Cost Of Medical Services Research Articles

Economic benefits of adequate molecular monitoring in patients with chronic myelogenous leukemia (CML).

7093 Background: Molecular monitoring every 3 months using quantitative polymerase chain reaction (qPCR) of BCR-ABL mRNA transcripts on International Scale is recommended by the National Comprehensive Cancer Network and the European LeukemiaNet for patients (pts) in chronic phase of CML. A previous study has shown an underutilization of qPCR in the community setting. This study assessed the impact of the frequency of molecular monitoring on hospitalization and medical costs among CML pts receiving 1st-line tyrosine kinase inhibitor (TKI) therapies. Methods: Two U.S. administrative claims databases were combined (01/2000-06/2012) to identify adult CML pts initiated on TKIs (imatinib, dasatinib, nilotinib). Pts were followed for 12 months from their first TKI prescription and categorized into 3 cohorts based on frequency of qPCR tests (i.e., 0, 1-2, and 3-4). Number of inpatient admissions and medical service costs (measured from a US payer perspective; adjusted to 2012 U.S. dollars) were compared between cohorts. Multivariate regression models adjusted for confounding factors (e.g., age, gender, CML complexity, TKI). Results: The study included 1,205 CML pts. Over the 12-month study period, 41.0% of the pts had no qPCR test, 31.9% had 1-2 tests, and 27.1 % had 3-4 tests. Compared to pts with no qPCR monitoring, those with 3-4 tests incurred 37% fewer CML-related (i.e., a primary CML diagnosis) inpatient admissions (p=.017) during the study period, leading to a $4,000 (p=.009) reduction in CML-related inpatient costs and $5,663 (p=.005) reduction in all-cause inpatient costs, accounting for the majority of the $5,997 reduction in total medical service costs (p=.049). Pts with 1-2 tests a year showed smaller and statistically insignificant reductions from those with no test in the frequency of hospitalization and medical costs. Conclusions: Among CML pts who initiated 1st-line TKIs, pts with 3-4 qPCR tests a year incurred fewer inpatient admissions and lower medical service costs compared to pts with no test. These findings suggest that pts would benefit from regular qPCR testing and underscore the value of molecular monitoring in the delivery of quality care for Ph+ CML-CP pts on TKI therapies.

The Effect of Pediatric Knowledge on Hospice Care Costs

The cost of hospice care is rising. Although providing care for children at end of life may be costly for hospices, it is unclear whether or not gaining pediatric knowledge and even establishing a pediatric program may be done cost effectively. The purpose of our study was to examine the effect of possessing pediatric knowledge (i.e., pediatric program, pediatric experience) on core hospice care costs. Using 2002 to 2008 California hospice data, the findings of the regression analysis suggest that having pediatric knowledge does not significantly increase nursing, physician, and medical social service costs. Having a pediatric program was related to increased counseling costs. Our findings shed important light on the minimal costs incurred when hospices decide to develop pediatric knowledge.

Surveillance of epilepsy and prevention of epilepsy and its sequelae

The Institute of Medicine's report, Epilepsy across the Spectrum: Promoting Health and Understanding contains two recommendations for increased epilepsy surveillance and one recommendation on prevention in epilepsy. Evidence supporting these recommendations and the information that can be gained from them is reviewed. Existing epilepsy surveillance data are inadequate to address factors such as seizure type, syndrome, socioeconomic status, and race/ethnicity in large representative populations. Ongoing surveillance is needed with follow-up of people with epilepsy for adverse epilepsy outcomes so that interventions to prevent these outcomes can be formulated. Substantial barriers to receiving appropriate medical care exist for minorities and the uninsured with epilepsy; more information on these differences and their causes is needed. Lack of standardized study methods and data sources results in differences in medical service costs, care and treatments, and limited information on cost-effectiveness of specific healthcare services for epilepsy. Future epilepsy surveillance should track incidence and prevalence over time, access to epilepsy care, direct and indirect costs, and the cost-effectiveness of treatment. Prevention efforts to decrease the occurrence of epilepsy and improve access and effectiveness of care will ameliorate adverse outcomes in epilepsy.

Erratum to: Cost Effectiveness of Guanfacine Extended-Release versus Atomoxetine for the Treatment of Attention-Deficit/Hyperactivity Disorder

Background: About 7% of children and adolescents are diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the US. Patients with ADHD who are intolerant of or do not have an optimal response to stimulants often use non-stimulants as alternative therapies. Guanfacine extendedrelease (GXR) and atomoxetine (ATX) are the only non-stimulants approved by the US Food and Drug Administration for once-daily use in the treatment of children and adolescents with ADHD in the US. ATX has been on the market since 2002 while GXR was recently approved in 2009. To date, there is no comparative effectiveness or cost-effectiveness study comparing the two drugs. Objectives: The aim of this study was to assess the cost effectiveness of GXR versus ATX for the treatment of ADHD in children and adolescents, using the comparative efficacy results from a matching-adjusted indirect comparison (MAIC). Methods: The MAIC method was used to compare the efficacy between GXR (target dose and lower doses) and ATX (target dose) in the absence of head-to-head clinical trials. Individual patients in the GXR trials were weighted such that the summary baseline characteristics and the efficacy of the placebo arm of the GXR trials matched exactly with those from published ATX trials. After weighting, the efficacy (i.e. change in the ADHD rating scale, fourth edition [ADHD-RS-IV] total score from baseline) was compared between each GXR dosing group and the ATX group. The results from the MAIC analyses were used to populate a 1-year Markov model that is used to compare the cost effectiveness of GXR versus ATX from a US third-party payer perspective. Effectiveness outcomes for each treatment group were estimated as the proportion of responders, defined as patients with ≥25% reduction in ADHD-RS-IV total score from baseline, and average quality-adjusted life years (QALYs). Utilities associated with response/non-response and disutilities due to adverse events were applied in the model. Costs included drug and medical service costs and were inflated to 2011 US dollars ($US). Incremental cost/QALY and incremental cost/responder were estimated. Univariate sensitivity analyses were conducted by varying all model parameters, including costs, utilities, and response rate. Results: The target dose of GXR was 0.12mg/kg/day. In match-adjusted populations with balanced baseline characteristics, patients receiving GXR at the dose of 0.09–0.12 (p = 0.0009) and 0.075–0.09 mg/kg/day (p = 0.0248) had better efficacy, while those receiving GXR at the dose of 0.046–0.075 mg/kg/day had comparable efficacy (p = 0.0699), compared with patients receiving ATX at the target dose of 1.2 mg/kg/day. In the base case of the cost-effectiveness analysis (CEA), GXR had incremental cost-effectiveness ratios of $US10 637/QALY and $US853/responder, compared with ATX (incremental costs: $US74; incremental effectiveness: 0.007 QALYs and 86 responders per 1000 patients treated). Results of all univariate sensitivity analyses showed that the model results were robust to changes in model inputs. Conclusions: To our knowledge, this is the first application of the novel comparative efficacy method of MAIC to a CEA model. The MAIC results indicate that GXR (0.075–0.12 mg/kg/day) was more effective than ATX (1.2 mg/kg/day) in the trial population. The CEA results indicate that GXR is cost effective compared with ATX for the treatment of ADHD in children and adolescents.

The Determinants of Rising Inequality in Health Insurance and Wages: An Equilibrium Model of Workers' Compensation and Health Care Policies

Over the last 30 years in the U.S., less educated workers have experienced a sharp decline in health insurance coverage rate and stagnant wage growth. In contrast, more educated workers' health insurance coverage rate has stayed relatively stable and their wages have rapidly grown. This paper investigates the determinants of the increase in inequality in health insurance coverage and wages by estimating an overlapping generations equilibrium model of labor and health insurance markets' demand and supply. The estimated model is used to quantify the effects of changes in aggregate factors (including rising cost of medical care services, Medicaid eligibility expansion, skill-biased technological changes in the labor market, and changes in the labor force composition) on the inequality of health insurance coverage and wages. I find that the interaction between the rising cost of medical services and labor market technological change is the most important determinant of the widening gap of health insurance coverage.

Surgical castration for androgen-deprivation therapy of prostate cancer – relevance in current practice

Objective: Rapid control of the disease is essential in the management of patients with critical and symptomatic metastatic prostate cancer. Pharmacological castration has become the main form of androgen-deprivation therapy (ADT) for prostate cancer, with luteinising hormone-releasing hormone (LHRH) agonists being used in more than 90% of cases. Surgical castration has become the less preferred modality. This article aims to explore the clinical and economic advantages of bilateral sub-capsular orchidectomy (BSCO). Method: Pre- and post-operative serial testosterone levels were taken from patients who had BSCO for adenocarcinoma of the prostate. The half-life of testosterone was calculated. The cost of surgical castration on the National Health Service (NHS) was compared to the cost of LHRH agonists. Results: Ten patients with a median prostate-specific antigen (PSA) level of 93 ng/ml (range 26 to 4557 ng/ml) were included. Their mean random pre-operative testosterone level was 13.8 ng/ml (range 6.8 to 21.8 ng/ml). The mean half-life of testosterone was 61.7 minutes when calculated from the first two hours, and 67 minutes when calculated from the total drop with no significant variation ( p = 0.464). Four patients reached castrate levels of testosterone within four to six hours. The total cost of an inpatient BSCO in the NHS was £850 to £1154. This was more or less equivalent to one year’s worth of the commonly used LHRH agonists without including the cost of medical services. Conclusions: Testosterone has a short half-life and reaches castrate levels within hours of the BSCO procedure. Rapid castration by BSCO would benefit patients with critical metastatic disease. BSCO on the NHS in patients with more than one year of life expectancy is also economically beneficial.

Incremental medical service costs associated with escalating methotrexate dosage versus switching to adalimumab in patients with psoriasis

Incremental medical service costs associated with escalating methotrexate dosage versus switching to adalimumab in patients with psoriasis

P157 Reasons for a delayed diagnosis in inflammatory bowel disease

to follow-up, ADA-treated patients had significant reductions whereas IMS-treated patients had increases in UC-related hospitalizations and LOS (table). UC-related outpatient service utilization and costs, as well as total inpatient and outpatient service costs, decreased significantly for ADA-treated patients vs. a small increase for IMS-treated patients. ADA-treated patients also had a significantly greater reduction in hospital LOS for colectomy. Conclusions: In this retrospective claims database analysis, ADA therapy was associated with greater reductions in UCrelated hospitalization rates, length of hospitalization for colectomy, and total inpatient and outpatient medical service costs compared with IMS therapy.

The Coming Golden Age of Disruptive Innovation in Health Care

The Coming Golden Age of Disruptive Innovation in Health Care

CBO links more Rx fi lled to less medical spending

The use of medications can lower the costs of related medical services, according to a new report from the Congressional Budget Office (CBO) that represents a change in the agency’s estimating methodology. The use of medications can lower the costs of related medical services, according to a new report from the Congressional Budget Office (CBO) that represents a change in the agency’s estimating methodology. Based on a review of recent research, a 1% increase in the number of prescriptions filled by Medicare beneficiaries would cause Medicare spending on medical services to fall by roughly 0.2%, CBO announced November 29. ■CBO announced a change in its estimating methodology that linked more prescriptions filled to less spending on medical services.■CBO did not consider pharmacists’ clinical services. ■CBO announced a change in its estimating methodology that linked more prescriptions filled to less spending on medical services.■CBO did not consider pharmacists’ clinical services. When estimating the budgetary impact of future legislation or proposals that have a direct impact on Medicare prescription drug use, the agency will first estimate a proposal’s effect on prescription drug costs and then estimate the effect on the number of prescriptions filled and any resulting offsetting effect on spending for medical services. The new way of analyzing drug costs stopped short of suggesting any positive benefits of pharmacists’ clinical services. “APhA is pleased that CBO recognizes some of the benefits of paying for medications,” said Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, APhA Executive Vice President and CEO. “Now, we have to help them recognize the benefits of making sure those medicines are used effectively by patients. That’s a key component of our advocacy agenda for 2013.” “The CBO study is a step forward in recognition of the value of drug therapy in preventing, controlling, and treating disease,” J. Lyle Bootman, PhD, ScD, Dean of the University of Arizona College of Pharmacy, told Pharmacy Today. “However, this all assumes that all of the appropriate steps in the prescribing, distribution, and patient use of the medication actually occur. Pharmacists’ clinical services—which are not routinely provided due to reimbursement issues—can potentially increase the value of drug therapy beyond that recognized in the recent report.” Bootman is also Professor of Pharmacy, Medicine, and Public Health, as well as Founding Executive Director of the Center for Health Outcomes & Pharmacoeconomic Research, at the University of Arizona. He is a former APhA President. The National Community Pharmacists Association (NCPA) released a statement from NCPA CEO B. Douglas Hoey, BSPharm, MBA, that commended the new CBO analysis but called it the “tip of the iceberg in terms of the savings independent community pharmacists can produce for Medicare and other health plans.” Hoey noted that CBO focused only on the quantity of prescriptions filled, but not on the quality resulting from “strong patient-pharmacist relationships in helping patients take their medication appropriately” as demonstrated in private research. CBO explained the effects of prescription drug use on Medicare’s spending for health care services. “Most often, pharmaceuticals have the effect of improving or maintaining an individual’s health,” the agency wrote. “Taking an antibiotic may prevent a more severe infection, and adhering to a drug regimen for a chronic condition such as diabetes or high blood pressure may prevent complications. In either of those circumstances, taking the medication may avert hospital admissions and thus reduce the use of medical services.” Before the announcement, CBO didn’t include an offsetting effect on medical services in estimates involving changes to prescription drug policies, according to the report. For example, CBO didn’t include an offset for the 2003 law establishing Medicare Part D. “At the time, there was little evidence of a relationship between prescription drug use and spending for medical services,” the agency wrote. “However, a body of research has since developed that demonstrates a connection between prescription drug use and the use of medical services.” CBO analyzed recent research to determine whether and how to include the offsetting effect. To illustrate the offset, the CBO report applied the change in methodology to the budgetary impact of the gradual closing of the Part D doughnut hole under the 2010 health care reform law. Using the revised methodology, the agency estimated that the net cost of implementing the law’s provisions closing the coverage gap will be $51 billion, rather than the $86 billion estimated previously. (See page 57 for more information on the closing of the coverage gap.)

The Determinants of Rising Inequality in Health Insurance and Wages: An Equilibrium Model of Workers' Compensation and Health Care Policies

I develop and structurally estimate a non-stationary overlapping generations equilibrium model of employment and workers’ health insurance and wage compensation, to investigate the determinants of rising inequality in health insurance and wages in the U.S. over the last 30 years. I nd that skill-biased technological change and the rising cost of medical care services are the two most important determinants, while the impact of Medicaid eligibility expansion is quantitatively small. I conduct counterfactual policy experiments to analyze key features of the 2010 Patient Protection and Aordable Care Act, including employer mandates and further Medicaid eligibility expansion. I nd that (i) an employer mandate reduces both wage and health insurance coverage inequality, but also lowers the employment rate of less educated individuals; and (ii) further Medicaid eligibility expansion increases employment rate of less educated individuals, reduces health insurance coverage disparity, but also causes larger wage inequality.

Service Utilization Following Participation in Cognitive Processing Therapy or Prolonged Exposure Therapy for Post-Traumatic Stress Disorder

This study evaluated the impact of a course of prolonged exposure or cognitive processing therapy on mental health and medical service utilization and health care service costs provided by the Department of Veterans Affairs (VA). Data on VA health service utilization and health care costs were obtained from national VA databases for 70 veterans who completed prolonged exposure or cognitive processing therapy at a Midwestern VA medical center. Utilization of services and cost data were examined for the year before and after treatment. Results demonstrated a significant decrease in the use of individual and group psychotherapy. Direct costs associated with mental health care decreased by 39.4%. Primary care and emergency department services remained unchanged.

Pattern and Determinants of Antenatal Booking at Abakaliki Southeast Nigeria

Background: Antenatal care is one of the pillars of SAFE Motherhood Initiative aimed at preventing adverse pregnancy outcome. Early antenatal booking is recommended for this benefit. Aim: The objective of this study was to determine the antenatal booking pattern of pregnant women and its determinants. Subjects and Methods: A cross‑sectional survey of pregnant women attending the antenatal booking clinic at Federal Medical Centre Abakaliki Ebonyi State between April 6, 2011 to August 5, 2011 was undertaken. Epi info 2008 version was used for analysis. Results: The mean age of the respondents was 27.46 (5.81) years and the mean gestational age at booking was 24.33 (5.52) weeks. A total of 83.1% (286/344) of the pregnant women booked after the first trimester while the remaining 16.9% (56/344) booked early. Socio‑biological variables and past obstetrics history did not contribute significantly to the gestational age at booking while sickness in index pregnancy, personal wishes, and financial constraint were statistically significant reasons given for seeking antenatal care. Majority of the pregnant women 37.2% (128/344) suggested that the second trimester was the ideal gestational age for booking while 18.3% (63/344) did not know the ideal gestational age for booking. Most pregnant women 81.1% ( 279/344) knew the benefits of early antenatal care even though they booked late 83.1% (286/344). Conclusion: Most pregnant women access antenatal care late at Abakaliki because of misconception and poverty. Health education and subsidization of cost of medical services will help in reversing the trend of late antenatal booking.

Abstract P5-18-12: Comparison of treatment patterns and outcomes in metastatic breast cancer patients initiated on trastuzumab vs. lapatinib; a retrospective analysis

Abstract Background: Trastuzumab-or lapatinib-based therapies are recommended by the National Comprehensive Cancer Network (NCCN) guidelines as preferred agents for metastatic HER2-positive breast cancer. Few studies have compared treatment patterns, healthcare resource utilization (HRU), and costs in metastatic breast cancer (MBC) patients receiving trastuzumab vs. lapatinib. The objective of this study was to compare discontinuation rates, HRU, and costs in MBC patients (pts) initiated on trastuzumab vs. lapatinib. Methods: MBC adult women initiated on trastuzumab or lapatinib on/after 03/13/2007 (lapatinib FDA-approval date) were selected from the US-based PharMetrics® Integrated Database (2000–2011). Selected pts were required to be continuously eligible in their healthcare plan ≥6 months prior to and ≥30 days following trastuzumab or lapatinib initiation date. Pts were observed over the period spanning from trastuzumab or lapatinib initiation date (without restriction on line of therapy) up to the end of continuous health plan enrollment or data availability, whichever occurred first. Trastuzumab or lapatinib discontinuation rates (gap ≥45 consecutive days) were compared using multivariate Cox proportional-hazards models and reported as hazard ratios (HRs). Incremental HRU was estimated using negative binomial regression models and reported as incidence rate ratios (IRRs). Monthly cost difference (2010 USD; measured from a payer perspective) were estimated using multivariate generalized linear or two-part models. Since a large proportion of lapatinib users were previously treated with trastuzumab, a sensitivity analysis was conducted to control for the impact of prior trastuzumab use. Results: Among the 643 pts selected, 381 and 262 pts were initiated on trastuzumab and lapatinib, respectively. Of the 262 pts initiated on lapatinib, 171 (65%) were previously treated with trastuzumab. After adjustment for confounders (demographics, index year, prior MBC therapies, comorbidities, baseline HRU, and MBC duration), compared to trastuzumab users, lapatinib users had a higher rate of treatment discontinuation (HR = 1.57; p < .001). While lapatinib users had a higher rate of outpatient visits (not treatment administration related) compared to trastuzumab users (HR = 1.19; p < 0.004), there were no observed significant differences of other HRU and total monthly healthcare costs between the two groups ($11,138±8,751 vs. $11,159 ±8,674, respectively; adjusted difference=$637 p = .397). Sensitivity analyses showed that pts who were initiated on lapatinib without prior trastuzumab use had a higher incidence of inpatient admissions (IRR = 1.74; p = .002) and greater overall medical service costs compared to pts who were initiated on trastuzumab (adjusted difference=$3,059; p < .001). Conclusion: Overall, while MBC pts initiated on trastuzumab or lapatinib had similar healthcare costs, pts initiated on lapatinib had higher rates of treatment discontinuation and outpatient visits (not treatment administration related). Medical costs were significantly higher among pts initiated on lapatinib without prior trastuzumab use. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-18-12.

Budget impact analysis of everolimus for the treatment of hormone receptor positive, human epidermal growth factor receptor-2 negative (HER2-) advanced breast cancer in the United States

Objective:To estimate the budget impact of everolimus as the first and second treatment option after letrozole or anastrozole (L/A) failure for post-menopausal women with hormone receptor positive (HR+), human epidermal growth factor receptor-2 negative (HER2-) advanced breast cancer (ABC).Methods:Pharmacy and medical budget impacts (2011 USD) were estimated over the first year of everolimus use in HR+, HER2- ABC from a US payer perspective. Epidemiology data were used to estimate target population size. Pre-everolimus entry treatment options included exemestane, fulvestrant, and tamoxifen. Pre- and post-everolimus entry market shares were estimated based on market research and assumptions. Drug costs were based on wholesale acquisition cost. Patients were assumed to be on treatment until progression or death. Annual medical costs were calculated as the average of pre- and post-progression medical costs weighted by the time in each period, adjusted for survival. One-way and two-way sensitivity analyses were conducted to assess the model robustness.Results:In a hypothetical 1,000,000 member plan, 72 and 159 patients were expected to be candidates for everolimus treatment as first and second treatment option, respectively, after L/A failure. The total budget impact for the first year post-everolimus entry was $0.044 per member per month [PMPM] (pharmacy budget: $0.058 PMPM; medical budget: −$0.014 PMPM), assuming 10% of the target population would receive everolimus. The total budget impacts for the first and second treatment options after L/A failure were $0.014 PMPM (pharmacy budget: $0.018; medical budget: −$0.004) and $0.030 PMPM (pharmacy budget: $0.040; medical budget: −$0.010), respectively. Results remained robust in sensitivity analyses.Limitations:Assumptions about some model input parameters were necessary and may impact results.Conclusions:Increased pharmacy costs for HR+, HER2- ABC following everolimus entry are expected to be partially offset by reduced medical service costs. Pharmacy and total budget increases were modest.

Cost Effectiveness of Guanfacine Extended-Release versus Atomoxetine for the Treatment of Attention-Deficit/Hyperactivity Disorder

About 7% of children and adolescents are diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the US. Patients with ADHD who are intolerant of or do not have an optimal response to stimulants often use non-stimulants as alternative therapies. Guanfacine extended-release (GXR) and atomoxetine (ATX) are the only non-stimulants approved by the US Food and Drug Administration for once-daily use in the treatment of children and adolescents with ADHD in the US. ATX has been on the market since 2002 while GXR was recently approved in 2009. To date, there is no comparative effectiveness or cost-effectiveness study comparing the two drugs. The aim of this study was to assess the cost effectiveness of GXR versus ATX for the treatment of ADHD in children and adolescents, using the comparative efficacy results from a matching-adjusted indirect comparison (MAIC). The MAIC method was used to compare the efficacy between GXR (target dose and lower doses) and ATX (target dose) in the absence of head-to-head clinical trials. Individual patients in the GXR trials were weighted such that the summary baseline characteristics and the efficacy of the placebo arm of the GXR trials matched exactly with those from published ATX trials. After weighting, the efficacy (i.e. change in the ADHD rating scale, fourth edition [ADHD-RS-IV] total score from baseline) was compared between each GXR dosing group and the ATX group. The results from the MAIC analyses were used to populate a 1-year Markov model that is used to compare the cost effectiveness of GXR versus ATX from a US third-party payer perspective. Effectiveness outcomes for each treatment group were estimated as the proportion of responders, defined as patients with ≥25% reduction in ADHD-RS-IV total score from baseline, and average quality-adjusted life years (QALYs). Utilities associated with response/non-response and disutilities due to adverse events were applied in the model. Costs included drug and medical service costs and were inflated to 2011 US dollars ($US). Incremental cost/QALY and incremental cost/responder were estimated. Univariate sensitivity analyses were conducted by varying all model parameters, including costs, utilities, and response rate. The target dose of GXR was 0.12 mg/kg/day. In match-adjusted populations with balanced baseline characteristics, patients receiving GXR at the dose of 0.09-0.12(p = 0.0016) [DOSAGE ERROR CORRECTED] and 0.075-0.09 mg/kg/day (p = 0.0248) had better efficacy, while those receiving GXR at the dose of 0.046-0.075 mg/kg/day had comparable efficacy (p = 0.0699), compared with patients receiving ATX at the target dose of 1.2 mg/kg/day. In the base case of the cost-effectiveness analysis (CEA), GXR had incremental cost-effectiveness ratios of $US10 637/QALY and $US853/responder, compared with ATX (incremental costs: $US74; incremental effectiveness: 0.007 QALYs and 86 responders per 1000 patients treated). Results of all univariate sensitivity analyses showed that the model results were robust to changes in model inputs. To our knowledge, this is the first application of the novel comparative efficacy method of MAIC to a CEA model. The MAIC results indicate that GXR (0.075-0.12 mg/kg/day) was more effective than ATX (1.2 mg/kg/day) in the trial population. The CEA results indicate that GXR is cost effective compared with ATX for the treatment of ADHD in children and adolescents.

PRM3 Standard Cost List for Economic Evaluation in Thailand

To develop standard unit costs of medical services provided by different health facilities, cost of patients coming for treatments, and reference values used in the economic evaluation. The project was conducted as a number of sub-projects. Analysis of unit cost of medical services was conducted in 5 hospitals employing the relative value unit method. Cost of health center services was calculated in 19 health centers employing standard costing and micro-costing methods. Cost of pharmaceutical services was analysed in 11 hospitals. Logistics cost of vaccines under the national vaccination program covered the supply chain from the central supplier to provincial health offices. Cost of patients coming to have treatments was collected by interviewing 900 patients from 6 health centers, 3 district hospitals and 3 provincial/regional hospitals. Reference values were obtained from documentary research. The results were published in a book, and can be accessed via the Health Intervention and Technology Assessment (HITAP) website (http://db.hitap.net/). They are composed of 3091 items of hospital medical services in two categories of hospitals: district and provincial/regional hospitals. Services of hospital pharmacy departments, and health services provided by health centers, include 9 and 68 items, respectively. Logistics cost of vaccines is presented as cost per dose of the vaccine supplied. Cost of patients is composed of distance, time, transportation cost and meal cost. Reference values are useful years of capital assets (i.e. buildings, vehicles, furniture and equipment), minimum wage, and gross domestic product per capita. This standard cost menu and reference values should make economic evaluations faster and more convenient. This is the first standard cost menu to be developed for Thailand. Some limitations exist, which will be improved upon in the next revision.

Outcomes Associated With Insulin Therapy Disruption After Hospital Discharge Among Patients with Type 2 Diabetes Mellitus who Had Used Insulin Before and During Hospitalization

To evaluate outcomes associated with insulin therapy disruption after hospital discharge in patients with type 2 diabetes mellitus who had used insulin before and during hospitalization. In this observational, retrospective analysis of medical records obtained from a coordinated health system in the United States, patients with type 2 diabetes mellitus who had used insulin 30 days before and during hospitalization were included. Clinical and cost outcomes were compared between patients who continued insulin therapy and those who had disrupted insulin therapy after hospital discharge. In total, 2160 records were analyzed (851 patients with continued insulin therapy and 1309 patients with disrupted insulin therapy). Mean baseline glycated hemoglobin A1c levels were 8.56% and 7.73% in patients who continued insulin therapy and patients who disrupted insulin therapy, respectively (P<.001), suggesting that patients who discontinued insulin therapy had better glycemic control at baseline. Continued insulin therapy was associated with an expected greater reduction in glycated hemoglobin A1c (P<.001); similar hypoglycemia rates; lower risks of all-cause hospital readmission, diabetes-related readmission, and all-cause emergency department visits; and improved survival. Continued insulin therapy was associated with $3432 lower total medical service costs than disrupted therapy over the 6-month postdischarge period. Ensuring adherence to insulin therapy in patients who require insulin therapy after hospitalization should be a priority for postdischarge patient care programs. However, the clinical implications of this study are limited by the fact that it could not be determined whether all patients required insulin therapy after hospital discharge.

The comparative economic burden of mild, moderate, and severe fibromyalgia: results from a retrospective chart review and cross-sectional survey of working-age U.S. adults.

Patients with fibromyalgia report persistent widespread pain, fatigue, and substantial functional limitations, which may lead to high health resource use (HRU) and lost productivity. Previous analyses of the U.S. population have not examined the direct and indirect costs of fibromyalgia by severity level. To assess (a) HRU, direct and indirect costs associated with fibromyalgia in routine clinical practice in the United States using a patient-centric approach, and (b) the relationship of fibromyalgia severity level to HRU and costs. This study recruited a nonprobability convenience sample of 203 subjects aged 18 through 65 years between August 2008 and February 2009 from 20 U.S. community-based physician offices. Subjects had a prior diagnosis of fibromyalgia by a rheumatologist, neurologist, or pain specialist; received treatment at the enrolling physician's practice for at least 3 months; experienced widespread pain for at least 3 months; and experienced pain in the previous 24 hours. Subjects completed a 106-item patient questionnaire that included 5 validated health-related quality-of-life instruments and study-specific questions about demographics; clinical history; overall health; treatment satisfaction; and impact of fibromyalgia on cognitive function, daily activities, and employment status. Subjects also self-reported hours of unpaid informal caregiver time because of inability to perform daily activities (e.g., housework, child care), out-of-pocket expenses for medical and nonmedical services, and lost productivity related to fibromyalgia for the previous 4 weeks. The 20-item Fibromyalgia Impact Questionnaire total score was used to stratify subjects into fibromyalgia severity groups (0 to less than 39 = mild, 39 to less than 59 = moderate, 59 to 100 = severe). Staff at each site recorded clinical characteristics, HRU, and medication use attributable to fibromyalgia on a paper clinical case report form (CRF) based on a 3-month retrospective medical chart review. Unit costs for 2009 were assigned to the 3-month HRU data reported on the CRF and 4-week subject-reported lost productivity. Costs were then annualized and reported in the following categories: direct medical, direct nonmedical, and indirect. Differences across severity levels were evaluated using the Kruskal-Wallis test (continuous measures) and Pearson chi-square or Fisher's exact tests (categorical measures) at the 0.05 alpha level. Of the 203 subjects, 21 (10.3%) had mild, 49 (24.1%) had moderate, and 133 (65.5%) had severe fibromyalgia. For subjects with mild, moderate, and severe fibromyalgia, respectively, the number of fibromyalgia-related medications (3-month means: 1.8, 2.3, and 2.8, P = 0.011) and office visits to health care providers (3-month means: 2.7, 5.2, and 6.9, P < 0.001) significantly differed across severity levels. Across severity levels, total medical and nonmedical out-of-pocket costs also differed (P = 0.025). Mean [median] 3-month total direct costs (including payer costs for HRU and out-of-pocket costs for medical and nonmedical services) were $1,213 [$1,150], $1,415 [$1,215], and $2,329 [$1,760] for subjects with mild, moderate, and severe fibromyalgia, respectively (P = 0.002); and mean [median] 3-month indirect costs (including subject-reported absenteeism, unemployment, disability, and the estimated value of unpaid informal care) were $1,341 [$0], $5,139 [$1,680], and $8,285 [$7,030] (P < 0.001). Mean total indirect costs accounted for 52.5%, 78.4%, and 78.1% of mean total costs for subjects with mild, moderate, and severe fibromyalgia, respectively. Direct and indirect costs related to fibromyalgia are higher among subjects with worse fibromyalgia severity. Indirect costs account for a majority of fibromyalgia-related costs at all fibromyalgia severity levels.

Does Government subsidy for costs of medical and pharmaceutical services result in higher service utilization by older widowed women in Australia?

BackgroundIn Australia, Medicare, the national health insurance system which includes the Medical Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS), provides partial coverage for most medical services and pharmaceuticals. For war widows, the Department of Veterans’ Affairs (DVA) covers almost the entire cost of their health care. The objective of this study was to test whether war widows have higher usage of medical services and pharmaceuticals.MethodsData were from 730 women aged 70–84 years (mostly World War II widows) participating in the Australian Longitudinal Study on Women’s Health who consented to data linkage to Medicare Australia. The main outcome measures were PBS costs, claims, co-payments and scripts presented, and MBS total costs, claims and gap payments for medical services in 2005.ResultsThere was no difference between the war widows and similarly aged widows in the Australian population without DVA support on use of medical services. While war widows had more pharmaceutical prescriptions filled they generated equivalent total costs, number of claims and co-payments for pharmaceuticals than widows without DVA support.ConclusionsOlder war widows are not using more medical services and pharmaceuticals than other older Australian women despite having financial incentives to do so.