual salary earned by full-time pharmacists: position, gender, seniority, academic degree, age, number of hours worked per week, size of hospital, and location of hospital. The relationships among the variables were evaluated using linear regression analysis. Of 1500 questionnaires mailed, 502 usable responses from full-time pharmacists were received. Six factors--gender, position, seniority, size of hospital, academic degree, and number of hours worked per week--had significant direct impact on financial compensation. Pharmacists' position also had an indirect effect on salary through the number of hours worked per week, with managers working more hours than nonmanagers. Position was influenced by seniority, gender, size of hospital, and academic degree. Male pharmacists earned more than their female counterparts. Age and hospital location had no significant influence on annual salary, position, or the number of hours worked per week. Overall, path analysis showed only 11 of 21 relationships among the nine variables to be significant. Seniority, gender, size of hospital, academic degree, position, and number of hours worked per week all had a significant effect on salary.
Data Collection↗
Incidence and cost of steroid side effects after renal transplantation.
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Adrenal Cortex Hormones↗
An economic evaluation of oral compared with intravenous ganciclovir for maintenance treatment of newly diagnosed cytomegalovirus retinitis in AIDS patients.
This prospective, clinical economic study was done to determine the cost impact of oral compared with intravenous (i.v.) ganciclovir for the maintenance treatment of newly diagnosed cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS). Efficacy and safety data were extracted from a trial of oral and i.v. ganciclovir. Medical care utilization and reimbursement data were obtained from the clinical trial, a survey of home care and nursing companies, an 11-member physician panel, and a Medicaid cost database. The primary outcome measures were time to first retinitis progression and associated direct medical care expenditures. Nonmedical costs and quality-of-life benefits were not considered. Based on masked evaluation of retinal photographs, the Kaplan-Meier mean time to first progression was 62 days for i.v. ganciclovir and 57 days for oral ganciclovir (a nonsignificant difference). he expected mean cost of treatment for i.v. ganciclovir was significantly different at $8587.00 compared with $4938.00 for oral treatment. Sensitivity analysis using funduscopically determined mean time to first progression showed similar cost savings. We concluded that oral ganciclovir is a cost-saving alternative to i.v. ganciclovir for the maintenance treatment of AIDS patients with newly diagnosed CMV retinitis. Cost differences are attributable to reduced home care expenditures and lower incidence and costs of treating major adverse events in the oral treatment group.
Acquired Immunodeficiency Syndrome↗
Management strategies for ribavirin-induced hemolytic anemia in the treatment of hepatitis C: clinical and economic implications.
OBJECTIVES: Recently published studies have demonstrated increased efficacy and cost-effectiveness of combination therapy with interferon and alpha-2b/ribavirin compared with interferon-alpha monotherapy in the treatment of chronic hepatitis C (CHC). Combination therapy is associated with a clinically important adverse effect: ribavirin-induced hemolytic anemia (RIHA). The objective of this study was to evaluate the direct health-care costs and management of RIHA during treatment of CHC in a clinical trial setting. METHODS: A systematic literature review was conducted to synthesize information on the incidence and management of RIHA. Decision-analytic techniques were used to estimate the cost of treating RIHA. Uncertainty was evaluated using sensitivity analyses. RESULTS: RIHA, defined as a reduction in hemoglobin to less than 100 g/L, occurs in approximately 7% to 9% of patients treated with combination therapy. The standard of care for management of RIHA is reduction or discontinuation of the ribavirin dosage. We estimated the direct cost of treating clinically significant RIHA to be $170 per patient receiving combination therapy per 48-week treatment course (range $68-$692). The results of the one-way sensitivity analyses ranged from $57 to $317. In comparison, the cost of 48 weeks of combination therapy is $16,459. CONCLUSIONS: The direct cost of treating clinically significant RIHA is 1% ($170/$16,459) of drug treatment costs. Questions remain about the optimal dose of ribavirin and the incidence of RIHA in a real-world population. Despite these uncertainties, this initial evaluation of the direct cost of treating RIHA provides an estimate of the cost and management implications of this clinically important adverse effect.
Anemia, Hemolytic↗