Savings In Medical Expenditures Research Articles

Modeling the economic value of cardiometabolic virtual-first care programs.

This study simulated the potential multiyear health and economic benefits of participation in 4 cardiometabolic virtual-first care (V1C) programs: prevention, hypertension, diabetes, and diabetes plus hypertension. Using nationally available data and existing clinical and demographic information from members participating in cardiometabolic V1C programs, a microsimulation approach was used to estimate potential reduction in onset of disease sequelae and associated gross savings (ie, excluding the cost of V1C programs) in health care costs. Members of each program were propensity matched to similar records in the combined 2012-2020 National Health and Nutrition Examination Survey files based on age, sex, race/ethnicity, body mass index, and diagnosis status of diabetes and/or hypertension. V1C program-attributed changes in clinical outcomes combined with baseline biometric levels and other risk factors were used as inputs to model disease onset and related gross health care costs. Across the V1C programs, sustained improvements in weight loss, hemoglobin A1c, and blood pressure levels were estimated to reduce incidence of modeled disease sequelae by 2% to 10% over the 5 years following enrollment. As a result of sustained improvement in biometrics and reduced disease onset, the estimated gross savings in medical expenditures across the programs would be $892 to $1342 after 1 year, and cumulative estimated gross medical savings would be $2963 to $4346 after 3 years and $5221 to $7756 after 5 years. In addition, high program engagement was associated with greater health and economic benefits. V1C programs for prevention and management of cardiometabolic chronic conditions have potential long-term health and financial implications.

Changes in clinical markers observed from pharmacist-managed cardiovascular risk reduction clinics in federally qualified health centers: A retrospective cohort study.

Reductions in hemoglobin A1c (HbA1C) have been associated with improved cardiovascular outcomes and savings in medical expenditures. One public health approach has involved pharmacists within primary care settings. The objective was to assess change in HbA1C from baseline after 3-5 months of follow up in pharmacist-managed cardiovascular risk reduction (CVRR) clinics. This retrospective cohort chart review occurred in eight pharmacist-managed CVRR federally qualified health clinics (FQHC) in Indiana, United States. Data were collected from patients seen by a CVRR pharmacist within the timeframe of January 1, 2015 through February 28, 2020. Data collected include: demographic characteristics and clinical markers between baseline and follow-up. HbA1C from baseline after 3 to 5 months was assessed with pared t-tests analysis. Other clinical variables were assessed and additional analysis were performed at 6-8 months. Additional results are reported between 9 months and 36 months of follow up. The primary outcome evaluation included 445 patients. Over 36 months of evaluation, 3,803 encounters were described. Compared to baseline, HbA1C was reduced by 1.6% (95%CI -1.8, -1.4, p<0.01) after 3-5 months of CVRR care. Reductions in HbA1C persisted at 6-8 months with a reduction of 1.8% ([95%CI -2.0, -1.5] p<0.01). The follow-up losses were 29.5% at 3-5 months and 93.2% at 33-36 months. Our study augments the existing literature by demonstrating the health improvement of pharmacist-managed CVRR clinics. The great proportion of loss to follow-up is a limitation of this study to be considered. Additional studies exploring the expansion of similar models may amplify the public health impact of pharmacist-managed CVRR services in primary care sites.

Longitudinal Association of Salaries for Medical Staff With Medical Service Utilization and Expenditure in China, 2007-2016.

Objectives: To test the hypothesis that higher salary levels of the medical staff are associated with lower medical service utilization and expenditure.Methods: Using longitudinal data from 31 Chinese provinces for the period 2007-2016, we constructed fixed effects models to analyze the association between the salary of medical staff and medical service utilization, medical expenditure, medication expenditure, and medication proportion.Results: A 10,000 CNY increase in medical staff's salaries was associated with a 0.89% decrease in the average number of annual inpatient admissions per person; 1.88 and 1.59% decreases in average expenditures per outpatient visit and inpatient admission, respectively; 3.05 and 2.66% decreases in drug expenditures per outpatient visit and inpatient admission, respectively; 0.58 percent point and 0.39 percent point decreases in the share of drug expenditure in outpatient and inpatient, respectively. When medical staff's salaries increased by 450,000 CNY, the turning point was reached when the maximum medical expenditure savings offset the medical staff salary increases, yielding a 634 billion CNY surplus from medical expenditure.Conclusions: Our results supported the hypothesis that higher salary levels of the medical staff are associated with lower medical service utilization and expenditure. Further studies are requested to test whether higher medical staff's salaries will attenuate over-treatment and that savings from reduced prescriptions and service charges will offset the increased salaries of medical staff.

Weight Loss-Associated Decreases in Medical Care Expenditures for Commercially Insured Patients With Chronic Conditions.

Objective:Savings associated with weight loss for populations with chronic conditions are poorly understood. The purpose of this study was to estimate medical expenditure savings associated with weight loss among commercially insured adults with chronic medical conditions.Methods: The:2001–2015 Medical Expenditure Panel Survey data were used to estimate the effect of changes in body mass index (BMI) on health expenditures from instrumental variable regression models.Results:Decreases in annual medical expenditures associated with a reduction in BMI of 1 kg/m2 varied by condition (eg, $289 for back pain and $752 for diabetes). The greater the weight loss, the greater the savings. The higher the baseline BMI, the greater the savings for similar levels of weight loss.Conclusions:The detailed estimates of savings for populations with chronic conditions can be used by employers to evaluate the cost-effectiveness of weight management interventions.

Economic burden of asthma in Singapore

Background and objectiveUp-to-date economic burden of asthma in Singapore is currently unknown.MethodsWe quantify the per capita and total annual costs of asthma for adults and children by level of symptom...

Financial implications of New York City's weight management initiative.

To estimate potential annual savings in medical expenditures from a subsidized weight management program from the NYC Government perspective. Longitudinal observational study. Employees of New York City (NYC) government and enrolled dependents. 14,946 participants with overweight and obesity. WW (formerly Weight Watchers®) 'Workshop' and 'Digital' programs. Participation rate, enrollment duration, weight change, and predicted gross and net total and per capita medical expenditure savings and return on investment (ROI). Participation rate, enrollment duration, weight change, and program costs are based on direct observation. Predicted savings are simulated based on published data relating weight loss to medical expenditure reductions. In total, 47% of participating employees and 50% of participating dependents lost weight during the enrollment period. Mean (median) enrollment duration for employees was 7.1 months (7.0) and for dependents was 6.9 months (6.0). Mean (median) weight losses for the employees in 'Workshops' and 'Digital' was 6.6 lbs (2.80) and 6.3 lbs (0.0). For dependents, weight losses were 7.4 lbs (3.59) and 11.6 lbs (2.0). Per capita and total predicted net savings to NYC Government from employees was estimated to be $120 and $1,486,102 for an ROI of 143%. Including dependents, predicted net savings increases to $1,963,431 for an ROI of 189%. Over 80% of savings came from participants in the Obese III category. An evidence-based weight management program has the potential to generate a positive ROI for employers. Future studies should validate these estimates using actual data and more rigorous designs.

Efficacy and costs of a workplace wellness programme.

Research investigating the efficacy of workplace wellness programmes to promote exercise, and by extension, reduce obesity and increase productivity has proliferated in recent years. Although preliminary work is encouraging, more work is needed. To evaluate the effects and overall cost of a workplace exercise programme on multiple physical outcomes, including body mass index, aerobic fitness and muscular fitness. Data from the Bruin Health Improvement Programme .5 (BHIP) between August 2013 and July 2018 were analysed. BHIP is a 12-week workplace wellness programme that assesses multiple areas of physical and mental health. For this study, changes in weight, waist-to-hip ratio, aerobic fitness and muscular endurance were analysed using paired samples t-tests and chi-squared tests. Using results from a prior analysis of Medical Expenditure Panel Survey, the estimated medical expenditure savings associated with weight loss were also analysed. A total of 518 participants (84% female) took part in the BHIP programme (mean age = 41 years, SD = 1.17). There were significant decreases in all anthropometric indices and significant increases in all fitness outcomes (P < 0.01) from baseline to follow-up. Estimated programme cost per participant, per session was $473 US Dollars (USD), and weight loss is estimated to reduce annual medical care costs by ~$2200 USD. Results showed significant improvements in all physical outcomes of interest. Additionally, there appears to be an inverse relationship between improvements in employee health and employer healthcare costs. Strengths, limitations and future directions are discussed.

Burden of lung cancer attributable to ambient fine particles and potential benefits from air quality improvements in Beijing, China: A population-based study

ObjectiveWe aimed to establish a representative exposure response function between PM2.5 and lung cancer to evaluate the impact on lung cancer burden and the benefits gained in association with the environmental policy change in Beijing, China. MethodsBased on population-based cancer registration data during 2001–2016, using a spatiotemporal Poisson regression model, long-term concentrations of PM2.5 were linked to sex-age adjusted incidence rates of total lung cancer and its pathological subtypes. We calculated the health and monetary benefits associated with air quality improvement using the cost of illness method. ResultsIn the constructed regression model, a 10 μg/m3 increment of PM2.5 was associated with increases of 6.0% (95% confidence interval [95% CI]: 4.3%, 7.7%), 14.8% (10.3%, 19.4%), and 6.5% (3.3%, 9.8%) in the incidence of total lung cancer, squamous cell carcinoma, and adenocarcinoma, respectively. The estimated associations indicate that long-term exposure to PM2.5 contributed 1947 to 3059 incident cases of lung cancer per year among the residents in Beijing during the study period. Clean air actions saved 4978 (95% CI: 2711, 7417) lung cancer cases, which brought a savings of 218 (118, 324) million RMB (~31 [17, 46] million US dollars) in direct inpatient medical expenditures. If air quality had met national standards of long-term PM2.5 (35 μg/m3) in 2014–2016, 10,003 (95% CI: 9325, 10,650) lung cancer cases could have been prevented and direct inpatient medical expenditures of 438 (409, 466) million RMB (~63 [58, 67] million US dollars) could have been saved. ConclusionsThis study enriches epidemiological study, confirming the association between exposure to PM2.5 and lung cancer or its subtypes, and provides novel evidence for the notable reduction in lung cancer burden and medical expenditure savings that were achieved through air quality improvements in Beijing from 2014 to 2016.

Assessing the potential outcomes of achieving the World Health Organization global non-communicable diseases targets for risk factors by 2025: is there also an economic dividend?

ObjectivesThis study assesses the change in premature mortality and in morbidity under the scenario of meeting the World Health Organization (WHO) global targets for non-communicable disease (NCD) risk factors (RFs) by 2025 in France. It also estimates medical expenditure savings because of the reduction of NCD burden. Study designA microsimulation model is used to predict the future health and economic outcomes in France. MethodsA ‘RF targets’ scenario, assuming the achievement of the six targets on RFs by 2025, is compared to a counterfactual scenario with respect to disability-adjusted life years and healthcare costs differences. ResultsThe achievement of the RFs targets by 2025 would save about 25,300 (and 75,500) life years in good health in the population aged 25–64 (respectively 65+) years on average every year and would help to reduce healthcare costs by about €660 million on average per year, which represents 0.35% of the current annual healthcare spending in France. Such a reduction in RFs (net of the natural decreasing trend in mortality) would contribute to achieving about half of the 2030 NCD premature mortality target in France. ConclusionsThe achievement of the RF targets would lead France to save life years and life years in good health in both working-age and retired people and would modestly reduce healthcare expenditures. To achieve RFs targets and to curb the growing burden of NCDs, France has to strengthen existing and implement new policy interventions.

Physical Activity and Disability: An Analysis on How Activity Might Lower Medical Expenditures.

This study evaluated the effect of increased physical activity on annual medical expenditures among people with disability, as well as people without disability. We performed a cross-sectional study with linked national survey data from 2004 to 2013 Medical Expenditure Panel Survey and from 2002 to 2012 National Health Interview Study. We investigated the effect of physical activity on the annual medical expenditures in 2013 US dollars, among people with and without disability who were 18- to 64-year-old adults. For people with disability, we found a statistically significant effect (P < .05) of physical activity on annual medical expenditures. Among people without disability, being inactive was associated with higher medical expenditures, compared with being sufficiently active. In our counterfactual analysis, among inactive people with disability, increasing activity to even a low level of activity could potentially save on average $2150.06 (95% confidence interval, 770.39 to 3529.72) annual medical costs. This analysis provides evidence that when an individual with a disability moves from inactive to active, the savings in medical expenditures are substantially larger than the savings for an individual without a disability ($2564.33 vs $393.34). Despite the challenge of participating in physical activity for people with disability, completing "some" activity may have large public health implications.

The Role of Oral Health Care Professionals in Providing Medical Services.

Integration of oral health care professionals (OHCPs) into medical care could advance efforts to control increasingly prevalent conditions such as cardiovascular disease, diabetes mellitus, human immunodeficiency virus infection, and hepatitis C infection, each of which is associated with significant morbidity and health care costs. Prevention and early intervention are effective for reducing the incidence and severity of these diseases, while increasing cost of health care may drive the need for nontraditional models of health education and delivery. Studies have suggested that a dental office is a suitable setting for the purpose of screening and referrals for these conditions and may result in medical expenditure savings. Such innovations would challenge the current dental educational model and the education and training of faculty. Implementing this change would require recognizing opportunities and challenges for the profession and the need for new competencies in dental curricula. Challenges and opportunities are described, including reimbursement models and integration of OHCPs into emerging health care delivery models. Ideas for curricular change are presented, including the need for added emphasis on biological sciences and the introduction of new courses to address systems thinking and forces driving preventive behavior. To embrace the evolving health care arena and be a part of the future interprofessional health care delivery dynamic, dental curricula should also include substantive interprofessional education opportunities. Such opportunities would provide the basic skills and training to recognize and appreciate patients' oral health issues in the broader context of their overall health and well-being. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Clinical and Economic Impact of a Digital, Remotely-Delivered Intensive Behavioral Counseling Program on Medicare Beneficiaries at Risk for Diabetes and Cardiovascular Disease.

BackgroundType 2 diabetes and cardiovascular disease impose substantial clinical and economic burdens for seniors (age 65 and above) and the Medicare program. Intensive Behavioral Counseling (IBC) interventions like the National Diabetes Prevention Program (NDPP), have demonstrated effectiveness in reducing excess body weight and lowering or delaying morbidity onset. This paper estimated the potential health implications and medical savings of a digital version of IBC modeled after the NDPP.Methods and FindingsParticipants in this digital IBC intervention, the Omada program, include 1,121 overweight or obese seniors with additional risk factors for diabetes or heart disease. Weight changes were objectively measured via participant use of a networked weight scale. Participants averaged 6.8% reduction in body weight within 26 weeks, and 89% of participants completed 9 or more of the 16 core phase lessons. We used a Markov-based microsimulation model to simulate the impact of weight loss on future health states and medical expenditures over 10 years. Cumulative per capita medical expenditure savings over 3, 5 and 10 years ranged from $1,720 to 1,770 (3 years), $3,840 to $4,240 (5 years) and $11,550 to $14,200 (10 years). The range reflects assumptions of weight re-gain similar to that seen in the DPP clinical trial (lower bound) or minimal weight re-gain aligned with age-adjusted national averages (upper bound). The estimated net economic benefit after IBC costs is $10,250 to $12,840 cumulative over 10 years. Simulation outcomes suggest reduced incidence of diabetes by 27–41% for participants with prediabetes, and stroke by approximately 15% over 5 years.ConclusionsA digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings. These findings affirm recommendations for IBC coverage by the U.S. Preventive Services Task Force.

Savings in Medical Expenditures Associated with Reductions in Body Mass Index Among US Adults with Obesity, by Diabetes Status.

BackgroundThe prevalence of obesity has more than doubled in the USA in the past 30 years. Obesity is a significant risk factor for diabetes, cardiovascular disease, and other clinically significant co-morbidities. This paper estimates the medical care cost savings that can be achieved from a given amount of weight loss by people with different starting values of body mass index (BMI), for those with and without diabetes. This information is an important input into analyses of the cost effectiveness of obesity treatments and prevention programs.MethodsTwo-part models of instrumental variables were estimated using data from the Medical Expenditure Panel Survey (MEPS) for 2000–2010. Models were estimated for all adults as well as separately for those with and without diabetes. We calculated the causal impact of changes in BMI on medical care expenditures, cost savings for specific changes in BMI (5, 10, 15, and 20 %) from starting BMI levels ranging from 30 to 45 kg/m2, as well as the total excess medical care expenditures caused by obesity.ResultsIn the USA, adult obesity raised annual medical care costs by $US3,508 per obese individual, for a nationwide total of $US315.8 billion (year 2010 values). However, the relationship of medical care costs over BMI is J-shaped; costs rise exponentially in the range of class 2 and 3 obesity (BMI ≥35). The heavier the obese individual, the greater the reduction in medical care costs associated with a given percent reduction in BMI. Medical care expenditures are higher, and rise more with BMI, among individuals with diabetes than among those without diabetes.ConclusionsThe savings from a given percent reduction in BMI are greater the heavier the obese individual, and are greater for those with diabetes than for those without diabetes. The results provide health insurers, employers, government agencies, and health economists with accurate estimates of the change in medical care expenditures resulting from weight loss, which is important information for calculating the cost effectiveness of interventions to prevent and treat obesity.Electronic supplementary materialThe online version of this article (doi:10.1007/s40273-014-0230-2) contains supplementary material, which is available to authorized users.

Hospice shared-care saved medical expenditure and reduced the likelihood of intensive medical utilization among advanced cancer patients in Taiwan—a nationwide survey

Hospice shared care (HSC) is a new care model that has been adopted to treat inpatient advanced cancer patients in Taiwan since 2005. Our aim was to assess the effect of HSC on medical expenditure and the likelihood of intensive medical utilization by advanced cancer patients. This is a nationwide retrospective study. HSC was defined as using "Hospice palliative care (HPC) teams to provide consultation and service to advanced cancer patients admitted in the nonhospice care ward." There were 120,481 deaths due to cancer between 2006 and 2008 in Taiwan. Patients receiving HSC were matched by propensity score to patients receiving usual care. Of the 120,481 cancer deaths, 12,137 paired subjects were matched. Medical expenditures for 1 year before death were assessed between groups using a database from the Bureau of National Health Insurance. Paired t and McNemar's tests were applied for comparing the medical expenditure and intensive medical utilization before death between paired groups. Compared to the non-HSC group, subjects receiving HSC had a lower average medical expenditure per person (US$3,939 vs. US$4,664; p<0.001). The HSC group had an adjusted net savings of US$557 (13.3%; p<0.001) in inpatient medical expenditure per person compared with the non-HSC group. Subjects that received different types of HPC had 15.4-44.9% less average medical expenditure per person and significantly lower likelihood of intensive medical utilization than those that did not receive HPC. HSC is associated with significant medical expenditure savings and reduced likelihood of intensive medical utilization. All types of HPC are associated with medical expenditure savings.

Obesity and Severe Obesity Forecasts Through 2030

Previous efforts to forecast future trends in obesity applied linear forecasts assuming that the rise in obesity would continue unabated. However, evidence suggests that obesity prevalence may be leveling off. This study presents estimates of adult obesity and severe obesity prevalence through 2030 based on nonlinear regression models. The forecasted results are then used to simulate the savings that could be achieved through modestly successful obesity prevention efforts. The study was conducted in 2009-2010 and used data from the 1990 through 2008 Behavioral Risk Factor Surveillance System (BRFSS). The analysis sample included nonpregnant adults aged ≥ 18 years. The individual-level BRFSS variables were supplemented with state-level variables from the U.S. Bureau of Labor Statistics, the American Chamber of Commerce Research Association, and the Census of Retail Trade. Future obesity and severe obesity prevalence were estimated through regression modeling by projecting trends in explanatory variables expected to influence obesity prevalence. Linear time trend forecasts suggest that by 2030, 51% of the population will be obese. The model estimates a much lower obesity prevalence of 42% and severe obesity prevalence of 11%. If obesity were to remain at 2010 levels, the combined savings in medical expenditures over the next 2 decades would be $549.5 billion. The study estimates a 33% increase in obesity prevalence and a 130% increase in severe obesity prevalence over the next 2 decades. If these forecasts prove accurate, this will further hinder efforts for healthcare cost containment.

Incorporating Indirect Costs into a Cost-Benefit Analysis of Laparoscopic Adjustable Gastric Banding

ObjectivesThe objective of this study was to estimate the time to breakeven and 5-year net costs of laparoscopic adjustable gastric banding (LAGB) taking both direct and indirect costs and cost savings into account. MethodsEstimates of direct cost savings from LAGB were available from the literature. Although longitudinal data on indirect cost savings were not available, these estimates were generated by quantifying the relationship between medical expenditures and absenteeism and between medical expenditures and presenteeism (reduced on-the-job productivity) and combining these elasticity estimates with estimates of the direct cost savings to generate total savings. These savings were then combined with the direct and indirect costs of the procedure to quantify net savings. ResultsBy including indirect costs, the time to breakeven was reduced by half a year, from 16 to 14 quarters. After 5 years, net savings in medical expenditures from a gastric banding procedure were estimated to be $4970 (±$3090). Including absenteeism increased savings to $6180 (±$3550). Savings were further increased to $10,960 (±$5864) when both absenteeism and presenteeism estimates were included. ConclusionsThis study presented a novel approach for including absenteeism and presenteeism estimates in cost-benefit analyses. Application of the approach to gastric banding among surgery-eligible obese employees revealed that the inclusion of indirect costs and cost savings improves the business case for the procedure. This approach can easily be extended to other populations and treatments.

A Longitudinal Study on the Relationship Between Weight Loss, Medical Expenditures, and Absenteeism Among Overweight Employees in the WAY to Health Study

To quantify the extent to which successful weight loss among overweight/obese employees translates into subsequent savings in medical expenditures and absenteeism. This analysis relied on medical claims and absenteeism data collected from overweight/obese employees at 17 community colleges in North Carolina. We find no evidence that participants achieving at least a 5% weight loss experienced reduced medical expenditures or lower absenteeism during the 12-month weight loss intervention or in the subsequent 2 years. These results suggest that a quick return on investment from weight loss programs, even effective ones, is unlikely. Nevertheless, as with other employee benefit decisions, the decision about whether to offer weight loss programs should take into account many factors, such as employee health, in addition to the potential for a quick return on investment.

A Return-on-Investment Simulation Model of Workplace Obesity Interventions

To calculate return-on-investment (ROI) from workplace obesity interventions, employers require information about costs saved by the intervention. This article presents a simulation model used to calculate ROI for workplace obesity interventions. We estimated annual savings in medical expenditures and absenteeism costs by amount of average weight loss for a nationally representative company. We also present several examples that use the model to evaluate the ROI for published workplace obesity interventions. Across all overweight and obese employees, 5% weight loss would result in a reduction in total annual costs (medical plus absenteeism) of $90 per person. The results suggest that low-cost policy or environmental change interventions in worksites may be more likely to be cost saving than high cost, individually targeted behavioral change interventions unless they result in substantial weight loss.

Advance directives and medical treatment at the end of life

To assess the consequences of advance medical directives—which explicitly specify a patient’s preferences for one or more specific types of medical treatment in the event of a loss of competence—we analyze the medical care of elderly Medicare beneficiaries who died between 1985 and 1995. We compare the care of patients from states that adopted laws enhancing incentives for compliance with advance directives and laws requiring the appointment of a health care surrogate in the absence of an advance directive to the care of patients from states that did not. We report three key findings. First, laws enhancing incentives for compliance significantly reduce the probability of dying in an acute care hospital. Second, laws requiring the appointment of a surrogate significantly increase the probability of receiving acute care in the last month of life, but decrease the probability of receiving nonacute care. Third, neither type of law leads to any savings in medical expenditures.

A high-sensitivity alternative to “routine” genetic amniocentesis: Multiple urinary analytes, nuchal thickness, and age

Objective: Our purpose was to evaluate the Down syndrome screening efficiency of a new algorithm consisting of multiple urinary biochemical and ultrasound markers for use in high-risk groups such as women of advanced maternal age. Study Design: The urinary β-core fragment of human chorionic gonadotropin (β-core fragment) and total urinary estriol, along with fetal nuchal thickness, were measured prospectively in pregnant women who were undergoing genetic amniocentesis at midtrimester (15 to 24 weeks). The most common indication for amniocentesis was advanced maternal age (90.2%). An analyte ratio (β-core fragment/total estriol ratio) was developed. The values were expressed as multiples of the normal median. An increase in the observed nuchal thickness (delta nuchal thickness) above that expected on the basis of the biparietal diameter was calculated. On the basis of the mean and standard deviations of the urinary analyte ratio in normal fetuses and also Down syndrome, we calculated individual Down syndrome likelihood ratios for each of the two parameters, using gaussian analysis. The product of the likelihood ratios, based on delta nuchal thickness and urinary β-core fragment–total estriol values times the maternal age–related risk, gave the overall Down syndrome risk. The screening efficiency of our algorithm at various risk thresholds was determined. Results: There were 13 (2.8%) cases of Down syndrome in a total study population of 457. At a risk threshold of >1 in 70, the sensitivity was 92.3% for a false-positive rate of 4.5%. Corresponding values at a risk threshold of >1 in 78 were a sensitivity of 100% with a false-positive rate of 5.2%. Conclusion: By combining urinary analyte, nuchal thickness, and maternal age data, we achieved a high Down syndrome detection rate with a low false-positive rate. This algorithm would be attractive as an alternative to “routine” amniocentesis based solely on advanced maternal age. The potential benefits of this protocol could include a significant reduction in the rate of amniocentesis, along with substantial savings in medical expenditures. (Am J Obstet Gynecol 1999;180:169-73.)