Direct Medical Care Research Articles

An Economic Evaluation of Atorvastatin for Primary Prevention of??Cardiovascular Events in Type??2??Diabetes

The CARDS trial, a multicentre, randomized, controlled trial, found that atorvastatin 10 mg/day for patients with type 2 diabetes mellitus and normal low-density lipoprotein (LDL)-cholesterol significantly reduced cardiovascular (CV) events, including stroke. We estimated the cost effectiveness of atorvastatin as primary prevention against CV disease from the short-term and lifetime US payer perspectives. We constructed a decision analytic (Markov) model to evaluate long-term costs and outcomes for atorvastatin 10 mg/day versus no HMG-CoA reductase inhibitor (statin) therapy for patients with type 2 diabetes and no history of a CV event. CV event rates and survival were based on risk equations calibrated to CARDS and applied to a US type 2 diabetes population; the atorvastatin effect on CV events was based on hazard ratios from CARDS; direct medical care costs were based on US treatment patterns and published costs analyses of patients with diabetes. Costs were valued in $US, year 2005 values; costs and benefits were discounted at 3% per annum. Within the time horizon of the trial (5 years), the cost effectiveness of atorvastatin was $US137 276 per QALY. At 10 years, the incremental cost per QALY improved to $US3640 per QALY. At 25 years, overall costs were lower and QALYs higher in the atorvastatin arm. Costs of managing CV events were lower after 5 years for patients treated with atorvastatin. For patients with type 2 diabetes and one additional risk factor for CV disease, normal LDL-cholesterol and no history of a CV event, primary prevention with atorvastatin appears to be cost saving and improve outcomes over 25 years, although it is costly from a short-term US payer perspective. From both a medical and an economic viewpoint, primary prevention is desirable in this patient population.

The Direct and Indirect Cost Burden of Illness of Ulcerative Colitis

Purpose: To estimate the direct medical costs and indirect costs (productivity related) for commercially-insured patients with Ulcerative Colitis. Methods: Data were obtained from the 1999 to 2005 MarketScan Commercial Claims and Encounters (CCAE), Medicare Supplemental, and Health and Productivity Management databases. Patients with a diagnosis of Ulcerative Colitis and at least a 1-year disease-free pre-period were found resulting in 8,970 nonelderly patients with Ulcerative Colitis and 2,958 elderly patients with Ulcerative Colitis. 12-month direct medical care expenditures (medical and prescription drug) for patients with Ulcerative Colitis were compared to expenditures among an equal number of propensity-score matched comparison group members. Propensity scores were estimated via demographic characteristics and comorbidities. Indirect costs, as measured by absenteeism and short-term disability costs, were compared for a sub-sample of employees in each group. Regression analysis controlled for demographic and case mix factors. A range of cost burden estimates were produced by varying the estimation and matching techniques. Results: Average 12-month direct medical care expenditures were $4,982 for nonelderly and $8,572 for elderly comparison group members. Average estimated direct medical expenditures for patients with Ulcerative Colitis exceeded comparison group members by as much as $11,331 for nonelderly patients and $6,609 for elderly patients (all P < .01). Average absenteeism costs were $6,021 for employees with Ulcerative Colitis, although this was not significantly different from the comparison group. Average short term disability expenditures were $1,386, which was almost three times the amount for the comparison group (P < .05). Conclusion: Ulcerative Colitis is a costly disorder and merits consideration as interventions are developed to manage the burden of disease and improve productivity.

Economic burden of metastatic bone disease in the U.S.

Previous research has documented the prevalence of primary bone cancer; however, there are few data available regarding the impact of metastatic bone disease (MBD) on national expenditure. In this study, the authors quantified the prevalence and direct medical care costs of patients with MBD and the resulting cost impact on U.S. oncology expenditure. Anonymous, patient-level data on health care utilization and cost were obtained from the Thomson Medstat MarketScan research databases. In total, 396,200 patients who were diagnosed with cancer between 2000 and 2004 were selected for the study. Patients with MBD were matched subsequently to non-MBD controls. A 2-part linear regression model was used to compare cases with controls to quantify the incremental cost associated with the disease. Cancer prevalence in the U.S. during the study period was estimated at 4,861,987 cases annually, and 5.3% (n=256,137) of those patients had MBD. Rates of MBD were highest in patients with multiple myeloma (28.8%) and lung cancer (15.6%). The mean direct medical cost for all cancers combined was $75,329 for patients with MBD and $31,382 for controls. Regression-adjusted, incremental costs were $44,442 (P<.001) across all cancer types. The incremental cost was highest for patients with multiple myeloma ($63,455) and lowest for patients with lung cancer ($24,946). The national cost burden for patients with MBD was estimated at $12.6 billion, which is 17% of the $74 billion in total direct medical cost estimated by the National Institutes of Health, suggesting that MBD is a significant driver of overall oncology cost.

The Lifetime Distribution of the Incremental Societal Costs of Autism

To describe the age-specific and lifetime incremental societal costs of autism in the United States. Estimates of use and costs of direct medical and nonmedical care were obtained from a literature review and database analysis. A human capital approach was used to estimate lost productivity. These costs were projected across the life span, and discounted incremental age-specific costs were computed. United States. Hypothetical incident autism cohort born in 2000 and diagnosed in 2003. Discounted per capita incremental societal costs. The lifetime per capita incremental societal cost of autism is $3.2 million. Lost productivity and adult care are the largest components of costs. The distribution of costs over the life span varies by cost category. Although autism is typically thought of as a disorder of childhood, its costs can be felt well into adulthood. The substantial costs resulting from adult care and lost productivity of both individuals with autism and their parents have important implications for those aging members of the baby boom generation approaching retirement, including large financial burdens affecting not only those families but also potentially society in general. These results may imply that physicians and other care professionals should consider recommending that parents of children with autism seek financial counseling to help plan for the transition into adulthood.

The Forest and the Trees: the Human Costs of Cancer

The Forest and the Trees: the Human Costs of Cancer

Pediatrics in the Community: The Earn-A-Bike Program

1. Robert J. Haggerty, MD As Pediatrics in Review begins a new series focusing on community pediatrics, we are privileged to begin with an introduction by one of the most influential leaders in that area, Dr Robert J. Haggerty, the founding editor of this journal.—LFN The quality of children’s health results from many factors other than the direct medical care they receive in physicians’ offices, important as that is. Critical are the physical, psychosocial, educational, and recreational environments in which they live. All of these make up a healthy community for children. The concept of community pediatrics includes dedication to serving all children in a community and to working with other individuals to improve the environment of the communities in which children live as well as to ensure their access to medical care. It is entirely appropriate that Pediatrics in Review begin a section on community pediatrics. This journal has been dedicated, since its inception 27 years ago, to meeting pediatricians’ need for up-to-date reviews designed to help them deliver better health care to children. Our readers serve the children in their offices well, but many do even more in the wider community. In an article I wrote in Pediatrics in 1999, (1) I observed that there were a number of successful examples of programs that teach the “how to do it” of …

Supplement Editorial

The Prevention Instrument project of the Alzheimer's Disease Cooperative Study (ADCS) seeks to develop instruments to assess treatment efficacy including potential economic benefit. The Resource Use Inventory (RUI) is an instrument that has been used to capture resource utilization and costs in populations with Alzheimer disease (AD). However, resource utilization and costs for healthy, cognitively intact elderly as they begin to demonstrate cognitive deterioration are not well understood. In addition, the loss that relates to the subjects' own time as they transition through cognitive impairment is not well documented.To evaluate the utility of the RUI in a sample of cognitively intact elderly individuals living in the community and enrolled in AD prevention trials.The RUI was administered to 644 subjects and their study partners either at home or in the clinic. For half of each sample, 3-month retesting was carried out. The RUI consisted of 9 questions. The first part of the RUI captured subjects' use of direct medical care (eg, hospitalizations) and nonmedical care (eg, home health aides). The second part of the RUI captured the time caregivers spend providing care to the subjects. The third part of the RUI captured subjects' participation in volunteer work and employment. The assessment interval for each question was the past 3 months.The percentage of RUI forms returned incomplete or inaccurate for both in-clinic and at-home groups was extremely low. There were no differences in utilization rates between in-clinic and at-home group for all items in the RUI. Except for use of outpatient procedures, tests, or treatments, there were no differences in utilization rates between subjects who filled out the RUI with the help of their study partners or by themselves. Items in the RUI were sensitive to subjects' cognitive and functional status and demographic characteristics.Home-based completion of the RUI by participants in an AD prevention study is feasible, and seems to provide data that are reliable and valid. The instrument will be useful for tracking resource and time use through transition from healthy to cognitive impairment.

The Association Between Activity-Based Costing System Adoption and Hospital Performance

This study explores the relation between activity-based costing (ABC) information use and four measures of hospital performance - profitability, revenue enhancement, cost containment, and societal commitment. Specifically, we address the issue of whether, relative to non-adopters, hospitals enhance revenues, reduce costs, increase profitability, and display a greater commitment to the community after the implementation of activity-based costing strategies. We further explore whether the adoption of ABC affects performance and utilization differently depending on ownership type (for profit, non-profit, or government). The empirical evidence suggests that activity-based costing procedures produced mixed results in the two ownership groups. The presence of an advanced cost management strategy in the for-profit sector was associated with increased profitability (return on beds). In contrast, activity-based costing procedures in the government/non-profit sector were associated with enhanced revenue-producing activities, such as increased inpatient admissions and outpatient visits. While no evidence of improved cost controls was uncovered, government/non-profit adopters maintained pre-adoption levels of direct medical care, while non-adopters reduced costs by eliminating value-adding medical personnel. Society does not appear to benefit, however, from the adoption of ABC in the government/non-profit sector through the purchase of larger amounts of productive assets or the provision of added amounts of charity care. Indeed, adopters and non-adopters, alike, displayed positive changes in their community involvement in the post-adoption period. To sum, healthcare providers in both sectors utilized advanced cost management strategies in different ways to adapt to adverse changes in their unique environments.

Measuring the full economic costs of diet, physical activity and obesity‐related chronic diseases

Most studies that have focused on the costs of obesity have ignored the direct effects of obesity-related patterns of diet and physical activity. This study reviews the full effects of each component--poor dietary and physical activity patterns and obesity--on morbidity, mortality and productivity. The direct healthcare costs are based on a review of the effects of these factors on key diseases and the related medical care costs of each disease. The indirect costs on reduced disability, mortality and sickness during the period of active labour force participation prior to retirement are also examined. A case study is prepared for China to provide some guidance in the utilization of this review for economic analysis of obesity. The case study shows that the indirect costs are often far more important than the direct medical care costs. The Chinese case study found that the indirect effects of obesity and obesity-related dietary and physical activity patterns range between 3.58% and 8.73% of gross national product (GNP) in 2000 and 2025 respectively.

An economic analysis of National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) JBR.10, a randomized trial of adjuvant vinorelbine plus cisplatin versus observation in early stage non-small cell lung cancer (NSCLC)

7155 Background: NCIC CTG JBR.10 is among the landmark trials to establish 3rd generation platinum-based adjuvant chemotherapy as standard of care after complete resection of stages IB-II NSCLC, improving 5-year survival by 15% and median survival by 21 months (p 0.04). The cost-effectiveness of adjuvant chemotherapy from the perspective of Canada’s public health care system was undertaken in a retrospective analysis based on the JBR.10 study population. Methods: Direct medical resource utilization data, from prospective trial data of patients enrolled onto the BR.10 trial at the 5 largest accruing Canadian centres, were identified and collected retrospectively. Direct medical costs included treatment, hospitalization and procedures. Data were captured from the time of randomization until death or study closure (April, 2004). Non-medical direct and indirect costs were not included. Available costs are presented both with and without discounting at 5% per year. Costs (2005 $CAN) were obtained from provincial sources. Average costs per treatment arm (adjuvant chemotherapy vs. observation) were calculated. Basic demographic statistics were calculated. Results: Utilization data were collected from 172 patients (36% of the trial population), 83 randomized to observation and 89 to chemotherapy. Preliminary results are available for the non-drug related costs of direct medical care including hospitalization and procedures. The mean cost of treatment for patients in the observation arm is $15,323 (25–75% IQR $1,933-$17,831), and $18,701 (25–75% IQR $2,873-$18,781) for patients in the adjuvant chemotherapy arm (2005 $CAN). Conclusion: Non-drug related costs are only slightly higher in patients treated with adjuvant chemotherapy in the NCIC BR.10 trial, despite substantially longer survival for this group of patients. These preliminary results will be updated and cost effectiveness data will be available in May 2006. No significant financial relationships to disclose.

Economic burden of Parkinson's disease in a developing country: A retrospective cost analysis in Shanghai, China

We investigated economic costs from patients with Parkinson's disease (PD) in Shanghai, China, which could be used as a baseline for future evaluations. Data were collected from 190 patients by interview during 1-year period. Direct medical care costs averaged approximately Chinese yuan, renminbi (RMB) 4,305 (USD 519, or EUR 410) per year per patient, of which drugs (RMB 2,677) accounted for the major costly component. Nonmedical direct costs were much less than direct health care costs, averaging approximately RMB 3,301 (USD 398, or EUR 314). Costs due to loss of productivity averaged approximately RMB 73 (USD 8.8, or EUR 7.0) per patient per year. Taken together, the overall mean annual cost for PD in our series was approximately RMB 7,679 (USD 925, or EUR 731), and these costs accounted for around half of the mean annual income. Total cost was significantly associated with the disease severity and the frequency of outpatient visits. In addition, levodopa equivalent dose (LED) and the number of drugs being taken were also closely related with the drug cost. The results indicate that the economic burden of Chinese PD patients is heavy.

The Use of Spanish by Medical Students and Residents at One University Hospital

To describe how medical trainees report communication with Spanish-speaking patients, and to assess trainees' desire to improve their language skills and have those skills formally evaluated. A questionnaire was mailed to all fourth-year medical students and non-first-year residents in family practice, pediatrics, medicine, medicine-pediatrics, emergency medicine, and obstetrics-gynecology at the University of Rochester School of Medicine and Dentistry in 2004 (N = 263). The response rate was 92% (241/263). Each respondent had at least one year of clinical experience at the hospital. Of the 83% (199/241) who reported less than conversational Spanish language skills, 53% had taken a history and/or provided medical advice directly to Spanish-speaking patients without any form of interpretation. When an interpreter was used, professional interpretation services were used less frequently than other forms of interpretation (42% versus 58%, p < .05). Analyses were performed on the 68% (164/241) who reported having at least rudimentary Spanish skills: 85% reported that they would probably or definitely participate in further individual language training, 70% expressed at least possible willingness to have their Spanish formally evaluated, and 80% predicted that it is at least possible that they will use their Spanish as attending physicians. At the time of this study, this hospital's medical students and residents from multiple specialties used inadequate Spanish language skills to provide direct medical care despite the availability of professional interpretation services. Most of these trainees were motivated to improve their Spanish and would welcome evaluation of their language skills.

Clinical features associated with costs in early AD

Few studies on cost of caring for patients with Alzheimer disease (AD) have simultaneously considered multiple dimensions of disease costs and detailed clinical characteristics. To estimate empirically the incremental effects of patients' clinical characteristics on disease costs. Data are derived from the baseline visit of 180 patients in the Predictors Study, a large, multicenter cohort of patients with probable AD followed from early stages of the disease. All patients initially lived at home, in retirement homes, or in assisted living facilities. Costs of direct medical care included hospitalizations, outpatient treatment and procedures, assistive devices, and medications. Costs of direct nonmedical care included home health aides, respite care, and adult day care. Indirect costs were measured by caregiving time. Patients' clinical characteristics included cognitive status, functional capacity, psychotic symptoms, behavioral problems, depressive symptoms, extrapyramidal signs, comorbidities, and duration of illness. A 1-point increase in the Blessed Dementia Rating Scale score was associated with a $1,411 increase in direct medical costs and a $2,718 increase in unpaid caregiving costs. Direct medical costs also were $3,777 higher among subjects with depressive symptoms than among those who were not depressed. Medical care costs and unpaid caregiving costs relate differently to patients' clinical characteristics. Poorer functional status is associated with higher medical care costs and unpaid caregiving costs. Interventions may be particularly useful if targeted in the areas of basic and instrumental activities of daily living.

The Economic Cost of Physical Inactivity and Excess Weight in American Adults

Physical inactivity and excess weight in American adults have reached epidemic levels. This article describes how cost data from previously conducted analyses in several states were used to quantify the costs of physical inactivity and excess weight among American adults. Medical and workers' compensation cost data on selected medical conditions were obtained from various health plans and state agencies in seven states. Productivity loss norms were obtained from published studies. The estimated financial burden which includes direct medical care, workers' compensation, and productivity loss costs among the seven states is $93.32 billion for physical inactivity and $94.33 billion for excess weight. The estimated nationwide cost of these risk factors is approximately $507 billion with projected costs exceeding $708 billion in 2008. Projected cost-savings of $31 billion per year could be realized with a 5% drop in these risk factors. The cost of physical inactivity and excess weight among American adults is significant. More research on best-of-class interventions to curtail the high prevalence of these risk factors is needed.

What is the Cost to Employers of Direct Medical Care for Chronic Obstructive Pulmonary Disease?

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the United States. In 2000, an estimated 10.5 million people had COPD, of which more than 7.2 million were from the under-age 65 employed population. The prevalence of COPD in the workforce population was substantial with 46.5% of current employment among adults having the disease. However, the cost burden in the employed population is unknown. We examined COPD prevalence and costs in a large employment-based population. Using claims data from 1999 to 2003, we estimated the cost associated with COPD-related hospitalizations, emergency department visits, outpatient services, and prescription drug use. Per patient use of hospital care for COPD decreased during 1999 through 2003, including a decrease in the number of hospital admissions (from 0.10 in 1999 to 0.04 in 2003) and in the length of stay in hospitals (from 0.53 in 1999 to 0.17 in 2003). The number of outpatient visits, however, increased from 3.45 in 1999 to 3.80 in 2003. COPD-related per patient total medical costs decreased from $1460 in 1999 to $1138 in 2003 largely because of a decrease in the cost of hospitalizations for COPD. In contrast, mean per patient expenditures for outpatient services increased over the same period from $243 in 1999 to $295 in 2003. The cost of COPD to employers is high, but the cost could be reduced by programs aimed at preventing new cases of COPD, reducing hospitalizations, and providing more outpatient services to COPD patients.

A Cross-Sectional Comparison of Direct Medical Care Costs among COPD and Asthma Patients Living in the Community in Northern Ireland

Asthma and COPD are known to have significant health and economic consequences. Little is known about the costs of the latter in the UK. In this study we report the results of a comparison of the direct medical costs associated with COPD and asthma, where diagnoses are based on a robust prevalence study of a random sample of the Northern Ireland population. A two-stage survey was used to identify individuals with COPD and asthma. The diagnoses of asthma and COPD were based on patient history and lung function. Patients completed a detailed questionnaire covering healthcare utilization over the past 12 months, socioeconomic characteristics, impact of the disease on quality of life, and activities of daily living. Forty-nine patients were diagnosed with COPD and 57 with asthma. Three asthma patients were excluded from the main analysis because they were thought to have atypical inpatient stays or other resource use. The mean direct healthcare cost for each COPD patient was estimated at pound171.69 ($US309; year 2000 value) per annum, significantly less than the average cost of asthma among the 54 analyzed of pound544.54 ($US980) [p < 0.05]. A correlation analysis revealed that among COPD patients, disease severity, defined by lung function, was a significant predictor of costs. Community-based costs for asthma are greater than those for COPD; this may relate in part to a relative under-diagnosis of COPD (73.5% COPD vs 15.8% asthma). As anticipated, the cost of COPD increases as FEV(1) decreases. Further analysis will enable modeling of the cost consequences of both increased diagnosis and better management of COPD.

The NIEHS Responds to Hurricane Katrina

The NIEHS Responds to Hurricane Katrina

HEALTH RELATED QUALITY OF LIFE AND DIRECT MEDICAL CARE COST IN NEWLY DIAGNOSED YOUNGER MEN WITH PROSTATE CANCER

We evaluated health related quality of life (HRQOL) and the direct medical care cost (DMC) in young men receiving radical prostatectomy. In this prospective cohort study, 40 newly diagnosed patients with prostate cancer (PCa) who were younger than 65 years were matched with 40 cancer-free men. Participants completed the Medical Outcome Study Short Form and UCLA-PCa Index surveys prior to treatment, and at 3, 6, 12 and 24-month followup. Cost data were obtained from a hospital based administrative database and clinical data were obtained via structured medical chart review. Demographics and HRQOL were compared using the t, Fisher exact and chi-square tests. The Wilcoxon and log-T tests were used to compare DMC. Multivariate regression models were used to assess the incremental cost of PCa and predictors of 24-month prostate specific HRQOL. Patients with PCa had a mean annual DMC of 4,160 dollars for the treatment year with a mean length of stay of 3.5 days. They had 3-fold higher DMC than controls. At 12 months, generic HRQOL values were similar to baseline values. Sexual function showed trends toward improvement 6 months after surgery. Urinary function improved significantly by 6 months, although it decreased thereafter. Bowel function and bother returned to baseline values by 3 months. On multivariate regression marital status was a significant predictor of 5 domains of prostate specific HRQOL at 24 months. Patients with PCa reported weaker sexual function, urinary function and sexual bother at 2 years after treatment compared with their baseline values. There exists an opportunity for improving prostate specific HRQOL in men with early stage PCa.

Cost savings from use of emergency contraceptive pills in Australia

Emergency contraception, which prevents pregnancy after unprotected sexual intercourse, has the potential to reduce significantly the incidence of unintended pregnancy and the consequent need for abortion and to reduce medical care costs. To determine the savings generated by use of Postinor-2, the levonorgestrel regimen of emergency hormonal contraception, in Australia. We modelled the cost savings when women obtain Postinor-2 directly from a pharmacist where cost savings are measured as the cost of pregnancies averted by use of Postinor-2 per dollar spent on Postinor-2. Each dollar spent on a single treatment with Postinor-2 saves A$2.27-A$3.81 in direct medical care expenditures on unintended pregnancy depending on assumptions about savings from costs avoided by preventing mistimed births. Postinor-2 is cost-saving even under the least favourable assumption that mistimed births when prevented today occur 2 years later. Results are robust even to large changes in model input parameters. Emergency contraception is cost saving. More extensive use of emergency contraception could save considerable medical and social costs by reducing unintended pregnancies, which are expensive.

Burden of illness in Parkinson's disease

This study quantifies direct medical care costs for individual patients with Parkinson's disease (PD) and projects total national costs of PD. Anonymous, patient-level data on health care utilization and cost were obtained from Medstat's MarketScan Research Databases. Patients were selected for study if they had either two instances of a diagnosis of PD or one diagnosis and two or more prescriptions for PD-related medication. A control group of persons without PD was selected for comparison. Total annual health care utilization and costs were calculated for both PD patients and controls. A total of 20,016 patients with PD were identified and followed up for an average of 853 days. The mean age of the patients was 73.6 years, and 51.2% were women. Total annual direct costs were 23,101 US Dollars (SD 27,529) per patient with PD versus 11,247 US Dollars (SD 16,486) for controls. The regression-adjusted incremental direct cost of PD versus control was 10,349 US Dollars (95% confidence interval, 9,053, 11,645). Adding 25,326 US Dollars in indirect costs, and multiplying by 645,000 cases of PD in the United States, the total cost to the nation is projected to be 23 billion US Dollars annually. This estimate is higher than most previous studies, with important implications for health care delivery systems worldwide.