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PubMed1999

Screening for breast cancer: time, travel, and out-of-pocket expenses.

BACKGROUND: We estimated the personal costs to women found to have a breast problem (either breast cancer or benign breast disease) in terms of time spent, miles traveled, and cash payments made for detection, diagnosis, initial treatment, and follow-up. METHODS: We analyzed data from personal interviews with 465 women from four communities in Florida. These women were randomly selected from those with a recent breast biopsy (within 6-8 months) that indicated either breast cancer (208 women) or benign breast disease (257 women). One community was the site of a multifaceted intervention to promote breast screening, and the other three communities were comparison sites for evaluation of that intervention. All P values are two-sided. RESULTS: In comparison with time spent and travel distance for women with benign breast disease (13 hours away from home and 56 miles traveled), time spent and travel distance were statistically significantly higher (P<.001) for treatment and follow-up of women with breast cancer (89 hours and 369 miles). Personal financial costs for treatment of women with breast cancer were also statistically significantly higher (breast cancer = $604; benign breast disease = $76; P < .001) but were statistically significantly lower for detection and diagnosis (breast cancer = $170; benign breast disease = $310; P < .001). Among women with breast cancer, time spent for treatment was statistically significantly lower (P = .013) when their breast cancer was detected by screening (68.9 hours) than when it was detected because of symptoms (84.2 hours). Personal cash payments for detection, diagnosis, and treatment were statistically significantly lower among women whose breast problems were detected by screening than among women whose breast problems were detected because of symptoms (screening detected = $453; symptom detected = $749; P = .045). CONCLUSION: There are substantial personal costs for women who are found to have a breast problem, whether the costs are associated with problems identified through screening or because of symptoms.

Aged↗
PubMed2006

Retrospective cost-effectiveness analysis of screening mammography.

BACKGROUND: Many guidelines recommend screening mammography every 1-2 years for women older than 40 years; more than 70% of women now participate in routine screening. No studies have examined the societal impact of screening practices over the past decade in the United States on costs and quality-adjusted life-years (QALYs). We performed a retrospective cost-effectiveness analysis comparing actual and alternative screening mammography scenarios. METHODS: We used a discrete-event simulation model of breast cancer epidemiology to estimate the costs and the number of QALYs that were associated with observed screening mammography patterns in the United States from 1990 to 2000 for women aged 40 years or older. We also estimated costs and QALYS for no screening and for 64 alternative screening scenarios. Incremental cost-effectiveness ratios were computed. Sensitivity analyses were performed on key parameters. RESULTS: Actual U.S. screening patterns from 1990 to 2000 accrued 947.5 million QALYs and cost $166 billion over the lifetimes of the screened women, resulting in a gain of 1.7 million QALYs for an additional cost of $62.5 billion compared with no screening. Among those polices that were not dominated--i.e., for which no alternative existed that produced more QALYs for lower costs--screening all women aged 40-80 years annually per some U.S. guidelines was the most expensive option, costing $58,000 per additional QALY gained compared with the next most costly alternative, screening all women aged 45-80 years annually. Many alternative screening scenarios generated more QALYs for less cost (with savings up to $6 billion) than actual screening patterns over the study period. Sensitivity analysis showed that conclusions about the cost-effectiveness of screening mammography policies were highly sensitive to small, short-term detrimental effects on quality of life from the screening test itself. CONCLUSIONS: Choosing among the efficient policies to guide current screening recommendations requires consideration of costs to promote participation in screening and measurement of acute quality-of-life effects of mammography.

Adult↗
PubMed2006

Cost-utility analysis of short- versus long-course palliative radiotherapy in patients with non-small-cell lung cancer.

BACKGROUND: Radiotherapy can effectively palliate the symptoms of poor-prognosis patients with non-small-cell lung cancer. However, controversy remains about whether short-course or more protracted radiotherapy schedules provide better value for the money. We conducted a societal cost-utility analysis of a Dutch multicenter randomized trial with 1-year follow-up that compared the efficacy of radiotherapy schedules consisting of 10 fractions of 3 Gy (10 x 3 Gy) versus two fractions of 8 Gy (2 x 8 Gy) in 297 patients with inoperable stage IIIA/B or stage IV non-small-cell lung cancer. this trial found that the 10 x 3-Gy group had better survival than the 2 x 8-Gy group. METHODS: Lifetime quality-adjusted life-years (QALYs) were estimated using the EuroQol questionnaire. Lifetime societal costs were estimated using a model estimated based on data from cost questionnaires filled out by a subset of patients (n = 56). Differences were analyzed statistically using two-sided nonparametric bootstrapping. RESULTS: Compared with the 2 x 8-Gy group, the 10 x 3-Gy group accrued statistically significantly more QALYs (20.0 versus 13.2 weeks; difference = 6.8 weeks, 95% confidence interval [CI] = 0.1 to 13.5 weeks, P = .05), which was mainly due to the statistically significantly better survival (38.1 versus 27.4 weeks; difference = 10.7 weeks, 95% CI = 0.9 to 20.6 weeks, P = .03) without a statistically significant difference with respect to the average valuation of health (P = .27). Total radiotherapy and radiotherapy-related costs were estimated at 5236 dollars for the 10 x 3-Gy group and 2512 dollars for the 2 x 8-Gy group (difference = 2724 dollars, 95% CI = 2501 dollars to 2947 dollars, P<.001). The 39% increase in life expectancy in the 10 x 3-Gy group as compared with the 2 x 8-Gy group was associated with a 30% increase in survival-related nonradiotherapy costs (11,254 dollars versus 8651 dollars, difference 2602 dollars, 95% CI = -357 dollars to 5562 dollars, P = .09). The cost-utility ratio for the 10 x 3-Gy schedule versus the 2 x 8-Gy schedule was estimated at 40,900 dollars per QALY (95% CI = 19,400 dollars to 1,100,000 dollars per QALY). CONCLUSIONS: In these poor-prognosis non-small-cell lung cancer patients, the estimated cost-utility ratio for the palliative 10 x 3-Gy schedule was acceptable according to current economic standards. However, the additional costs for the protracted schedule were justified not by improved quality of life but by longer survival.

Adult↗
PubMed2001

Examining the direct costs and effectiveness of syphilis detection by selective screening and partner notification.

Selective screening and partner notification are two principal means of preventing and controlling syphilis in the United States, yet few studies have been undertaken to compare and evaluate the cost or effectiveness of detecting syphilis using either strategy. The objective of this paper is to assess from the perspective of a health department the cost-effectiveness of selective screening compared with the strategy of partner notification in the detection of early syphilis in Houston, Texas, in 1994 and 1995. The cost-effectiveness analysis was performed using the recurring direct costs associated with detecting syphilis by both strategies. The middle estimates for the total direct costs associated with selective screening and partner notification were $579,101 and $229,529, respectively, for the 1466 and the 567 cases of early syphilis detected. On a cost per case basis, selective screening was more cost-effective than partner notification in the detection of primary, secondary and maternal syphilis cases. However, when consideration was given to prophylactic treatment, partner notification was more cost-effective in the detection of all early stage disease. Our findings suggest that the relative benefit of partner notification over selective screening depends on prophylactic treatment and an increase in worker productivity.

Communicable Disease Control↗
PubMed2006

The economic cost of sleep disorders.

STUDY OBJECTIVES: To determine the economic cost of sleep disorders in Australia and relate these to likely costs in similar economies. DESIGN AND SETTING: Analysis of direct and indirect costs for 2004 of sleep disorders and the fractions of other health impacts attributable to sleep disorders, using data derived from national databases (including the Australian Institute of Health and Welfare and the Australian Bureau of Statistics). MEASUREMENTS: Direct health costs of sleep disorders (principally, obstructive sleep apnea, insomnia, and periodic limb movement disorder) and of associated conditions; indirect financial costs of associated work-related accidents, motor vehicle accidents, and other productivity losses; and nonfinancial costs of burden of disease. These were expressed in US dollars (dollar). RESULTS: The overall cost of sleep disorders in Australia in 2004 (population: 20.1 million) was dollar 7494 million. This comprised direct health costs of dollar 146 million for sleep disorders and dollar 313 million for associated conditions, dollar 1956 million for work-related injuries associated with sleep disorders (net of health costs), dollar 808 million for private motor vehicle accidents (net of health costs), dollar 1201 million for other productivity losses, dollar 100 million for the real costs associated with raising alternative taxation revenue, and dollar 2970 million for the net cost of suffering. CONCLUSIONS: The direct and indirect costs of sleep disorders are high. The total financial costs (independent of the cost of suffering) of dollar 4524 million represents 0.8% of Australian gross domestic product. The cost of suffering of dollar 2970 million is 1.4% of the total burden of disease in Australia.

Australia↗
PubMedDate not supplied

The costs of CT procedures in an academic radiology department determined by an activity-based costing (ABC) method.

PURPOSE: The purpose of this work was to determine the costs of computed tomography (CT) procedures in a large academic radiology department, including both professional (PC) and technical (TC) components, by analyzing actual resource consumption using an activity-based costing (ABC) method and comparing them with Medicare payments. METHOD: Over a 12 month period from July 1, 1996, to June 30, 1997, 1,011 CT procedures, representing 16 Physicians' Current Procedural Terminology (CPT) codes and 98.3% of CT studies performed, were carefully observed by a research assistant trained in ABC methodology. Information collected during these time and motion studies included personnel/machine time and direct materials used. Actual resource units used during the different activities in each CT procedure were valued using appropriate cost drivers. Unit values for both direct and overhead costs were calculated: the cost of an individual procedure equaled the sum of component costs. Costs were compared with PC and TC payments according to the 1997 Medicare Fee Schedule. RESULTS: Total costs of CPT codes 70450 (CT Head unenhanced), 71260 (CT Chest enhanced), and 74160 (CT Abdomen enhanced), which represented 71.2% of CT studies performed, were $189.19, $273.53, and $343.20, respectively. For all 16 nonmodified CPT codes analyzed, Medicare's professional reimbursement was less than the professional cost, whereas its technical reimbursement exceeded respective cost in 14 of the 16 codes. CONCLUSION: In the setting and time period studied, Medicare underreimbursed professional costs while overreimbursing technical costs.

Academic Medical Centers↗
PubMed2001

Economic evaluation of aquatic exercise for persons with osteoarthritis.

OBJECTIVES: To estimate cost and outcomes of the Arthritis Foundation aquatic exercise classes from the societal perspective. DESIGN: Randomized trial of 20-week aquatic classes. Cost per quality-adjusted life year (QALY) gained was estimated using trial data. Sample size was based on 80% power to reject the null hypothesis that the cost/QALY gained would not exceed $50,000. SUBJECTS AND METHODS: Recruited 249 adults from Washington State aged 55 to 75 with a doctor-confirmed diagnosis of osteoarthritis to participate in aquatic classes. The Quality of Well-Being Scale (QWB) and Current Health Desirability Rating (CHDR) were used for economic evaluation, supplemented by the arthritis-specific Health Assessment Questionnaire (HAQ), Center for Epidemiologic Studies-Depression Scale (CES-D), and Perceived Quality of Life Scale (PQOL) collected at baseline and postclass. Outcome results applied to life expectancy tables were used to estimate QALYs. Use of health care facilities was assessed from diaries/questionnaires and Medicare reimbursement rates used to estimate costs. Nonparametric bootstrap sampling of costs/QALY ratios established the 95% CI around the estimates. RESULTS: Aquatic exercisers reported equal (QWB) or better (CHDR, HAQ, PQOL) health-related quality of life compared with controls. Outcomes improved with regular class attendance. Costs/QALY gained discounted at 3% were $205,186 using the QWB and $32,643 using the CHRD. CONCLUSION: Aquatic exercise exceeded $50,000 per QALY gained using the community-weighted outcome but fell below this arbitrary budget constraint when using the participant-weighted measure. Confidence intervals around these ratios suggested wide variability of cost effectiveness of aquatic exercise.

Aged↗
PubMed1998

One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Subgroup analysis, recurrence, and additional health care utilization.

STUDY DESIGN: A randomized trial was conducted in which patients with back and neck pain, visiting a general practitioner, were allocated to chiropractic or physiotherapy. OBJECTIVES: To compare outcome and costs of chiropractic and physiotherapy as primary treatment for patients with back and neck pain, with special reference to subgroups, recurrence rate, and additional health care use at follow-up evaluation 12 months after treatment. SUMMARY OF BACKGROUND DATA: Earlier studies on the effect of spinal manipulation have shown inconsistent results. Mostly they include only short-term follow-up periods, and few cost-effectiveness analyses have been made. METHODS: A group of 323 patients aged 18-60 years who had no contraindications to manipulation and who had not been treated within the previous month were included. Outcome measures were changes in Oswestry scores, pain intensity, and general health; recurrence rate; and direct and indirect costs. RESULTS: No differences were detected in health improvement, costs, or recurrence rate between the two groups. According to Oswestry score, chiropractic was more favorable for patients with a current pain episode of less than 1 week (5%) and physiotherapy for patients with a current pain episode of greater than 1 month (6.8%). Nearly 60% of the patients reported two or more recurrences. More patients in the chiropractic group (59%) than in the physiotherapy group (41%) sought additional health care. Costs varied considerably among individuals and subgroups; the direct costs were lower for physiotherapy in a few subgroups. CONCLUSIONS: Effectiveness and costs of chiropractic or physiotherapy as primary treatment were similar for the total population, but some differences were seen according to subgroups. Back problems often recurred, and additional health care was common. Implications of the result are that treatment policy and clinical decision models must consider subgroups and that the problem often is recurrent. Models must be implemented and tested.

Adolescent↗
PubMed2005

Estimating resource use and cost of prophylactic management of neutropenia with filgrastim.

The study objective is to develop a methodology for the measurement of time, resource use and cost of the prophylactic management of neutropenia with filgrastim in different settings where the drug is routinely used: in-hospital care, outpatient care and home care. The activity-based costing method is used to analyse the cost of managing prophylactically neutropenia and comprises four steps. First, department heads in each of the chosen settings were selected and interviewed to obtain key elements in the workflow that involves the management of neutropenia, followed by the second step involving in-depth, structured interviews of key personnel. The third step was the measurement of the time required for frequently occurring activities in monitoring neutropenia and the administration of filgrastim by a study nurse. Finally, information on resource unit costs and personnel salaries were collected from the administration units to calculate an average cost. Sensitivity analyses were undertaken on estimated variables in the study. A list of eight to 14 consecutive activities linked to the prophylactic management of neutropenia was observed. The number and type of activities do not differ between an in-hospital oncology ward and an outpatient setting except for blood samplings. The difference is more pronounced between hospital and home care settings, as in the latter the patient performs many of the activities him/herself. The cost estimate per setting for prophylactic drug use is 6.30 Euros for in-hospital care, 3.67 Euros for outpatient care and 5.49 Euros for home care. Taking the two most frequently occurring scenarios per chemotherapy cycle (i.e. with or without febrile neutropenia), the following cost estimates are obtained: 60.41 Euros for a patient with febrile neutropenia and 56.77 Euros for a patient without febrile neutropenia, excluding drug costs. With the activity-based costing method it is possible to accurately demonstrate cost savings in the management of neutropenia using the newer drug therapies.

Ambulatory Care↗
PubMed2006

Farm-related injury event, social consequences and injury reporting in the Land Lantbruk newspaper in Sweden: a retrospective study of farm-related injury reporting during 2000-2005.

OBJECTIVE: The aim of the present study was to detect how a leading news paper, the Land Lantbruk in Stockholm, Sweden, informs the public and specifically the rural sector in Sweden and the Scandinavian countries concerning injury events (farm-related injury event) and the use of injury prevention and control. Injury reporting in the Land Lantbruk has been studied from the point of injury prevention and control. A study of injury prevention and rural health and safety in Australia shows that the newspaper The Land that serves Australia's rural community should 'be an under-utilised vehicle for news and commentary on rural health and safety issues'. DESIGN: The study period was from January 2000 to February 2005. A total of 178 articles were reviewed and analysed. The articles were available on a newspaper database in the Land Lantbruk newspaper. Articles that addressed farm-related injury event and rural health and safety were chosen and organised into subgroups. RESULTS: Tractor and motor vehicle safety (35%) was most common among the injury reporting. Although the newspaper Land Lantbruk provided excellent coverage of the causes of these events, the reports tended to focus on circumstances and did not provide information on injury prevention or the advantages of also coverage of the social and psychosocial long-term consequences of accidents. CONCLUSION: In the prevention work of reducing farm-related injuries in the rural sector in the Scandinavian countries and decreasing the human suffering represented by this health problem, rural politicians, insurance companies, rural authorities and also handicap organisations should listen more to the injured individuals and their own experiences relative to the difficulty of life after an accident. The reaction of family and relatives, and experiences of the long-term social consequences, have not been included in the media coverage. Journalists at the Land Lantbruk could also share experiences of the Swedish coverage of rural health and safety from Australian journalists from The Land.

Accident Prevention↗
PubMedDate not supplied

The SCOPE study: health-care consumption related to patients with chronic obstructive pulmonary disease in France.

OBJECTIVE: The main objective of the SCOPE study was to estimate the total direct medical costs of patients with treated chronic obstructive pulmonary disease (COPD) in France according to severity stages. METHODS: Total medical resources consumption of a sample of COPD patients was collected over a 12-month period through a national physician survey (including both general practitioners and lung specialists). This survey was completed for 255 patients. Data were then extrapolated to all patients with diagnosed and treated COPD in France. Average total medical resources consumption of a COPD patient per year was 4366 euros. Among this cost 41% was directly related to COPD follow-up, 25% to COPD-related complications (mainly exacerbations), and 34% to other diseases. More than one-third of the total direct COPD cost was related to hospitalizations and 31% to drug consumption. COPD-related costs increased markedly with severity based on FEV1 (but data suggested the existence of a threshold effect). SCOPE data did not show any evidence of a significant relationship between direct medical cost and patient age, sex, addiction to tobacco, or duration of COPD. The total medical consumption of COPD patients in France was 3.5 billion euros and accounted for 3.5% of the total medical expenditures (prevalence of COPD was estimated 1.3% in the general population). RESULTS: The SCOPE study revealed the high level of medical resources consumption of patients with COPD. CONCLUSIONS: The burden of COPD itself and its complications appeared to be of considerable magnitude in France especially for severe COPD.

Aged↗
PubMedDate not supplied

Health and economic consequences of sevelamer use for hyperphosphatemia in patients on hemodialysis.

OBJECTIVES: The safety and efficacy of sevelamer hydrochloride in binding phosphate in patients with end-stage renal disease and its ability to attenuate the progression of cardiac calcification have been well documented but not the longer-term health and economic implications. Thus, a model of the predicted long-term consequences of sevelamer compared with calcium-based binders (acetate and carbonate) was developed. METHODS: Long-term cardiovascular implications of 1 year of treatment with phosphate binders in patients on hemodialysis are estimated based on the patient's demographics, comorbidities, and physiologic and renal parameters. The initial calcification score and expected changes over 1 year are derived using regression equations developed from the Treat-to-Goal study and translated to cardiovascular disease risk based on equations developed from a long-term cohort study. In this article, the implications of cardiovascular disease for life expectancy and medical costs are accounted for from a US payer perspective. RESULTS: The cardioprotective effect of sevelamer over 1 year is estimated to result in a 12% reduction in cardiovascular events compared with calcium acetate. In a population of 100 patients, the savings of 205,600 dollars accrued due to avoiding nine cardiovascular events with sevelamer, largely offset the increased binder costs, leading to a favorable cost-effectiveness ratio of about 2200 dollars per (discounted) life-year gained. CONCLUSIONS: Although both binders provide equivalent phosphate binding capacity, the results indicate that the advantage of 1 year of treatment with sevelamer in attenuating the progression of calcification has important clinical and economic consequences, suggesting that this provides good value for money.

Acetates↗
PubMed1997

Cost-effectiveness of anterotemporal lobectomy in medically intractable complex partial epilepsy.

PURPOSE: The value of high-cost health technologies is being increasingly scrutinized by providers of health care. An understanding of the costs and outcomes of high-technology epilepsy care is required to ensure efficient resource allocation. METHODS: Decision analysis was used to estimate the cost effectiveness of anterotemporal lobectomy (ATL) as compared with standard medical management in medically-intractable epilepsy. Local (Rochester, NY, U.S.A.) cost data were applied to a model of lifetime discounted costs and outcomes of evaluation, ATL, and follow-up in a hypothetical cohort of patients. RESULTS: Base case analysis yielded a marginal cost-effectiveness ratio (MECR) of $15.581/quality-adjusted life year (QALY). Extensive sensitivity analyses identified extreme conditions in which evaluation for ATL was dominant (more effective and less costly) or in which it might be considered not worth the cost (MCER > $50,000/QALY). CONCLUSIONS: Estimates of ATL cost effectiveness fall within a generally acceptable range, even when uncertainty about many model parameters is taken into account. Under assumptions based on available data in the literature, the cost effectiveness of ATL compares favorably with that of other health technologies. Prospective multicenter studies of regional-cost and practice variations; long-term probabilities of year-to-year transitions between seizure outcome states and their effects on quality of life (QOL), and the effect of nonsurgical treatments on seizure control and QOL are needed to provide the critical data to confirm and constrain these estimates.

Anticonvulsants↗
PubMed1995

Cost-benefit analysis of transesophageal echocardiography in cardiac surgery.

This article evaluates the costs and outcomes associated with TEE during and after cardiac surgery. The costs include the direct and indirect costs--the complications of TEE. The outcomes include the positive consequences or the benefits: money and lives saved. The article uses liberal (high) estimates of the direct and indirect costs of TEE and conservative (low) estimates of the benefits. The exact cost or benefit depends on the number of cases performed. The analysis shows that patients having surgery for congenital heart disease derive the greatest overall benefit: around $600 per case studied. Patients having valvular repair surgery derive the next greatest benefit: around $450 per case studied. In contrast patients having valve replacement have an overall cost of around $150 per case studied. Patients having surgery for coronary artery disease also derive an overall benefit: around $100-$300 per case studied, depending upon assumptions regarding TEE's role in prevention of intraoperative strokes. This analysis indicates that the financial benefits of TEE are substantial and frequently outweigh costs in patients requiring cardiac surgery.

Cardiac Surgical Procedures↗
PubMed1995

The use of a break-even analysis: financial analysis of a fast-track program.

OBJECTIVE: To calculate the financial break-even point and illustrate how changes in third-party reimbursement and eligibility could affect a program's fiscal standing. METHODS: Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast-track program during June 1993. The fast-track program is located within the confines of the emergency medicine and trauma center at a 1,050-bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break-even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect. RESULTS: Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs. CONCLUSIONS: Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third-party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break-even volumes.

Cost-Benefit Analysis↗
PubMed1999

Cost-analysis of management strategies for children with vesico-ureteric reflux.

This study is an economic evaluation of three treatment strategies for vesico-ureteric reflux in children: neo-implantation; subureteric injection; and antibacterial prophylaxis. Cost-analysis was used to compare the strategies, implying that the differences in benefits between them were not measured. Direct and indirect costs are included, taking the analytical viewpoint of the community. For the surgical strategies, data from four different hospitals in Sweden were used, and for the prophylactic strategy, data was gathered through a survey of 31 hospitals. The treatment strategies were ranked in the following order (bilateral reflux in parentheses): (i) subureteric injection SEK 25,000-28,000 (26,000-36,000); (ii) antibacterial prophylaxis SEK 16,000-36,000; and (iii) neo-implantation SEK 65,000-90,000 (72,000-95,000).

Anti-Bacterial Agents↗