Incremental Medical Costs Research Articles

Medical costs of sorafenib compared with sunitinib in treatment of patients <65 years with renal cell carcinoma: A retrospective claims database analysis

e17536 Background: Sorafenib (SR) and sunitinib (SU) are FDA approved (12/05 and 1/06, respectively) tyrosine kinase inhibitors for patients (pts) with advanced renal cell carcinoma (RCC). Little is known of their cost impact. We conducted this study to quantify overall direct costs (inpatient, outpatient, pharmacy) for each treatment in privately insured pts (<65 y). Given differences between private and public insurer payment scales, pts ≥65 y were not included in this study but are the subject of a planned further analysis. Methods: A retrospective US claims-based study was conducted using data covering all US census regions for ≥18 million lives from MarketScan MedStat (1/02–12/07). Inclusion criteria were ≥2 RCC claims (ICD-9 189.0, 198.0), continuous health care coverage, >180 days of coverage before RCC diagnosis. SR and SU pts were identified based on oral therapy after initial RCC-related claim (intent-to-treat). Observation period was from first drug-dispensing date until ≤12 mo or first of therapy switch, nephrectomy, disenrollment, or study end (12/31/07). Univariate and multivariate Tobit analyses were conducted; control factors included age, sex, region, plan type, comorbidity, prior Tx/procedures, and time since RCC Dx. Results: Of 10,462 RCC pts identified, 144 and 220 received initial therapy with SR and SU, respectively. In the 180 days before RCC diagnosis, total direct medical costs, baseline demographics, and comorbidities were similar between groups. The univariate incremental total monthly medical cost for SU was $2,049 (P<.001) more than for SR, representing yearly costs for SU $24,588 more than for SR. Multivariate analyses for incremental total monthly costs for SU also remained significant at $1,399 (P<.001). Conclusions: Retrospective analysis of this US claims database for RCC pts <65 treated first with SR showed statistically significant lower total medical costs (particularly inpatient costs) than for pts treated first with SU. [Table: see text] [Table: see text]

Gastro-oesophageal acid-related disease, co-morbidity and medical care cost

To analyse the incremental medical care cost of gastro-oesophageal acid-related disease (GERD), and its interactive effects with other diagnoses. A retrospective cohort study was conducted. Six hundred GERD patients were randomly selected and 600 non-GERD patients were selected, matched by age, gender, prescription pharmaceutical benefits and insurance status. Information on demographics, direct medical care cost (DMC) (inpatient, ambulatory and pharmaceuticals) and health service utilization was obtained from a large, not-for-profit managed-care organization across 3 years (1996-1998). DMCs were compared between GERD and non-GERD groups using the bootstrap method. Random coefficient log linear regression models were used to analyse incremental cost and assess its association with other diagnoses. The mean annual DMC for the GERD group was $4906, as compared to $2054 for the non-GERD group. The increase in the DMC in the GERD group was attributable to increased co-morbidity. Age and gender had no effect on total cost for the GERD population. Among costs of services, the GERD group had a 2.00-fold higher cost associated with outpatient services, a 1.70-fold higher cost associated with inpatient services, and a 2.70-fold higher cost associated with pharmacy. GERD is a chronic disease often associated with other diagnoses that significantly affect total DMC. Although the direct cost of treating GERD is low, patients with GERD had significantly higher total medical care cost than those without GERD. The addition of one more disease to a person's existing group of diseases has an important long-term health cost impact.

Medical Costs of Untreated Anemia in Elderly Patients with Predialysis Chronic Kidney Disease

The objective of this study was to quantify the incremental medical costs that are associated with untreated anemia among elderly patients with predialysis chronic kidney disease (CKD). An analysis of claims and laboratory data between January 1999 and February 2005 was conducted. Inclusion criteria were age >/=65 yr, two or more hemoglobin readings, one or more claims for CKD, and two or more GFR values of <60 ml/min per 1.73 m(2) (stages 3 to 5 CKD). Patients were excluded when they had cancer or lupus, had received organ transplantation, or were treated for anemia. An open-cohort design was used to classify patients' observation periods into anemia and nonanemia. Both univariate and multivariate analyses were conducted to compare periods of anemia and nonanemia for average monthly medical costs; the latter was adjusted for age, gender, GFR, diabetes, hypertension, liver cirrhosis, coronary artery disease, myocardial infarction, and left ventricular hypertrophy. A subset analysis of patients with moderate CKD (stage 3) was conducted. A total of 2001 patients were identified. Untreated anemia was associated with a significant increase in medical costs, with an unadjusted incremental monthly cost of $1089 (P < 0.0001) and a cost ratio of 1.8:1 relative to nonanemia. After controlling for covariates, untreated anemia remained significantly associated with a cost increase (adjusted incremental monthly cost $503; cost ratio 1.4:1; P < 0.0001). Similar significant cost burden was observed in the subset of patients with moderate CKD. The retrospective observational design may be more susceptible to bias than a randomized, controlled trial. This large study, which was based on real-life practice data, demonstrated that untreated anemia in elderly patients with predialysis CKD was associated with a significant increase in medical costs.

Direct medical costs associated with Parkinson's disease: A population‐based study

The objective was to provide population-based estimates of incremental medical costs associated with Parkinson's disease (PD) from onset forward. All Olmsted County, Minnesota, residents with confirmed PD onset from 1987 through 1995 (n = 92) and one age- and sex-matched non-PD referent subject per case were identified with retrospective record review and followed in provider-linked billing data for direct medical costs (excluding outpatient pharmaceutical costs) from 1 year before index (i.e., year of symptom onset) through 10 years after index. Costs for each referent subject were subtracted from those for his/her matched case. Tests for statistical significance used Wilcoxon signed ranks. Preindex costs were similar [median difference in annual costs (MD) = -3 dollars; P = 0.59]. One year post index, PD subjects exhibited borderline significantly higher costs compared to referent subjects (MD = 581 dollars; P = 0.052); the difference diminished over 5 years (MD = 118 dollars; P = 0.82). By 5 to 10 years, however, PD subjects exhibited significantly higher costs (MD = 1,146 dollars; P = 0.01). Over the full 10 years, excess costs were concentrated among PD subjects without rest tremor (MD = 2,261 dollars, P < 0.01, for those without tremor and -229 dollars, P = 0.99, for those with tremor). These population-based estimates of PD-associated direct medical costs from onset forward can uniquely inform policy decisions and cost-effectiveness research.

Chemotherapy-Induced Emesis: Quality of Life and Economic Impact in the Context of Current Practice in Canada

In this study, we estimated the proportion of patients who experience chemotherapy-induced nausea and vomiting (CINV) in current practice and evaluated the impact of CINV on quality of life and cost in Canada. Patients receiving highly emetogenic chemotherapy were recruited from 4 Canadian oncology centers. Patients used diaries to record information on their activities, incidence of nausea and vomiting, and health resources consumed each day for 5 days following chemotherapy. They also completed the Functional Living Index–Emesis (FLIE) questionnaire and a health utility instrument before chemotherapy and 5 days later. Of the 323 patients recruited, 266 (82%) completed their diary. On day 1, 26% of patients reported nausea or vomiting (acute emesis). From day 2 to day 5 after chemotherapy, 44% reported nausea or vomiting (delayed emesis). Patients who experienced nausea or vomiting during the study period had a decrease in FLIE score of 22% and a decrease in health utility of 15%. Patients with nausea or vomiting reported an average of 19 hours per cycle during which they were unable to perform their normal activities. Also, friends or relatives spent an average of 10 hours helping these patients. Incremental medical costs per patient experiencing CINV were $61 Canadian. Including productivity losses, total incremental costs were $592 Canadian per patient. Despite use of antiemetics, CINV remains problematic, impacting the quality of life of patients with cancer and increasing costs.

Health plan budget impact analysis for pimecrolimus.

Budget impact models are useful tools for managed care organizations to make drug formulary decisions. The objective of this study was to estimate the incremental budgetary change in per-member-per-month (PMPM) medical and pharmacy costs for atopic dermatitis (AD) or eczema after the introduction of pimecrolimus cream 1%, a topical calcineurin inhibitor. Estimates of the percentage of patients seeking care, treatment patterns, and quantities of medications dispensed for AD were measured using 2001 and 2002 medical and pharmacy records in a proprietary database for health plans distributed throughout the United States. Approximately 2.5 million health plan members had continuous health insurance coverage during the study period. Costs for medications were assigned using the 2003 wholesale acquisition cost, and costs for physician visits were based on average 2003 Medicare reimbursement rates. Efficacy data from clinical trials were used to model the impact of pimecrolimus on subsequent physician visits. Sensitivity analyses were performed to evaluate the impact of varying the percentage of patients seeking care, practice patterns, medication quantities, percentage of pimecrolimus users, and levels of patient cost sharing. The estimated percentage of health plan members seeking care for AD in 2001 was 3.2%. The estimated total cost PMPM for AD treatment prior to introduction of pimecrolimus was 0.362 dollars for all covered lives, assuming no patient cost sharing. In the year after its introduction, 5.2% of the AD population filled a prescription for pimecrolimus. The incremental increase in pharmacy benefit cost was 0.008 dollars PMPM in 2003 dollars, but the total incremental medical and pharmacy cost was 0.002 dollars PMPM after accounting for the projected reduction in physician visit costs, representing a 0.7% increase in all AD-related costs. Based on sensitivity analyses, the incremental total cost PMPM after the introduction of pimecrolimus ranged from -0.004 dollars to 0.026 dollars. Using claims data for the medical treatment of AD in 2001-2002 and the utilization of pimecrolimus, the addition of pimecrolimus as a treatment option for AD had a minimal impact on PMPM costs for AD-related care in 2003 dollars. As with all pharmacoeconomic models, health plans should perform their own budget forecasting using assumptions derived from their own pharmacy and medical claims data.

Feasible economic strategies to improve screening compliance for colorectal cancer in Korea

While colorectal cancer (CRC) is an ideal target for population screening, physician and patient attitudes contribute to low levels of screening uptake. This study was carried out to find feasible economic strategies to improve the CRC screening compliance in Korea. The natural history of a simulated cohort of 50-year-old Korean in the general population was modeled with CRC screening until the age of 80 years. Cases of positive results were worked up with colonoscopy. After polypectomy, colonoscopy was repeated every 3 years. Baseline screening compliance without insurance coverage by the national health insurance (NHI) was assumed to be 30%. If NHI covered the CRC screening or the reimbursement of screening to physicians increased, the compliance was assumed to increase. We evaluated 16 different CRC screening strategies based on Markov model. When the NHI did not cover the screening and compliance was 30%, non-dominated strategies were colonoscopy every 5 years (COL5) and colonoscopy every 3 years (COL3). In all scenarios of various compliance rates with raised coverage of the NHI and increased reimbursement of colonoscopy, COL10, COL5 and COL3 were non-dominated strategies, and COL10 had lower or minimal incremental medical cost and financial burden on the NHI than the strategy of no screening. These results were stable with sensitivity analyses. Economic strategies for promoting screening compliance can be accompanied by expanding insurance coverage by the NHI and by increasing reimbursement for CRC screening to providers. COL10 was a cost-effective and cost saving screening strategy for CRC in Korea.

Cost-effectiveness of vaccination against invasive pneumococcal disease among people 50 through 64 years of age: role of comorbid conditions and race.

Guidelines are increasingly recommending preventive services starting at 50 years of age, and policymakers are considering such a recommendation for pneumococcal polysaccharide vaccination. The finding that pneumococcal vaccination is cost-saving for people 65 years of age or older raises the question of the vaccination's implications for other older adults, especially black people, whose disease incidence exceeds that of nonblack people, and those with high-risk conditions. To assess the implications of vaccinating black and nonblack people 50 through 64 years of age against invasive pneumococcal disease. Cost-effectiveness analysis. Published literature for vaccination effectiveness and cost estimates; data on disease incidence and case-fatality rates from the Centers for Disease Control and Prevention. Hypothetical cohort 50 through 64 years of age with the 1995 U.S. age distribution. Lifetime. Societal. Pneumococcal polysaccharide vaccination compared with no vaccination. Incremental medical costs and health effects, in quality-adjusted life-years per vaccinee. Vaccination saved medical costs and improved health among high-risk black people (27.55 dollars savings per vaccinee) and nonblack people (5.92 dollars savings per vaccinee), excluding survivors' future costs. For low-risk black and nonblack people and the overall general population, vaccination cost 2477 dollars, 8195 dollars, and 3434 dollars, respectively, to gain 1 year of healthy life. Excluding survivors' future costs, in the general immunocompetent population, cost per quality-adjusted life-year in global worst-case results ranged from 21 513 dollars for black people to 68 871 dollars for nonblack people; in the high-risk population, cost ranged from 11 548 dollars for black people to 39 000 dollars for nonblack people. In the global best case, vaccination was cost-saving for black and nonblack people in the general immunocompetent and high-risk populations, excluding survivors' future costs. The cost-effectiveness range was narrower in probabilistic sensitivity analyses, with 95% probabilistic intervals ranging from cost-saving to 1594 dollars for black people and from cost-saving to 12 273 dollars for nonblack people in the general immunocompetent population. Costs per quality-adjusted life-year for low-risk people with case-fatality rates from 1998 were 2477 dollars for black people and 8195 dollars for nonblack people, excluding survivors' medical costs. These results support the current recommendation to vaccinate high-risk people and provide useful information for considering extending the recommendation to the general population 50 through 64 years of age. Lack of evidence about the effectiveness of revaccination for people 65 years of age or older, when disease risks are higher, argues for further research to guide vaccination policy.

The cost-effectiveness of photodynamic therapy for fellow eyes with subfoveal choroidal neovascularization secondary to age-related macular degeneration

Purpose Photodynamic therapy (PDT) has recently been demonstrated to be beneficial for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD). Herein, we determine the cost-effectiveness of PDT for the treatment of subfoveal choroidal neovascularization (CNV) in patients with disciform degeneration in one eye and whose second and better-seeing eye develops visual loss secondary to predominantly classic subfoveal CNV. The analysis was performed from the perspective of a for-profit third-party insurer. Design Cost-utility Markov models were created to determine the cost-effectiveness of PDT under two different scenarios, by using efficacy data derived from the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study and patient-based utilities. Methods Decision analyses were performed by incorporating data from the TAP Study, expected longevity data, and patient-based utilities. Cost-effective models were then created by incorporating incremental medical costs. Various sensitivity analyses were carried out to determine the robustness of our models. A Monte Carlo simulation was also used to determine whether there was a significant difference in quality-of-life adjusted years (QALYs) gained between PDT therapy and the placebo. Results For the hypothetical patient whose second and better-seeing eye becomes affected and who has 20/40 vision at baseline in this affected eye (base case 1), PDT was associated with a 10.7% relative increase in their quality-of-life (treatment conferred an additional undiscounted 0.1342 QALYs over a 2-year period). For the hypothetical patient whose second and better-seeing eye becomes affected and who has 20/200 vision at baseline in this affected eye (base case 2), PDT was associated with a 7.8% relative increase in their quality-of-life (treatment conferred an additional undiscounted 0.0669 QALYs over a 2-year period). Sensitivity analysis showed our models were robust and that PDT was usually the dominant treatment choice. Our cost-effective model demonstrated that the cost for a QALY was $86,721 (US dollars discounted at 3%) for base case 1, assuming 5.5 treatments; and $173,984 (USD discounted at 3%) for base case 2. Conclusions PDT will cost a third-party insurer $86,721 for an AMD patient with 20/40 vision in the better-seeing eye to obtain one QALY and $173,984 for an AMD patient with 20/200 vision in the better-seeing eye to obtain one QALY. PDT can be considered to be a treatment that is of only minimal cost-effectiveness for AMD patients who have subfoveal CNV in their second and better-seeing eyes and who have good presenting visual acuity at baseline. It is a cost-ineffective treatment for AMD patients who have poor visual acuities in their affected better-seeing eyes.

The cost-effectiveness of early vitrectomy for the treatment of vitreous hemorrhage in diabetic retinopathy.

Diabetic vitrectomy has been found to be efficacious for the treatment of vitreous hemorrhage secondary to diabetic retinopathy. The purpose of this study is to determine the cost-effectiveness of early vitrectomy for the management of vitreous hemorrhage secondary to diabetic retinopathy. The analysis was performed from the perspective of a third-party insurer. A cost-utility Markov model was used to determine the cost per quality-adjusted life year (QALY) gained from early versus deferral of vitrectomy. The model used 2-, 3-, and 4-year results from the Diabetic Retinopathy Vitrectomy Study, patient-based utilities, life expectancy data, and incremental medical costs. Early vitrectomy was the dominant strategy and was associated with a gain of 0.41 QALYs over the 57-year expected life span for a hypothetical patient. The cost per additional QALY gained from early vitrectomy treatment was $1910 (US$ discounted at 3%). When sensitivity analyses were performed by varying efficacy probabilities and utilities across their 95% confidence intervals, early treatment was always the dominant strategy. Additionally, even at the extreme sensitivity values, the cost per QALY of early vitrectomy treatment remained under $10,000. Overall, early vitrectomy for the treatment of vitreous hemorrhage secondary to diabetic retinopathy is highly cost-effective.

Type 2 diabetes: incremental medical care costs during the 8 years preceding diagnosis.

To describe and analyze medical care costs for the 8 years preceding a diagnosis of type 2 diabetes. From electronic records of a large group-model health maintenance organization (HMO), we ascertained the medical care costs preceding diagnosis for all members with type 2 diabetes who were newly diagnosed between 1988 and 1995. To isolate incremental costs (costs caused by the future diagnosis of diabetes), we subtracted the costs of individually age- and sex-matched HMO members without impending diabetes from the costs of members who were destined to receive this diagnosis. We also compared these prediagnosis costs with the first 3 years of postdiagnosis costs. An economic burden from impending diabetes is apparent for at least 8 years before diagnosis, beginning with costs for outpatient and pharmacy services. Diabetes-associated incremental costs (costs of type 2 diabetic patients minus matched costs of nondiabetic patients) averaged $1,205 per type 2 diabetic patient per year during the first eight prediagnostic years, including $1,913 each year for the 3 years preceding diagnosis. In the year immediately preceding diagnosis, incremental costs were equivalent to those observed in the second and third years after diagnosis. Incremental costs of diabetes begin at least 8 years before diagnosis and grow at an accelerating rate as diagnosis approaches and immediately after diagnosis. These incremental costs span the full range of medical services. Furthermore, the majority of these costs are for conditions not normally associated with diabetes or its complications.

Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis.

To describe and analyze the time course of medical care costs caused by type 2 diabetes, from the time of diagnosis through the first 8 postdiagnostic years. From electronic health maintenance organization (HMO) records, we ascertained the ongoing medical care costs for all members with type 2 diabetes who were newly diagnosed between 1988 and 1995. To isolate incremental costs (costs caused by the diagnosis of diabetes), we subtracted the costs of individually matched HMO members without diabetes from costs of members with diabetes. The economic burden of diabetes is immediately apparent from the time of diagnosis. In year 1, total medical costs were 2.1 times higher for patients with diabetes compared with those without diabetes. Diabetes-associated incremental costs (type 2 diabetic costs minus matched costs for people without diabetes) averaged $2,257 per type 2 diabetic patient per year during the first 8 postdiagnostic years. Annual incremental costs varied relatively little over the period but were higher during years 1, 7, and 8 because of higher-cost hospitalizations for causes other than diabetes or its complications. For the first 8 years after diabetes diagnosis, patients with type 2 diabetes incurred substantially higher costs than matched nondiabetic patients, but those high costs remained largely flat. Once the growth in costs due to general aging is controlled for, it appears that diabetic complications do not increase incremental costs as early as is commonly believed. Additional research is needed to better understand how diabetes and its diagnosis affect medical care costs over longer periods of time.

Incremental costs of enrolling cancer patients in clinical trials: a population-based study.

Payment for care provided as part of clinical research has become less predictable as a result of managed care. Because little is known at present about how entry into cancer trials affects the cost of care for cancer patients, we conducted a matched case-control comparison of the incremental medical costs attributable to participation in cancer treatment trials. Case patients were residents of Olmsted County, MN, who entered phase II or phase III cancer treatment trials at the Mayo Clinic from 1988 through 1994. Control patients were patients who did not enter trials but who were eligible on the basis of tumor registry matching and medical record review. Sixty-one matched pairs were followed for up to 5 years after the date of trial entry for case patients or from an equivalent date for control patients. Hospital, physician, and ancillary service costs were estimated from a population-based cost database developed at the Mayo Clinic. Trial enrollees incurred modestly (no more than 10%) higher costs over various follow-up periods. The mean cumulative 5-year cost in 1995 inflation-adjusted U.S. dollars among trial enrollees after adjustment for censoring was $46424 compared with $44 133 for control patients. After 1 year, trial enrollee costs were $24645 compared with $23 964 for control patients. This study suggests that cancer chemotherapy trials may not imply budget-breaking costs. Cancer itself is a high-cost illness. Clinical protocols may add relatively little to that cost.

Allergic rhinitis in Rochester, Minnesota residents with asthma: Frequency and impact on health care charges

Background: Asthma is a common and costly condition. Concomitant asthma and allergic rhinitis (AR) have been shown to increase the medication costs for people with asthma. No studies have compared medical care costs of those with and without concomitant AR. Objectives: We sought to determine the prevalence and incremental medical care costs of concomitant AR. Methods: For each member of a population-based asthma cohort, we used all their medical charts within Olmsted County to record age at first diagnosis of asthma; the presence and age of any diagnosis of AR; and the total, ambulatory, and respiratory care–related costs of medical care. Costs were compared for age- and sex-specific strata of people with asthma who did and did not have AR. Results: AR was most commonly diagnosed in people whose asthma was diagnosed before age 25 (prevalence of 59%) and uncommonly diagnosed in anyone after age 40 (prevalence <15%). Yearly medical care charges were on average 46% higher for those with asthma and concomitant AR than for persons with asthma alone, controlling for age and sex. We were unable to assess the impact of treatment of AR on medical care charges. Conclusions: Physicians should consider the diagnosis of AR (prevalence >50%) in all symptomatic children and young adults with asthma. Further evaluation is necessary to evaluate the ability of treatment to decrease the incremental costs of AR in persons with asthma. (J Allergy Clin Immunol 1999;103:54-9.)

Economic evaluation of vaccination against influenza in New Zealand.

The objective of this study was to evaluate the costs and benefits of influenza vaccination for the population aged 65 years and over, from the perspectives of individuals and health insurers, government and society. The annual incremental direct medical costs and benefits of influenza vaccination (compared with the nonvaccination, or 'do nothing', option) were evaluated using New Zealand healthcare resource usage and unit cost data [in 1992 New Zealand dollars ($NZ); $NZ1 = $US0.5458, June 1992] applied to cohort studies reported in the literature. The costs and benefits to society as a result of vaccination of people aged 65 years and older (20% of people in this age group are currently vaccinated) were estimated to be: (i) additional direct medical costs of vaccination of $NZ1.42 million [$NZ17.78 per vaccination]; (ii) direct medical costs avoided of $NZ5.35 million ($NZ67.18 per vaccination); and (iii) net benefits of $NZ3.93 million ($NZ49.40 per vaccination). The direct medical costs avoided per dollar cost of vaccination were $NZ1.04 for individuals, $NZ4.69 for government and $NZ3.78 for society as a whole. If the vaccination uptake for this group is increased in 20% increments, the net benefit to society increases by a further $NZ3.93 million per year at each step. If the economic evaluation is extended to include vaccination of at-risk individuals under 65 years of age, net benefits to society increase by 15%. Influenza vaccination for people aged 65 years and over is cost effective from the perspective of society, government and the individual. If the vaccination rate for at-risk individuals in New Zealand could be increased to 60%, the net benefits reported in this study would increase by 200%. However, the costs of promotion and education to achieve this vaccination rate would need to be deducted from the net benefits. Strategies to increase the vaccination rate include altering the cost of vaccinations to the individual, intensifying education and promotion programmes, and changing the mode of delivery.