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PubMed1998

Costs of drug treatment in Parkinson's disease.

Parkinson's disease (PD) has a major socioeconomic impact on society. The chronic, progressive course of the disease, which often leads to severe disability, results in high expenses for the medical resources used for treatment, care, and rehabilitation of patients as well as reduced or lost productivity as a result of illness or premature death. In Great Britain, it has been estimated that the National Health Service spends up to 383 million pound sterling (1992) annually for the care of PD. This emphasizes the importance of assessing the costs related to this disease. A detailed knowledge of the cost allocation would provide a solid basis on which health care priorities can be rationally set. Next to hospitalization, drug treatment accounts for the highest expense for direct medical costs of PD. Therefore, this analysis focuses on the costs of drug treatment for PD. The cost analysis was based on a retrospective study of 409 patients with PD who were seen over a 1-year period in our movement disorders clinic. The cost of therapy varied considerably depending on the severity of the condition (assessed in the "off" phase), the incidence of motor fluctuations, and the type of PD. In the early stage of the disease (Hoehn and Yahr stage I [HY I]), mean daily costs for therapy were DM (German marks) 6.60, which increased in later stages of the disease (HY V) to DM 22.00. If rare cases requiring continuous subcutaneous apomorphine infusion were included, mean daily costs of patients in HY V rose to DM 32.50 (the mean daily costs of subcutaneous apomorphine-treated patients in HY V: DM 74.30). Patients with motor fluctuations accounted for higher costs (DM 16.50) compared with those without motor fluctuations (DM 7.80). With respect to the three subtypes of PD, the mean daily expenditure was DM 7.00 for the tremor-dominant type, DM 12.40 for the akinetic-rigid type, and DM 10.80 for the mixed type. In the group of 409 PD patients included in this analysis, the average daily expenditure for drug treatment totaled DM 10.70 per patient (including patients on subcutaneous apomorphine).

Antiparkinson Agents↗
PubMed1995

Blood product costing: relationship to price and clinical efficacy.

Detailed information is provided about primary product costing and price issues as they affect transfusion manufacturing practice and clinical transfusion practice. Product price is shown to have a crucial influence upon clinical practice and associated research. By focusing particularly upon cost-benefit analysis of blood product transfusion therapy a substantive conclusion is drawn that price should equal the associated manufacturing cost. Clinical outcome studies relate clinical efficacy to the manufacturing specification of the product, which should therefore determine the product cost. Thus, the true manufacturing cost is the sum of all the process activity costs that create the final product specification, e.g. red cell number+volume reduction+leucocyte reduction+microbiological safety, for processed red cells. Sometimes different product specifications may compete for a single activity cost, e.g. one-spin processing achieves volume reduction and leucocyte reduction for processed red cells but also plasma removal for protein fractionation. A method for understanding the relative clinical importance of different products is described, which guides the cost allocation process. Furthermore, for some products there is uncertainty about the clinical benefits of some components of the specification, e.g. leucocyte load and immunomodulation, and a method is described for ranking this quality-uncertainty level objectively. The optimal costing model must ensure that the product with the highest uncertainty ranking is assured a high degree of cost stability. These concepts prepare the way for a Quality Associated Costing model for blood products that correlates with clinical efficacy.

Blood Transfusion↗
PubMed1989

[Enhanced economies of study in thyroid diseases].

Scientifically substantiated figures of material costs spent on the main types of radiotherapy of thyroid tumors were calculated on the basis of data of the clinical diagnostic departments of the First I. M. Sechenov Moscow Medical Institute. Cost calculation was based on the principle of the use of means in the nonindustrial field of economy. The cost of each investigation was calculated as full expenses (main funds and current costs) allocated for a particular type of investigation in any arbitrary period of time, divided into the number of investigations performed over this period. Standardization of investigations taking account of the elaborated tactical schemes makes it possible to decrease notably (almost by 20%) material costs on the investigation of thyroid patients.

Costs and Cost Analysis↗
PubMed1999

Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.

OBJECTIVE: To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. DATA SOURCES/STUDY SETTING: The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. STUDY DESIGN: We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. PRINCIPAL FINDINGS: The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. CONCLUSIONS: Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment. The economies experienced by the largest chains may provide an explanation for their recent growth in market share. The heterogeneity of results by chain size implies that characterizing units using a simple chain status indicator variable is inadequate. Cost differences by facility type and the effects of the ongoing growth of large chains are worthy of continued monitoring to inform both payment policy and antitrust enforcement.

Ambulatory Care Facilities↗
PubMed1998

Evaluation of quality of life of childhood cancer survivors: a methodological conundrum.

QOL assessment in pediatric oncology is seriously understudied, especially compared with the adult population. The limited progress is due to the methodological complexity of the task, which should not be viewed as insurmountable. Given a precise study question, the methodological issues can be clarified simply, piece by piece. Researchers must consider very carefully the specific characteristics that define a study population in order to choose an instrument that is domain-appropriate and valid for the assessment paradigm. The first priority should be that a researcher must identify the means of accessing the information of interest. In the pediatric population, information about children's status may be elicited from parents, medical personnel, teachers, or the children themselves. Clearly, the type of instrument to be used for assessment is dependent on the choice of reporter. Researchers must also account for developmental age and disease; in assessing generic and disease-specific functioning, the "functional scale" against which an individual is compared must implicitly reflect the types of activities and/or levels of functioning that are realistic norms for the patient. Equally important is the analysis of independent domains in order to characterize the dynamics/divergence of clinical status and functional status. What are the merits of conducting QOL research for the pediatric cancer-survivor population? The policy implications are profound and pervasive both for the individual survivors (regarding treatment, care, and his/her ultimate ability to reintegrate into society) and for society (regarding resource allocation, cost planning, and productivity). Commensurate with the rapid advancement of oncologic therapy, there is now an expanding cohort of pediatric cancer survivors. Current estimates suggest that, by the turn of the century, 200,000 children will be in this category. The long-term survivorship of this cohort is still poorly defined. However, as the survivors mature, it is likely that their needs will evolve as well-whether for treatment of secondary malignancies, long-term morbidities, and fertility issues or for neuropsychological dysfunction, emotional counseling, or occupational issues. Children, as survivors, are unique, in that their future (the context within which long-term outcome is defined) spans decades. Based on a median age at diagnosis of 6 years, survivors can expect to live an additional 66 years. From a cost or policy perspective, children represent enormous future potential. The implications of children's long-term outcomes must be considered regarding the change in future potential secondary to survivorship. Pediatric QOL research plays a role both inside and outside the health care system. Clearly, in the provision of health care, QOL data may be used to improve or modify patient care by supplementing information about the clinical status of individual patients. Information about an individual's general functioning, particularly as it diverges from disease-specific functioning, complements clinical data to facilitate comprehensive care. Information about the long-term outcomes of pediatric cancer, as a whole, will influence the policies of health care institutions and the allocation of health care resources. By expanding the scope of survivorship (or cure) to include long-term clinical and general "costs" the "cost of cure" is shifted: this shift will ultimately impact estimations of cost effectiveness, with ramifications for the evaluation of hospital-wide protocols, utilization priorities, and cost policies. Outside of the hospital, the implications of QOL research are equally ubiquitous. Pediatric survivors will live an estimated 7 decades after "cure," during which time they will exist almost entirely outside the realm of health care; yet, their condition as a survivor, with or without the long-term clinical toxicities secondary to treatment, will continue to affect some or all of thei

Adolescent↗
PubMed2004

Economic evaluation of treatments for cancer in childhood.

Treatment of cancer in childhood is an expensive undertaking for the health-care system and for the affected families. As there is a substantial burden of treatment-related morbidity, it is important to determine whether the effects of treatment are worth these monetary costs, especially from a societal perspective. Economic evaluation affords a comparison of the costs and consequences (effects) of relevant therapeutic alternatives. Preference-based measures of health-related quality of life are particularly useful for assessing the effects of treatment, for these tools integrate mortality and morbidity. These measures provide utility scores that can be used as weights on survival data to compute quality-adjusted life years (QALYs). Costs are incurred both within and outside of the health-care system. The former should include those in front-line patient care departments (e.g. nursing); the pro-rated share of the expenses of service departments (e.g. materials management) to those in the front line; and the fully allocated costs for capital invested in lands, building and equipment. The latter are costs borne by families that are both out-of-pocket (e.g. for over-the-counter drugs) as well as related to time spent in providing care, which may involve foregone income. Costs and consequences should be subject to discounting; a process for converting those items incurred in the future into contemporary equivalents. Economic evaluation provides estimates of incremental discounted costs per discounted QALY gained. By almost any interpretative standard this appears attractive with respect to cancer in childhood. Examples are provided with the encouragement that economic evaluation be undertaken in more clinical trials in paediatric oncology.

Child↗
PubMed1987

Developing a solid base for a cost accounting system.

Henry Ford Hospital recently conducted a procedural costing study to determine if more accurate costs for various institutional procedures could be developed. The hospital conducted the study in two phases. The first phase looked at a specific department while phase two took a broader approach and covered the entire institution. This article examines the department-specific phase in which the diagnostic radiology department was selected as the participant. The study concluded that by allocating costs to the procedural level using relative value units and feeding this information into the case-mix system, departmental costs could be accurately identified.

Accounting↗
PubMed2005

Toward efficient riparian restoration: integrating economic, physical, and biological models.

This paper integrates economic, biological, and physical models to explore the efficient combination and spatial allocation of conservation efforts to protect water quality and increase salmonid populations in the Grande Ronde basin, Oregon. We focus on the effects of shade on water temperatures and the subsequent impacts on endangered juvenile salmonid populations. The integrated modeling system consists of a physical model that links riparian conditions and hydrological characteristics to water temperature; a biological model that links water temperature and riparian conditions to salmonid abundance, and an economic model that incorporates both physical and biological models to estimate minimum cost allocations of conservation efforts. Our findings indicate that conservation alternatives such as passive and active riparian restoration, the width of riparian restoration zones, and the types of vegetation used in restoration activities should be selected based on the spatial distribution of riparian characteristics in the basin. The relative effectiveness of passive and active restoration plays an important role in determining the efficient allocations of conservation efforts. The time frame considered in the restoration efforts and the magnitude of desired temperature reductions also affect the efficient combinations of restoration activities. If the objective of conservation efforts is to maximize fish populations, then fishery benefits should be directly targeted. Targeting other criterion such as water temperatures would result in different allocations of conservation efforts, and therefore are not generally efficient.

Animals↗
PubMedDate not supplied

[Prescription and costs of artificial nutrition before and after a new utilization protocol].

In order to improve the quality of prescription and reduce expenditure, the artificial nutrition department has designed a new usage protocol: justification sheet, table of indications for parenteral nutrition (PN), nutritional assessment, etc. The Pharmacy Department is in charge of the follow-up of this programme and maintaining the database derived from it. Comparing the data for the year before (1996) and after (1998) implementation of this programme, we can see that as a result 9 patients/day switched from total parenteral nutrition by central administration to hypocaloric peripheral nutrition, with the prevalence of the former dropping to 1.4% of admissions and 2% of stays. The share of enteral nutrition (30.6%) and hypocaloric peripheral nutrition (27.8%) increases in the overall expenditure on artificial nutrition, with a reduction in the total parenteral nutrition (41.6%). The costs of parenteral nutrition per admission and stay are reduced by 39.3% and 33.5%, respectively, to 1,625 and 183 pesetas. This represents a saving of 16.5 million pesetas. The expenditure on PN elements declines by two percentage points to 2.2% of pharmaceutical expenditure. As an additional benefit, it is possible to identify each of the clinical situations which give rise to this indication and to allocate costs by diagnosis and department. Together with the containment of expenditure, it has been possible to increase the participation of everyone in the rational use of clinical nutrition thus highlighting its interdisciplinary nature.

Costs and Cost Analysis↗
PubMed1985

An economic comparison of Tubex injection systems with traditional ampuls and vials.

A time and motion study was performed at the Hospital of the University of Pennsylvania to measure and compare the direct and indirect costs of the original Tubex and Tubex Fast-Trak injection systems with comparable costs associated with single dose ampuls, vials, and multi-dose vials. Data collection involved observation of 170 injections prepared by 29 nurses on two oncology units over a 7-week period. The time and nondrug supply costs of the Tubex Fast-Trak were lower than those of all other injection systems observed, including the original Tubex. Although the drug acquisition component was higher for the Tubex systems than for conventional injection methods, an analysis of the total cost of the use of Tubex Fast-Trak demonstrated that on an annual basis, the system is nearly equal in cost to the use of single ampuls and vials. Important advantages of the prefilled cartridge system should be considered in addition to labor, supply, and drug costs when selecting cost-effective injection systems. Systems like Tubex offer advantages that may lower total cost of care, such as reduction in wastage, pilferage, contamination, dosage error, and improved cost allocation accuracy. When polled about their opinion, the majority of nurses who participated in the study indicated that Tubex Fast-Trek was their first choice over other injection methods observed.

Costs and Cost Analysis↗
PubMed2005

Creating standard cost measures across integrated health care delivery systems.

BACKGROUND: Economic analyses are increasingly important in medical research. Accuracy often requires that they include large, diverse populations, which requires data from multiple sources. The difficulty is in making the data comparable across different settings. This article focuses on how to create comparable measures of health care resource use and cost using data from seven health plans and delivery systems participating in the Cancer Research Network's HMOs Investigating Tobacco study. METHODS: We used a data inventory to identify variation in data capture across sites and used data dictionaries to develop algorithms for assigning standardized cost to the three major components of health care use: outpatient, inpatient, and pharmacy. RESULTS: The plans included in this study varied from fully integrated, closed-panel models to plans and delivery systems that include network or independent physician association components. Information derived from the data inventory and data dictionary instruments demonstrated a substantial variation in both the content and capture of data across all sites and across all components of usage. The methods we employed for cost allocation varied by usage component and were based on our ability to leverage the data points available to best reflect actual resource use. CONCLUSIONS: The importance of this article is the method of ascertaining, cataloging, and addressing the within- and between-plan differences in health care resource use. Second, the decisions we made to address the differences between health plans provide other researchers a starting point when creating a cost algorithm for multisite retrospective research.

Adult↗
PubMed2004

Population variation in the cost and benefit of tolerance and resistance against herbivory in Datura stramonium.

In this study we examine the hypothesis that divergent natural selection produces genetic differentiation among populations in plant defensive strategies (tolerance and resistance) generating adaptive variation in defensive traits against herbivory. Controlled genetic material (paternal half-sib families) from two populations of the annual Datura stramonium genetically differentiated in tolerance and resistance to herbivory were used. This set of paternal half-sib families was planted at both sites of origin and the pattern of genotypic selection acting on tolerance and resistance was determined, as well as the presence and variation in the magnitude of allocational costs of tolerance. Selection analyses support the adaptive differentiation hypothesis. Tolerance was favored at the site with higher average level of tolerance, and resistance was favored at the site with higher average level of resistance. The presence of significant environmentally dependent costs of tolerance was in agreement with site variation in the adaptive value of tolerance. Our results support the expectation that environmentally dependent costs of plant defensive strategies can generate differences among populations in the evolutionary trajectory of defensive traits and promote the existence of a selection mosaic. The pattern of contrasting selection on tolerance suggests that, in some populations of D. stramonium, tolerance may alter the strength of reciprocal coevolution between plant resistance and natural enemies.

Adaptation, Biological↗
PubMed1996

A study of the quality of life and cost-utility of renal transplantation.

The objective of this study was to assess the cost-utility of renal transplantation compared with dialysis. To accomplish this, a prospective cohort of pre-transplant patients were followed for up to two years after renal transplantation at three University-based Canadian hospitals. A total of 168 patients were followed for an average of 19.5 months after transplantation. Health-related quality of life was assessed using a hemodialysis questionnaire, a transplant questionnaire, the Sickness Impact Profile, and the Time Trade-Off Technique. Fully allocated costs were determined by prospectively recording resource use in all patients. A societal perspective was taken. By six months after transplantation, the mean health-related quality of life scores of almost all measures had improved compared to pre-transplantation, and they stayed improved throughout the two years of follow up. The mean time trade-off score was 0.57 pre-transplant and 0.70 two years after transplantation. The proportion of individuals employed increased from 30% before transplantation to 45% two years after transplantation. Employment prior to transplantation [relative risk (RR) = 23], graft function (RR 10) and age (RR 1.6 for every decrease in age by one decade), independently predicted employment status after transplantation. The cost of pre-transplant care ($66,782 Can 1994) and the cost of the first year after transplantation ($66,290) were similar. Transplantation was considerably less expensive during the second year after transplantation ($27,875). Over the two years, transplantation was both more effective and less costly than dialysis. This was true for all subgroups of patients examined, including patients older than 60 and diabetics. We conclude that renal transplantation was more effective and less costly than dialysis in all subgroups of patients examined.

Adult↗
PubMed1998

Sustained visual-spatial attention produces costs and benefits in response time and evoked neural activity.

This study investigated the simple reaction time (RT) and event-related potential (ERP) correlates of biasing attention towards a location in the visual field. RTs and ERPs were recorded to stimuli flashed randomly and with equal probability to the left and right visual hemifields in the three blocked, covert attention conditions: (i) attention divided equally to left and right hemifield locations; (ii) attention biased towards the left location; or (iii) attention biased towards the right location. Attention was biased towards left or right by instructions to the subjects, and responses were required to all stimuli. Relative to the divided attention condition, RTs were significantly faster for targets occurring where more attention was allocated (benefits), and slower to targets where less attention was allocated (costs). The early P1 (100-140 msec) component over the lateral occipital scalp regions showed attentional benefits. There were no amplitude modulations of the occipital N1 (125-180 msec) component with attention. Between 200 and 500 msec latency, a late positive deflection (LPD) showed both attentional costs and benefits. The behavioral findings show that when sufficiently induced to bias attention, human observers demonstrate RT benefits as well as costs. The corresponding P1 benefits suggest that the RT benefits of spatial attention may arise as the result of modulations of visual information processing in the extrastriate visual cortex.

Adolescent↗
PubMed2004

A cost-benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price?

OBJECTIVE: To determine the net benefit and costs associated with gown use in preventing transmission of vancomycin-resistant Enterococcus (VRE). DESIGN: A cost-benefit analysis measuring the net benefit of gowns was performed. Benefits, defined as averted costs from reduced VRE colonization and infection, were estimated using a matched cohort study. Data sources included a step-down cost allocation system, hospital informatics, and microbiology databases. SETTING: The medical intensive care unit (MICU) at Barnes-Jewish Hospital, St. Louis, Missouri. PATIENTS: Patients admitted to the MICU for more than 24 hours from July 1, 1997, to December 31, 1999. INTERVENTIONS: Alternating periods when all healthcare workers and visitors were required to wear gowns and gloves versus gloves alone on entry to the rooms of patients colonized or infected with VRE. RESULTS: On base-case analysis, 58 VRE cases were averted with gown use during 18 months. The annual net benefit of the gown policy was dollar 419,346 and the cost per case averted of VRE was dollar 1,897. The analysis was most sensitive to the level of VRE transmission. CONCLUSIONS: Infection control policies (eg, gown use) initially increase the cost of health services delivery. However, such policies can be cost saving by averting nosocomial infections and the associated costs of treatment. The cost savings to the hospital plus the benefits to patients and their families of avoiding nosocomial infections make effective infection control policies a good investment.

Cohort Studies↗
PubMed1995

Practice expenses in the MFS (Medicare fee schedule): the service-class approach.

The practice expense component of the Medicare fee schedule (MFS), which is currently based on historical charges and rewards physician procedures at the expense of cognitive services, is due to be changed by January 1, 1998. The Physician Payment Review Commission (PPRC) and others have proposed microcosting direct costs and allocating all indirect costs on a common basis, such as physician time or work plus direct costs. Without altering the treatment of direct costs, the service-class approach disaggregates indirect costs into six practice function costs. The practice function costs are then allocated to classes of services using cost-accounting and statistical methods. This approach would make the practice expense component more resource-based than other proposed alternatives.

Cost Allocation↗
PubMed2003

Adjunctive human papillomavirus testing in the 2-year follow-up of women with low-grade cervical cytologic abnormalities: a randomized trial and economic evaluation.

CONTEXT: Although human papillomavirus (HPV) testing may aid in managing low-grade abnormality on screening cervical cytology, patient compliance with repeat testing programs requires consideration. OBJECTIVES: To determine effectiveness and costs of repeated Papanicolaou (Pap) test and oncogenic HPV testing for detecting cervical intraepithelial neoplasia 2 or 3. DESIGN: We conducted a randomized controlled trial of combined Pap test and cervical HPV testing by Hybrid Capture 1 test compared with Pap test alone; tests were performed every 6 months for up to 2 years. The study end point was colposcopic examination performed on all women at 2 years, or earlier if an HPV test was positive or if a Pap test showed high-grade squamous intraepithelial lesion. SETTING: Sixty-six community family practices. PARTICIPANTS: Two hundred fifty-seven women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion on screening cervical cytology. MAIN OUTCOME MEASURES: Detection of histologically confirmed cervical intraepithelial neoplasia 2 or 3, fully allocated costs, and loss to follow-up. RESULTS: Combined Pap test and HPV testing detected 11 (100%) of 11 cases of cervical intraepithelial neoplasia 2/3, whereas Pap test alone detected 7 (63.6%) of these 11 cases (P =.14); corresponding specificities were 39 (46.4%) of 84 and 45 (71.4%) of 63 (P =.005). The cost-effectiveness ratio was Can $4456 per additional case of high-grade cervical intraepithelial neoplasia. Sixty-nine (26.8%) of the 257 women (24.6% combined group vs 29.1% Pap test only group, P =.41) defaulted from testing or from colposcopy when referred with an abnormal result. CONCLUSIONS: Combined testing was more costly but may detect more cases of cervical intraepithelial neoplasia 2/3 than Pap test alone. However, poor adherence limits usefulness of a management strategy that requires repeated follow-up.

Adult↗