Differences In Total Health Care Costs Research Articles

Impact of rifaximin use following an initial overt hepatic encephalopathy hospitalization on rehospitalization and costs

AimTo assess the impact of rifaximin (± lactulose) use following discharge of an initial overt hepatic encephalopathy (OHE) hospitalization on OHE rehospitalizations and healthcare costs in a real-world setting.MethodsAdults (18–64 years) with an OHE hospitalization were identified from MarketScan® Commercial claims (Q4′15–Q2′20), classified into two mutually exclusive treatment cohorts (i.e. rifaximin and no rifaximin treatment), and further stratified into four subgroups based on decreasing quality of care (QoC; i.e. Type 1 – rifaximin without delay post-discharge; Type 2 – rifaximin with delay post-discharge; Type 3 – lactulose only post-discharge; Type 4 – no rifaximin/lactulose treatment post-discharge). The impact of rifaximin use on 30-day and annualized OHE hospitalizations and healthcare costs were assessed between cohorts and by the QoC subgroup.ResultsCharacteristics were similar between the rifaximin (N = 1,452; Type 1: 1,138, Type 2: 314) and no rifaximin (N = 560; Type 3:337, Type 4: 223) treatment cohorts. The 30-day risk of OHE rehospitalization was lower for the rifaximin vs. no rifaximin treatment cohort (odds ratio 0.56, p < .01) and increased with decreasing QoC. The annual rate of OHE hospitalizations was 59% lower for the rifaximin treatment cohort (incidence rate ratio 0.41, p < .01) and increased with decreasing QoC. Compared to the no rifaximin treatment cohort, the rifaximin treatment cohort had higher pharmacy costs, lower medical costs, and no difference in total healthcare costs.LimitationsThis was a claims-based study subject to common data limitations such as billing inaccuracies or omissions in coded claims. Total healthcare costs were reported from a payer’s perspective, which do not capture indirect costs associated with patient burden.ConclusionsInitiation of rifaximin after an OHE hospitalization was associated with reduced OHE hospitalizations both in the 30-days following and annually. Further, reduced medical costs offset increased pharmacy costs, and no annual cost differences were observed between cohorts.

Economic Effects of Fixed-Dose Versus Loose-Dose Combination Therapy for Type 2 Diabetes Patients.

We examined the effects of fixe-dose combinations (FDCs) versus loose-dose combinations (LDCs) on costs from the payer and patient perspective and investigated potential channels contributing to differences in costs between the two modes of treatment. We investigated administrative data from 2017 to 2020 on diabetes patients in Germany. After using prospensity-score matching to remove dissimilarities between FDC and LDC patients, we compared changes in costs with a difference-in-differences approach. We analyzed pharmaceutical costs, inpatient and outpatient costs, other costs and total healthcare costs from the payer perspective, and co-payments from the patient perspective. The sample comprised 1117 FDC and 1272 LDC patients. Regression analysis revealed that FDC therapy significantly increased antidiabetic pharmaceutical spending in the first year by 5.5% (p<0.01), but decreased co-payments by 33% (p<0.01) in the first and 44% (p<0.01) in the second year. We also observed a trend towards higher outpatient spending in the first year. No significant differences were found with respect to inpatient or other costs. The increase in antidiabetic pharmaceutical spending did not contribute to a significant increase in total healthcare expenditure. We identified a shift of co-payments to the payer and higher adherence as possible mechanisms behind the increase in antidiabetic pharmaceutical spending. Although FDC therapy increased disease-specific pharmaceutical spending in the short term, this increase did not lead to differences in total healthcare costs from the payer perspective. From the patient perspective, FDC therapy may be the preferred treatment approach, because of significant saving in co-payments, which is likely attributable to the elimination of one co-payment and therefore a shift in costs to the payer.

Healthcare resource utilization and costs in 23–25-year-old women with human papillomavirus (HPV) associated anogenital diseases in Germany – a retrospective analysis of statutory health insurance claims data

BackgroundHuman papilloma virus (HPV) causes multiple anogenital diseases including cervical cancer and is the most common sexually transmitted infection. Healthcare resource utilization (HRU) associated with HPV-related anogenital diseases includes diagnostic and disease specific treatment regimens. A recent study showed disease burden of young women aged 23–25 years, who were the first populations eligible to receive HPV vaccination after its introduction in Germany. Cost for the German statutory health insurance (SHI) due to HPV‑related anogenital diseases in this population are unknown. This study aimed at assessing HRU and costs related to HPV-associated anogenital diseases for the Germany SHI.MethodsWe used a retrospective, matched cohort design to leverage the prior identified cohort of 23–25-year-old women born between 1989–1992 diagnosed with HPV-related anogenital disease from the Institute for Applied Health Research Berlin (InGef) Research Database. German SHI claims data from 2012–2017 were analyzed. The prior identified cases were matched (direct, without replacement) to women without anogenital diseases (1:10 ratio). HRU and costs for inpatient care, outpatient care, and pharmaceutical during a 3-year observation period were determined for both cases and controls and increments between the groups were assessed.Results2,972 women diagnosed with anogenital diseases (cases) who were matched to 29,720 women without anogenital diseases (controls). Cases had more outpatient visits (52.4 visits vs. 39.2 visits) and more cases (45.2% vs. 31.7%) were hospitalized at least once in the 3‑year observation period. Most common outpatient procedures performed in cases were conization of the cervix uteri (4.4% cases; n < 5 controls), followed by other excision and destruction of diseased tissue of the cervix uteri (3.1% in cases; 0.0% in controls). Median difference in total healthcare costs of €684 (mean difference: €1,089, 95%CI: €752–1,426) suggest that HPV-related anogenital diseases were responsible for approximately €3.2 Million more healthcare costs for the identified cases in the four birth cohorts within the 3‑year observation period in the InGef Research Database. Costs were mainly driven by outpatient care (41.6% of total costs).ConclusionIn Germany, HPV-related anogenital diseases among young women are associated with considerable HRU and financial expenditures, mostly driven by outpatient care.

The substantial costs to society associated with obesity – a Danish register-based study based on 2002-2018 data

ABSTRACT Introduction The Danish national health registers were used to investigate the economic burden of obesity, associated costs of comorbidities and a breakdown into direct and indirect costs. Methods The study population comprised all Danish adult citizens registered with a hospital diagnosis of obesity in the Danish National Patient Register between 2002 and 2018. Cases were matched with five controls via the Danish Civil Registration System. We estimated the difference in total healthcare costs and indirect costs between cases and controls and the difference in healthcare resource utilization. In a sub-analysis, we estimated total healthcare costs for persons who had been registered with one or more of 11 predefined comorbidities. Results People with obesity experienced a statistically significant twofold increase in average direct healthcare costs per year (EUR 5,934), compared with controls (EUR 2,788) and had statistically significantly higher indirect costs compared to controls. Total healthcare costs for people with obesity and one or more of the 11 comorbidities were 91.7%–342.8% higher than total healthcare costs of the population with obesity but none of the 11 comorbidities. Conclusion Obesity was associated with an increase in both direct and indirect costs. The presence of comorbidities was associated with additional healthcare costs. Key points Obesity is associated with an increase in direct and indirect costs in Denmark. Comorbidities are associated with additional healthcare costs.

The Effect of Bariatric Surgery on Healthcare Costs and Labor Market Attachment

PurposeWe aimed to estimate the total cost of bariatric surgery in Denmark.Materials and MethodsThe study population included all Danish citizens ≥ 18 years who had received bariatric surgery, identified in the Danish National Patient Register in the period from 2002 to 2018. Patients who had received bariatric surgery were matched with three controls on gender, year of birth, and region of residence. A difference-in-difference approach was used to estimate the healthcare costs attributable to bariatric surgery from 3 years before to 5 years after surgery.ResultsTotal healthcare costs for cases receiving bariatric surgery during the first 5 years following surgery amounted to EUR 32,899, and EUR 16,651 for their matched controls. Thereby, the difference in total healthcare costs (EUR 16,248) between persons receiving bariatric surgery and their matched controls was 2.2 times the DRG rate for the surgery itself (EUR 7387).Moreover, the results suggest that receiving bariatric surgery led to a total increase in gross earnings of EUR 5970 (5%) and a total reduction in receipt of transfer payments of EUR 4488 (12%) in the period up until 5 years after surgery.ConclusionThe results showed a significant and persistent increase in healthcare costs for people with obesity receiving bariatric surgery during the first 5 years after surgery. We also found that bariatric surgery was associated with increased attachment to the labor market.Graphical abstract

Contemporary Incremental Healthcare Costs for Allergic Rhinitis in the United States.

Describe contemporary changes in healthcare expenditure and utilization associated with allergic rhinitis (AR) over the past decade. Cross-sectional analysis. Patients reporting a diagnosis of AR were extracted from the 2018 Medical Expenditure Panel Survey and linked to the consolidated expenditures file. AR patients were then compared to non-AR patients to demonstrate differences in healthcare utilization for office visits, emergency facility visits, and prescriptions. In addition, differences in total healthcare costs, office-based costs, and prescription costs were calculated, using demographic- and comorbidity-adjusted multivariate models. Results were compared to those obtained in 2007. In 2018, an estimated 1.94 ± 0.2 million adult patients reported AR (0.8% of the US population receiving medical care), a 90% decrease from the 17.8 ± 0.7 million patients seen in a formal healthcare setting for AR in 2007 (7.9%). AR patients still formally seen in 2018 had an average of 4.4 ± 1.3 more office visits (P= .001) and 9.7 ± 2.2 more prescription fills (P< .001) than non-AR patients. In contrast to the 2007 findings, there was no difference in total health care expenditure per person with AR per year. When comparing total healthcare expenditure between 2018 and 2007, there was a net decrease of $1,176 per person with AR per year (P< .01). Patients reporting AR in a formal healthcare encounter fell significantly over the past decade, and per-person expenditure associated with an AR diagnosis also decreased significantly. The transition of nasal corticosteroids to over-the-counter was potentially a key driver behind these changes. 3 Laryngoscope, 132:1510-1514, 2022.

Contemporary Incremental Healthcare Costs for Chronic Rhinosinusitis in the United States.

Determine contemporary incremental increases in healthcare expenditures and utilization associated with chronic rhinosinusitis (CRS). Cross-sectional analysis of national health care survey data. Patients reporting a diagnosis of CRS were extracted from the 2018 Medical Expenditure Panel Survey medical conditions file and linked to the consolidated expenditures file. CRS patients were then compared to non-CRS patients determining differences in healthcare utilization for office visits, emergency facility visits, and prescriptions filled as well as differences in total healthcare costs, office-based costs, prescription medication costs, and self-expenditures using demographically and comorbidity adjusted multivariate models. Results were compared to 2007, adjusted for inflation. An estimated 7.28 ± 0.36 million adult patients reported CRS in 2018 (3.0 ± 0.1% of the adult U.S. population). The additional incremental healthcare utilizations associated with CRS relative to non-CRS patients for office visits, emergency facility visits, and number of prescriptions filled were 4.2 ± 0.6, 0.10 ± 0.03, and 6.0 ± 0.9, respectively (all P ≤ .003). Similarly, additional incremental healthcare expenditures associated with CRS for total health care expenses, office-based visit expenditures, prescription expenditures, and self-expenditures were $1,983 ± 569, $772 ± 139, $678 ± 213, and $68 ± 17, respectively (all P ≤ .002). Increases in total (+$1,062) and office based expenditures (+$360) compared to 2007 were significant. CRS continues to be associated with a substantial incremental increase in healthcare utilization and expenditures. These expenditures have significantly outpaced inflation expected increases. The national healthcare costs of CRS have increased to an estimated $14.4 billion per year. 3 Laryngoscope, 131:2169-2172, 2021.

Association between single limb standing test results and healthcare costs among community-dwelling older adults

Background and objectiveIdentifying risks for older adults who will require healthcare resources is critical for the government, healthcare providers, and consumers. The objective of this study was to examine the relationship between the results of the single limb standing (SLS) test and healthcare costs among community-dwelling older adults. MethodsWe used data obtained from a population-based prospective cohort study of the residents of Tadami town in Fukushima Prefecture, Japan. The participants were above 60 years of age and had undergone annual health check-ups, and data on their healthcare costs over the two-year study period were available. A censored regression model adjusted for potential confounders was used to estimate the mean difference in total healthcare costs between participants who could remain standing on a single limb for at least 30 s and those who could not. ResultsHealthcare costs of participants who passed the SLS test were significantly lower than those who did not. The mean difference between the two groups’ healthcare costs was 4064 USD (95 % confidence interval: 2661–5467 USD, p < 0.05). After adjusting for potential confounders, the mean difference between the two groups was smaller (1686 USD) but remained statistically significant (95 % confidence interval: 125–3246 USD, p < 0.05). ConclusionsAmong community-dwelling older adults, limited static balance (SLS time <30 s) was found to be associated with high healthcare costs in the two years after the SLS test. The SLS test may help identify individuals at high risk of becoming frequent users of healthcare services in the future.

A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze?

ObjectivesDiverting patients away from the emergency department (ED) has been proposed as a solution for mitigating overcrowding. This systematic review examined the impact of interventions designed to either bypass the...

Abstract 16714: Real-World Cost of All-Cause Hospitalizations Over a 12-Month Period After Acute Venous Thromboembolism

Recent clinical trial data have shown that newer oral anticoagulants may reduce all-cause hospitalizations in patients with venous thromboembolism (VTE) who complete anticoagulation therapy for 6-12 months. To understand the potential cost implications of such hospitalization reductions, this study sought to quantify the real-world cost of all-cause hospitalizations over a 12-month period after acute VTE. This was a retrospective cohort study using U.S. health insurance claims data. Patients included in the study were aged ≥18 years, had experienced a non-fatal hospitalization or ED visit with a principal diagnosis of VTE between 1-Jan-2007 and 31-Mar-2013 (first visit=index) and had ≥1 claim for anticoagulation (warfarin, enoxaparin, rivaroxaban) or placement of an inferior vena cava filter ≤30 days after index. For up-to one year after discharge from the hospitalization or ED visit for acute VTE, patients were followed to identify the occurrence and costs of all-cause hospitalizations. Multivariable regressions were used to compare per-patient per-month (PPPM) total healthcare costs between patients with vs. without a hospitalization during follow-up. The final cohort included 123,665 patients (mean age 59 years, 50% male). During an overall mean follow-up of 284 days after discharge from the acute VTE event, 33,843 patients were hospitalized at least once for any cause within 1 year and 37% of these hospitalized patients had at least one hospitalization for VTE. Among patients who were hospitalized, mean (standard deviation) PPPM hospital length of stay and PPPM costs for hospitalizations were 1.4 (2.8) and $5,800 ($14,723) at 1 year. Adjusted incremental PPPM differences in total healthcare costs between patients with vs. without a hospitalization during the 1-year follow-up were $ $4,808 (P&lt;0.001). Conclusion: Hospitalizations within 1 year after acute VTE are common and costly. VTE treatments which reduce hospitalizations after acute VTE may confer substantial cost offsets.

Total cost comparison of standard antenatal care with a weight gain restriction programme for obese pregnant women

To perform a cost comparison of a weight gain restriction programme for obese pregnant women with standard antenatal care, and to identify if there were differences in healthcare costs within the intervention group related to degree of gestational weight gain or degree of obesity at programme entry. A comparison of mean healthcare costs for participants of an intervention study at antenatal care clinics with controls in south-east Sweden. In total, 155 women in an intervention group attempted to restrict their gestational weight gain to <7 kg. The control group comprised 193 women. Mean costs during pregnancy, delivery and the neonatal period were compared with the costs of standard care. Costs were converted from Swedish Kronor to Euros (€). Healthcare costs during pregnancy were lower in the intervention group. There was no significant difference in total healthcare costs (i.e. sum of costs during pregnancy, delivery and the neonatal period) between the intervention group and the control group. Within the intervention group, the subgroup that gained 4.5-9.5 kg had the lowest costs. The total cost, including intervention costs, was € 1283 more per woman/infant in the intervention group compared with the control group (P=0.025). The degree of obesity at programme entry had no bearing on the outcome. The weight gain restriction programme for obese pregnant women was effective in restricting gestational weight gain to <7 kg, but had a higher total cost compared with standard antenatal care.

Comparison of utilization, cost, adherence, and hypoglycemia in patients with type 2 diabetes initiating rapid-acting insulin analog with prefilled pen versus vial/syringe

Background:Studies examining outcomes of different insulin delivery systems are limited. The objective of this study was to compare healthcare utilization, costs, adherence, and hypoglycemia rates in patients with type 2 diabetes mellitus (T2DM) initiating rapid-acting insulin analog (RAIA) using prefilled pen versus vial/syringe.Methods:A retrospective analysis was conducted using a US claims database (1/1/2007 to 12/31/2008). Inclusion criteria were: ≥18 years old, with T2DM, ≥12 months of continuous eligibility, and new to RAIA. Difference-in-difference analyses after propensity score matching were conducted to compare changes in outcomes from 6 months prior to and 6 months after initiating RAIA with a prefilled pen versus vial/syringe (Wilcoxon rank-sum test for costs and t-test for other outcomes). Categories of utilization and costs (2009 USD) included total and diabetes-related inpatient, outpatient, and emergency room. Adherence was measured by proportion of days covered (PDC). Hypoglycemia was identified using ICD-9-CM codes.Results:Baseline characteristics were similar between the prefilled pen (n = 239) and vial/syringe (n = 590) cohorts after matching. Adherence to RAIA was greater in the prefilled pen cohort than the vial/syringe cohort (PDC: 54.6 vs. 45.2%, p < 0.001). While the increase in diabetes-related pharmacy costs from before to after initiating RAIA was greater in the prefilled pen cohort than the vial/syringe cohort (+$900 vs. +$607, p < 0.001), the prefilled pen cohort was associated with greater reductions in the total diabetes-related costs (–$235 vs. +$61, p = 0.006) and the utilization of oral anti-hyperglycemic agents (–1.3 vs. –0.7, p = 0.016). There were no significant differences in other outcomes.Limitations:Claims databases do not provide optimal measures for adherence or T2DM severity, and only capture hypoglycemia events requiring clinical intervention.Conclusion:Initiating RAIA with a prefilled pen was associated with better adherence and greater reduction in total diabetes-related costs than a vial/syringe. There was no significant difference in total healthcare costs.

Retrospective Evaluation of Clinical Characteristics, Pharmacotherapy and Healthcare Resource Use among Patients Prescribed Pregabalin or Duloxetine for Diabetic Peripheral Neuropathy in Usual Care

To evaluate treatment patterns and costs among patients with painful diabetic peripheral neuropathy (pDPN) newly prescribed pregabalin or duloxetine in usual care settings. Using the PharMetrics® Database, patients with pDPN (ICD-9-CM codes 357.2 or 250.6x) newly prescribed pregabalin or duloxetine were identified. Patients initiated on duloxetine (n=713; mean age 55.4 ± 9.5 years) were propensity score-matched with patients initiated on pregabalin (n=713; mean age 56.3 ± 9.3 years). Prevalence of comorbidities, pain-related pharmacotherapy and healthcare resource use/costs (pharmacy, outpatient, inpatient, total) were examined during the 12 months preceding (pre-index) and following (follow-up) the date of the first pregabalin or duloxetine prescription. Both cohorts had multiple comorbidities and a substantial pain medication burden. Among pregabalin patients, use of other anticonvulsants (35.6% vs. 24.7%) and tricyclic antidepressants significantly decreased (18.2% vs. 13.7%) and serotonin-norepinephrine reuptake inhibitors (SNRIs) increased (7.9 % vs. 12.9%) in the follow-up period; all P values <0.05. Among duloxetine patients, use of other SNRIs (8.7% vs. 5.2%) and selective serotonin reuptake inhibitors decreased significantly (32.1% vs. 18.9%) in the follow-up period, but there were increases for anticonvulsants (42.1% vs. 48.4%), benzodiazepines (25.5% vs. 32%), and sedative/hypnotics (22.6% vs. 25.8%); all P values <0.05. Among pregabalin and duloxetine patients there were increases (P<0.05) in pharmacy, outpatient, and total healthcare costs from the pre-index to the follow-up period. Total medication costs in the follow-up period were significantly higher for duloxetine (median $6,763 [IQR $3,970-$10,914]) relative to pregabalin (median $6,059 [IQR $3,277-$9,865]); P=0.0017. Patients with pDPN prescribed pregabalin and duloxetine were characterized by a substantial comorbidity and pain medication burden. Although there were no differences in total healthcare costs, medication costs were significantly higher in the duloxetine cohort relative to the pregabalin cohort.

The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial

Direct healthcare costs of patients with symptomatic diverticular disease randomized for either laparoscopic or open elective sigmoid resection are compared. Cost-effectiveness analysis of the laparoscopic approach compared with open sigmoid resections is presented. An economic evaluation of the randomized control Sigma trial was conducted, comparing elective laparoscopic sigmoid resection (LSR) to open sigmoid resection (OSR) in patients with symptomatic diverticulitis. Prospective registration of detailed intervention units per patient resulted in actual resource use per individual patient. To avoid distributional assumptions, the nonparametric bootstrap was applied. For the cost-effectiveness analysis, differences in total cost between LSR and OSR were compared with the differences in VAS pain score, SF-36 values for general health, and complication rate. The difference in total healthcare costs between the group that received LSR (euro 9969) and the group that received OSR (euro 9366) was not statistically significant. The slight increase in total costs was determined mainly by the significantly higher operation costs of LSR (euro 6663 vs. euro 5306). Lower costs for hospitalization (euro 2983 vs. euro 3598), blood products (euro 87 vs. euro 240), paramedical services (euro 157 vs. euro 278), and emergency attendance (euro 72 vs. euro 115) in the LSR group partially compensated these increased operation costs. The incremental cost-effectiveness ratios (ICER) indicate that improvements in pain, quality of life, and complication rate could be achieved at limited costs. Total healthcare costs of laparoscopic and open elective sigmoid resections for symptomatic diverticular disease are similar. As the clinical outcomes are in favor of the LSR group, candidates for an elective sigmoid resection should preferably be approached laparoscopically.

Healthcare costs in renal transplant recipients using branded versus generic ciclosporin

Generic ciclosporin A modified (CsA) does not have an equivalent pharmacokinetic profile to branded CsA in some transplant populations, potentially leading to negative clinical consequences and increased long-term costs. To assess direct healthcare costs for de novo renal transplant recipients in the US receiving branded versus generic CsA in the first month after transplantation. Administrative claims data from eight private US health plans were linked to the Organ Procurement and Transplantation Network data. A total of 227 renal transplant cases between 1996 and 2004 were included: 183 were dispensed branded CsA and 44 received generic CsA. Log transformed multiple linear regression was used to model total first-year healthcare costs after the initial CsA claim, controlling for both patient demographics and clinical characteristics and clustering at the transplant centre level. After controlling for patient factors and pre-CsA costs, total healthcare costs were significantly higher (p = 0.04) for patients receiving generic CsA versus branded CsA. The main driver for the difference was the cost associated with immunosuppressants other than CsA (p = 0.01). Despite initial perceived cost savings associated with generic CsA, de novo renal transplant recipients incurred greater total healthcare costs than those treated with branded CsA. Patients receiving generic CsA may need higher doses or other immunosuppressants to maintain the transplanted kidney than patients receiving branded CsA. Providers and payers need to be aware of potential differences in total healthcare costs between formulations of bioequivalent critical-dose drugs to make the best choice for patient care.

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients

Objective This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures. Design This study is a randomised controlled trial. Participants This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture. Interventions The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients). Main outcome measure The outcomes measured included quality-adjusted life years (QALYs) and societal costs. Results At 12 months’ follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI) = −0.025, 0.078) while the mean difference in total health-care costs was €597 in favour of surgery (95% CI = −5291, 3777). Conclusion There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.

Fluoxetine. A pharmacoeconomic review of its use in depression.

Depressive illness is a common, often unrecognised and untreated condition with substantial associated costs, particularly indirect costs (e.g. lost productivity and absenteeism). The improved tolerability profile of fluoxetine and associated lower discontinuation rates, the relative safety of the drug in overdosage and its similar efficacy compared with tricyclic antidepressants have provided the main rationale for using this agent in depressed patients. Pharmacoeconomic analyses of fluoxetine have mainly sought to determine whether its higher acquisition cost in comparison with tricyclic antidepressants can be offset by reductions in other costs and whether the use of this agent as first-line therapy can be justified. Studies have also attempted to determine whether the selective serotonin reuptake inhibitors (SSRIs) can be distinguished from one another on pharmacoeconomic grounds; overall efficacy and tolerability of these agents appear to be similar, although tolerability data are conflicting. Most analyses have been of a retrospective database or clinical decision analytic model design; two prospective trials (one conducted in a naturalistic setting) have been conducted. These studies have mainly considered direct treatment costs only from the perspective of the healthcare payer. Available evidence suggests that overall total direct healthcare costs for patients who start antidepressant therapy with fluoxetine are similar to, or lower than, those for patients who start therapy with tricyclic agents or other SSRIs. Offsetting of the higher acquisition cost of fluoxetine compared with that of tricyclic agents may be accounted for by lower in- and outpatient costs with fluoxetine, a possible lower risk of absenteeism from work and lower mean total medical costs associated with acute overdosage. Between-treatment differences in drug use patterns may also, in part, explain the observed differences in total healthcare costs between fluoxetine and other antidepressants. In particular, patients beginning therapy with fluoxetine are more likely to receive treatment regimens that meet minimum recommended guidelines for dosage and duration and are less likely to require treatment switching/augmentation than those receiving tricyclic antidepressants or other SSRIs as initial therapy. In addition, fewer fluoxetine than tricyclic antidepressant recipients discontinue therapy early, and fewer fluoxetine recipients require upward dosage titration or concomitant anxiolytic/ hypnotic medications than patients receiving other SSRIs. In conclusion, fluoxetine is a well established antidepressant which possesses tolerability and safety advantages over the tricyclic agents. The available cost analyses show that these benefits can be obtained without additional overall cost to the healthcare provider. Cost advantages observed to date for fluoxetine over other SSRIs require confirmation.