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Biomedical subjects

Alastair Gray

Publications and source records attributed to Alastair Gray.

At least 19 recordsLinked to original sources
PubMed2006

Lifetime cost effectiveness of simvastatin in a range of risk groups and age groups derived from a randomised trial of 20,536 people.

OBJECTIVES: To evaluate the cost effectiveness of 40 mg simvastatin daily continued for life in people of different ages with differing risks of vascular disease. DESIGN: A model developed from a randomised trial was used to estimate lifetime risks of vascular events and costs of treatment and hospital admissions in the United Kingdom. SETTING: 69 hospitals in the UK. PARTICIPANTS: 20,536 men and women (aged 40-80) with coronary disease, other occlusive arterial disease, or diabetes. INTERVENTIONS: 40 mg simvastatin daily versus placebo for an average of 5 years. MAIN OUTCOME MEASURES: Cost effectiveness of 40 mg simvastatin daily expressed as additional cost per life year gained. Major vascular event defined as non-fatal myocardial infarction or death from coronary disease, any stroke, or revascularisation procedure. Results were extrapolated to younger and older age groups at lower risk of vascular disease than were studied directly, as well as to lifetime treatment. RESULTS: At the April 2005 UK price of 4.87 pounds sterling (7 euros; 9 dollars) per 28 day pack of generic 40 mg simvastatin, lifetime treatment was cost saving in most age groups and vascular disease risk groups studied directly. Gains in life expectancy and cost savings decreased with increasing age and with decreasing risk of vascular disease. People aged 40-49 with 5 year risks of major vascular events of 42% and 12% at start of treatment gained 2.49 and 1.67 life years, respectively. Treatment with statins remained cost saving or cost less than 2500 pounds sterling per life year gained in people as young as 35 years or as old as 85 with 5 year risks of a major vascular event as low as 5% at the start of treatment. CONCLUSIONS: Treatment with statins is cost effective in a wider population than is routinely treated at present.

Adult↗
PubMed2006

Systematic review of resource utilization in the hospital management of deliberate self-harm.

BACKGROUND: Deliberate self-harm (DSH) is a significant public health problem, representing a major burden in terms of morbidity to the individual and health-service utilization. While clinical guidelines suggest good practice for the short-term hospital management of DSH, there remains considerable variability in the way that services are provided. METHOD: A systematic review of the literature was undertaken to examine the current evidence on hospital resource use and costs involved in the short-term hospital management of adults following DSH and to elucidate the factors that influence these differences, in terms of clinical characteristics and service provision. RESULTS: Twenty-one papers reporting on 17 studies met the inclusion criteria for review. Clinical characteristics associated with an increase in resource use included overdose with tricyclic antidepressants (TCAs) compared with selective serotonin re-uptake inhibitors (SSRIs) (weighted ratio 2.6:1) and co-ingestion of alcohol with SSRIs. Variations in service provision, including medical admissions policy and provision of a specialist liaison service, affected resource utilization independently of the clinical needs of patients. CONCLUSIONS: Overdoses of TCAs incur substantially greater hospital costs than overdoses of SSRIs. Variations in the medical seriousness of DSH, and in the structure of service provision, affect the resources used in its short-term hospital management, with little evidence about the impact these differences have on clinical outcome. Research is needed to evaluate the impact of different styles of service provision on outcome, and to incorporate these factors into the trial design of future cost-effectiveness studies of interventions following DSH.

Health Care Costs↗
PubMed2006

Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain.

STUDY DESIGN: Economic evaluation alongside a pragmatic multicenter randomized controlled trial from the National Health Service (NHS) and societal perspective. OBJECTIVE: To perform a cost-utility analysis of routine physiotherapy treatment compared with an assessment session and advice from a physiotherapist for patients with subacute and chronic low back pain. SUMMARY OF BACKGROUND DATA: Lack of evidence for some types of physiotherapy intervention and a paucity of cost-effectiveness data for treatment of low back pain has led to controversy and uncertainty within the medical and allied professions. PATIENTS AND METHODS: A total of 286 patients with low back pain of more than a 6-week duration were randomized to physiotherapy treatment or advice on remaining active from a physiotherapist. Data were collected on back pain-related NHS and patients' costs over a 12-month post randomization period. The primary outcome measure was the Oswestry Disability Index at 12 months, with additional Oswestry Disability Index measures at 2 and 6 months. The EuroQol EQ-5D was used to calculate quality adjusted life years. Cost-effectiveness was expressed as the incremental cost per quality adjusted life year gained. Uncertainty was handled using confidence ellipses for the ratio and cost-effectiveness acceptability curves. RESULTS: The total NHS costs were not significantly different at 179 pounds sterling (221 pounds sterling) for physiotherapy and 159 pounds sterling (260 pounds sterling) for the advice group. However, patients in the physiotherapy group had significantly higher out-of-pocket health care expenditure (40 pounds sterling, 95% confidence interval 9 pounds sterling to 71 pounds sterling). Utility levels improved in both groups from baseline to 12 months, with no significant differences between groups. CONCLUSIONS: The results indicate no significant differences in either NHS costs or effects. However, the significantly higher out-of-pocket expenses incurred by patients receiving routine physiotherapy suggests that advice given by a physiotherapist should be considered as the first-line treatment for patients with this level of back pain disability.

Acute Disease↗
PubMed2006

Responsiveness of objective, disease-specific, and generic outcome measures in patients with chronic low back pain: an assessment for improving, stable, and deteriorating patients.

STUDY DESIGN: Analysis of outcome data collected prospectively from 250 patients recruited to the UK Spine Stabilization Trial. OBJECTIVES: To compare the responsiveness of the Shuttle Walking Test (SWT), which is an objective outcome measure, with that of a disease-specific (the Oswestry Disability Index) and 2 generic (the EQ-5D and SF-36) instruments in patients with chronic low back pain (LBP). SUMMARY OF BACKGROUND DATA: Studies assessing the performance of subjective disease-specific and generic measures have increased in recent years, although there is a paucity of research reporting the responsiveness of objective measures in patients with LBP. The focus of investigation has been on responsiveness to improvements in LBP symptoms. For patients with deteriorating health, it remains largely unclear how outcome instruments perform. METHODS: Baseline and 12-month outcome data collected on 250 patients with chronic LBP recruited to the Spine Stabilization Trial were analyzed using traditional measures of responsiveness. Analyses were performed for 3 groups of patients: those who rated their health status as improved, deteriorated, and stable at 12 months. RESULTS: The SWT was shown by all measures to be responsive to health improvement, although less so than other instruments. All instruments were able to detect small-to-moderate reductions in health. Instrument floor effects may be responsible for small SF-36 change scores recorded for deteriorating patients. CONCLUSIONS: Although shown to be responsive, including the SWT alongside disease-specific and generic instruments is unlikely to add additional information. All instruments appear responsive to patient deterioration, however, further research for the SF-36 is required.

Adult↗
PubMed2006

Protocol for the Arterial Revascularisation Trial (ART). A randomised trial to compare survival following bilateral versus single internal mammary grafting in coronary revascularisation [ISRCTN46552265].

BACKGROUND: Standard coronary artery bypass graft surgery uses a single internal mammary artery and supplemental vein or radial artery grafts. Several observational studies have suggested a survival benefit with two internal mammary artery grafts compared to a single internal mammary artery graft, but this has not been tested in a randomised trial. The Arterial Revascularisation Trial is a Medical Research Council and British Heart Foundation funded, multi-centre international trial comparing single internal mammary artery grafting versus bilateral internal mammary artery grafting. METHODS/DESIGN: Twenty centres in the UK, Australia, Poland and Brazil are planning to randomise 3000 coronary artery bypass graft surgery patients to single or bilateral internal mammary artery grafting. Supplemental grafts may be either saphenous vein or radial artery. Coronary artery bypass grafting can be performed as an on-pump or off-pump procedure. The primary outcome is survival at 10 years and secondary end-points include clinical events, quality of life and cost effectiveness. The effect of age, left ventricular function, diabetes, number of grafts, vein grafts and off-pump surgery are pre-specified subgroups. DISCUSSION: The Arterial Revascularisation Trial is one of the first randomised trials to evaluate the effects on survival and other clinical outcomes of single internal mammary artery grafting versus bilateral internal mammary artery grafting, and will help to establish the best approach for patients requiring coronary artery bypass graft surgery.

Journal Article↗
PubMed2006

Economic burden of cardiovascular diseases in the enlarged European Union.

AIMS: Cardiovascular disease (CVD), together with its main components, coronary heart disease (CHD), and cerebrovascular diseases, is the main source of morbidity and mortality in the European Union (EU), but to date, there has not been any systematic cost-of-illness study to assess the economic impact of CVD in the EU. METHODS AND RESULTS: CVD-related expenditure was estimated using aggregate data on morbidity, mortality, and healthcare resource use. Healthcare costs were estimated from expenditure on primary, outpatient, emergency, and inpatient care, as well as medications. Costs of unpaid care and lost earnings due to morbidity and premature death were included in the study. CVD was estimated to cost the EU Euro 169 billion annually, with healthcare accounting for 62% of costs. Productivity losses and informal care represented 21% and 17% of costs, respectively. CHD represented 27% and cerebrovascular diseases 20% of overall CVD costs. CONCLUSION: CVD is a leading public health problem. Our study is the first to assess the economic burden of CVD across the EU, and our results should help policy makers evaluate policy impact and prioritize research expenditures. However, because of data unavailability, our study has important limitations, which highlight the need for more accurate and comparable CVD-specific information.

Cardiovascular Diseases↗
PubMed2006

Lifetime effects, costs, and cost effectiveness of testing for human papillomavirus to manage low grade cytological abnormalities: results of the NHS pilot studies.

OBJECTIVES: To predict the incremental lifetime effects, costs, and cost effectiveness of using human papillomavirus testing to triage women with borderline or mildly dyskaryotic cervical smear results for immediate colposcopy. DESIGN: Modelling study. SETTING: Three centres participating in NHS pilot studies, United Kingdom. Population Women aged 25-64 with borderline or mildly dyskaryotic cervical smear results. INTERVENTIONS: Screening using conventional cytology, liquid based cytology, and four strategies with different age cut-off points and follow up times that used combined liquid based cytology and human papillomavirus testing (adjunctive human papillomavirus testing). RESULTS: The model predicts that compared with using conventional cytology without testing for human papillomavirus, testing for the virus in conjunction with liquid based cytology for women with borderline or mildly dyskaryotic cervical smear results (aged 35 or more) would cost 3735 pounds sterling (5528 euros; 6474 dollars) per life year saved. Extending adjunctive human papillomavirus testing in combination with liquid based cytology to include women aged between 25 and 34 costs an additional 4233 pounds sterling per life year saved. Human papillomavirus testing is likely to reduce lifetime repeat smears by 52%-86% but increase lifetime colposcopies by 64%-138%. CONCLUSIONS: Testing for human papillomavirus to manage all women with borderline or mildly dyskaryotic cervical smear results is likely to be cost effective. The predicted increase in lifetime colposcopies, however, deserves careful consideration.

Adult↗
PubMed2006

Effect of testing for human papillomavirus as a triage during screening for cervical cancer: observational before and after study.

OBJECTIVE: To assess the effect of introducing testing for human papillomavirus combined with liquid based cytology in women with low grade cytological abnormalities. DESIGN: Observational before and after study. SETTING: Three cervical screening laboratories, England. PARTICIPANTS: 5654 women aged 20-64 with low grade cytological abnormalities found at routine cervical screening in a pilot; 5254 similar women in the period before the pilot. INTERVENTIONS: Human papillomavirus testing combined with liquid based cytology in the management of women with borderline or mildly dyskaryotic cervical smear results compared with conventional smear tests, with immediate referral to colposcopy of women positive for human papillomavirus. RESULTS: 57.9% (3187/5506) of women tested in the pilot were positive for human papillomavirus. The rate of repeat smears fell by 74%, but the rate of referral to colposcopy for low grade cytological abnormalities more than doubled. The estimated negative predictive value of human papillomavirus testing varied between 93.8% and 99.7%. CONCLUSION: The addition of testing for human papillomavirus in women with low grade cytological abnormalities resulted in a reduction in the rate of repeat smears, but an increase in rates of referral to colposcopy.

Adult↗
PubMed2006

Cost-effectiveness of prophylactic magnesium sulphate for 9996 women with pre-eclampsia from 33 countries: economic evaluation of the Magpie Trial.

OBJECTIVE: To assess the cost-effectiveness of using magnesium sulphate for pre-eclampsia to prevent eclampsia. DESIGN: Multinational trial-based economic evaluation. SETTING: Thirty-three countries participating in the Magnesium Sulphate for Prevention of Eclampsia (Magpie) Trial. POPULATION: Women (9996) with pre-eclampsia from the Magpie Trial. METHODS: Outcome and hospital resource use data were available for the trial period from the Magpie Trial. Country-specific unit costs (U.S. dollar, year 2001) were obtained subsequently from participating hospitals by questionnaire. Cost-effectiveness was estimated for three categories of countries grouped by gross national income (GNI) into high, middle and low GNI countries using a regression model. Uncertainty was explored in sensitivity analyses. MAIN OUTCOME MEASURES: Eclampsia, hospital care costs and the incremental cost per case of eclampsia prevented. RESULTS: The number of women with pre-eclampsia who needed to receive magnesium sulphate to prevent one case of eclampsia was 324 [95% confidence interval (CI) 122, infinity] in high, 184 (95% CI 91, 6798) in middle and 43 (95% CI 30, 68) in low GNI countries. The additional hospital care cost per woman receiving magnesium sulphate was $65, $13 and $11, respectively. The incremental cost of preventing one case of eclampsia was $21,202 in high, $2473 in middle and $456 in low GNI countries. Reserving treatment for severe pre-eclampsia would lower these estimates to $12,942, $1179 and $263. CONCLUSIONS: Magnesium sulphate for pre-eclampsia costs less and prevents more eclampsia in low GNI than in high GNI countries. Cost-effectiveness substantially improves if it is used only for severe pre-eclampsia, or the purchase price is reduced in low GNI countries.

Anticonvulsants↗
PubMed2006

Costs of chemotherapy for indolent follicular non-Hodgkin's lymphoma in the UK: an observational study.

Non-Hodgkin's lymphoma (NHL) is the sixth most common cancer in the United Kingdom (UK). This analysis assessed the health service costs of patients receiving chemotherapy for indolent follicular NHL based on a retrospective analysis of patient records in the UK. Each patient was followed up for a period of 3 years or until death. The analysis included 181 patients, who received a total of 187 treatment periods. Costs were estimated from the perspective of the UK National Health Service. The study found the cost of providing treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) or fludarabine to patients with indolent follicular NHL to be lower than previously reported.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2006

Cost-utility analysis in a UK setting of self-monitoring of blood glucose in patients with type 2 diabetes.

BACKGROUND: Self-monitoring of blood glucose (SMBG) in type 2 diabetes patients has been shown in meta-analyses of randomized trials to improve HbA(1c) by approximately 0.4% when compared to no SMBG. However, the cost of testing supplies is high, improvements in health utility due to improved glycaemic control may be possible and cost-effectiveness has not been evaluated. METHODS: A peer-reviewed validated model projected improvements in lifetime quality-adjusted life years (QALYs), long-term costs and cost-effectiveness of SMBG versus no SMBG. Markov/Monte Carlo modelling simulated the progression of complications (cardiovascular, neuropathy, renal and eye disease). Transition probabilities and HbA(1c)-dependent adjustments came from the United Kingdom Prospective Diabetes Study (UKPDS) and other major studies. Effects of SMBG on HbA(1c) came from clinical studies, meta-analyses and population studies, but can only be considered 'moderate' levels of evidence. Costs of complications were retrieved from published sources. Direct costs of diabetes complications and SMBG were projected over patient lifetimes from a UK National Health Service perspective. Outcomes were discounted at 3.5% annually. Extensive sensitivity analyses were performed. RESULTS: Depending on the type of diabetes treatment (diet and exercise/oral medications/insulin), improvements in glycaemic control with SMBG improved discounted QALYs anywhere from 0.165 to 0.255 years, with increased total costs of 1013 pounds sterlings- 2564 pounds sterlings/patient, giving incremental cost-effectiveness ratios of 4508 pounds sterlings: 15,515 pounds sterlings/QALY gained, well within current UK willingness-to-pay limits. Results were robust under a wide range of plausible assumptions. CONCLUSIONS: Based on the moderate level of clinical evidence available to date, improvements in glycaemic control with interventions, including SMBG, can improve patient outcomes, with acceptable cost-effectiveness ratios in the UK setting.

Blood Glucose Self-Monitoring↗
PubMed2006

Improving hand-washing performance - a crossover study of hand-washing in the orthopaedic department.

INTRODUCTION: Effective hand-washing is essential for reducing the spread of infection in hospitals. We aimed to evaluate hand-washing performance of hospital personnel and to determine if this could be improved by education. MATERIALS AND METHODS: A total of 55 personnel working in the orthopaedic department were asked to clean their hands using an alcohol gel containing a clear fluorescent substance. They were unaware of the assessment method. Performance was assessed by examining their hands under UV light to identify areas that had been neglected. Subjects could visualise which areas they had missed and were then educated regarding hand-washing technique and retested after 7 days. RESULTS: Of the 55 subjects, 53 completed the study. Individual performance varied widely. Following a simple educational intervention, 49 out of 53 subjects improved from an average of 7.8% to 2.3% area missed (P < 0.001). CONCLUSIONS: We suggest that hand-washing effectiveness needs to be improved and that a simple educational intervention can be effective.

Adult↗
PubMed2005

Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial.

OBJECTIVE: To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with chronic low back pain. DESIGN: Economic evaluation alongside a pragmatic randomised controlled trial. SETTING: Secondary care. PARTICIPANTS: 349 patients randomised to surgery (n = 176) or to an intensive rehabilitation programme (n = 173) from 15 centres across the United Kingdom between June 1996 and February 2002. MAIN OUTCOME MEASURES: Costs related to back pain and incurred by the NHS and patients up to 24 months after randomisation. Return to paid employment and total hours worked. Patient utility as estimated by using the EuroQol EQ-5D questionnaire at several time points and used to calculate quality adjusted life years (QALYs). Cost effectiveness was expressed as an incremental cost per QALY. RESULTS: At two years, 38 patients randomised to rehabilitation had received rehabilitation and surgery whereas just seven surgery patients had received both treatments. The mean total cost per patient was estimated to be 7830 pounds sterling (SD 5202 pounds sterling) in the surgery group and 4526 pounds sterling (SD 4155 pounds sterling) in the intensive rehabilitation arm, a significant difference of 3304 pounds sterling (95% confidence interval 2317 pounds sterling to 4291 pounds sterling). Mean QALYs over the trial period were 1.004 (SD 0.405) in the surgery group and 0.936 (SD 0.431) in the intensive rehabilitation group, giving a non-significant difference of 0.068 (-0.020 to 0.156). The incremental cost effectiveness ratio was estimated to be 48,588 pounds sterling per QALY gained (- 279,883 pounds sterling to 372,406 pounds sterling). CONCLUSION: Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources. However, sensitivity analyses show that this could change-for example, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase.

Adult↗
PubMed2005

Economic evaluation of ultrasonography in the diagnosis and management of developmental hip dysplasia in the United Kingdom and Ireland.

BACKGROUND: Clinical neonatal hip screening is performed to identify hip instability and the increased risk of later hip subluxation and dislocation. However, there is minimal information regarding the costs of such screening to parents and health services. The aim of this study was to assess these costs in association with the use of ultrasonography for the diagnosis and management of neonatal hip instability. METHODS: We conducted a prospective economic analysis in conjunction with a randomized clinical trial (the Hip Trial), for which 629 patients were recruited from thirty-three centers in the United Kingdom and Ireland to be randomized to undergo either ultrasonographic hip examination (314 patients) or clinical assessment alone (315 patients). Information on clinical outcomes was obtained from hospital records and records from the Hip Trial. Resource information was obtained from hospital records and from repeated periodic cross-sectional surveys of the families. Typical unit costs were applied to resource information to obtain a cost per patient, and the mean costs in the two study groups were calculated and compared. RESULTS: The average overall health-service cost per patient (and standard deviation) was $1298 +/- $2168 in the ultrasonography group and $1488 +/- $2912 in the group that underwent clinical assessment alone, a net difference of -$190 (95% confidence interval, -$630 to $250). Families in which the infant was examined with ultrasonography had significantly lower costs associated with splinting: $92 compared with $118 in the group that underwent clinical assessment alone, a mean difference of -$26 (95% confidence interval, -$46 to -$6). Costs associated with surgery and total costs to the family were also slightly, but not significantly, lower in the ultrasonography group. CONCLUSIONS: Our results suggest that use of ultrasonography in the management of neonates with clinical hip instability is unlikely to impose an increased cost burden and may reduce costs to health services and families.

Health Care Costs↗
PubMed2004

Time to death and health expenditure: an improved model for the impact of demographic change on health care costs.

BACKGROUND: Obtaining well-founded estimates of the effect of demographic change on future health expenditures is a pressing issue in all developed countries. Thus far, expenditure projections have examined the effect of age on health care costs, but fail to account for the influence of remaining life expectancy on costs. OBJECTIVE: This paper seeks to create a more accurate projection model that considers the concentration of costs towards the end of life, and to compare this model with the more traditional approach that holds age- and sex-specific per capita expenditures constant. METHODS: We used a longitudinal hospital dataset which followed 90 929 patients aged 65 and older from 1970 to death, to create an economic model of hospital costs based on patient age and time remaining to death. We then applied the model to England population projections to predict the effect of demographic changes on hospital expenditures from 2002 to 2026. RESULTS: The decline in age-specific mortality rates over time postpones death to later ages, pushing back death-related costs. Accounting for this in expenditure projections gave a predicted annual growth rate of 0.40%-half of the rate predicted with a traditional method. CONCLUSIONS: Using richer data and more refined methods than have hitherto been employed, this study strongly confirms that the pressure of population increases and ageing demographic structure on hospital expenditures will be partially countered by the postponement of death-related hospital costs to later in life-a finding consistent with emerging epidemiological evidence, and heartening for policy makers and physicians alike.

Adolescent↗
PubMed2004

Psychological impact of human papillomavirus testing in women with borderline or mildly dyskaryotic cervical smear test results: cross sectional questionnaire study.

OBJECTIVE: To describe the psychological impact on women of being tested for human papillomavirus (HPV) when smear test results are borderline or mildly dyskaryotic. DESIGN: Cross sectional questionnaire study. SETTING: Two centres participating in an English pilot study of HPV testing in women with borderline or mildly dyskaryotic smear test results. PARTICIPANTS: Women receiving borderline or mildly dyskaryotic smear test results tested for HPV and found to be HPV positive (n = 536) or HPV negative (n = 331); and women not tested for HPV with borderline or mildly dyskaryotic smear results (n = 143) or normal smear results (n = 366). MAIN OUTCOME MEASURES: State anxiety, distress, and concern about test result, assessed within four weeks of receipt of results. RESULTS: Women with borderline or mildly dyskaryotic smear results who were HPV positive were more anxious, distressed, and concerned than the other three groups. Three variables independently predicted anxiety in HPV positive women: younger age (beta = -0.11, P = 0.03), higher perceived risk of cervical cancer (beta = 0.17, P < 0.001), and reporting that they did not understand the meaning of test results (beta = 0.17, P = 0.001). Testing HPV negative was not reassuring: among women with abnormal smear test results, those who were HPV negative were no less anxious than those who were not tested for HPV. CONCLUSIONS: Informing women more effectively about the meaning of borderline or mildly dyskaryotic smear test results and HPV status, in particular about the absolute risks of cervical cancer and the prevalence of HPV infection, may avoid some anxiety for those who are HPV positive while achieving some reassurance for those who test HPV negative.

Adult↗
PubMed2004

Ageing and health-care expenditure: the red herring argument revisited.

Zweifel and colleagues have previously proposed that proximity to death is a more important influence on health-care costs than age, suggesting that demographic change per se will not have a large impact on future aggregate health expenditure. However, issues of econometric methodology have led to challenges of the robustness of these findings. This paper revisits the analysis. Using a longitudinal hospital data set from Oxfordshire, England, the two-step Heckman model from the Zweifel study is first replicated, to find that neither age nor proximity to death have a significant effect on hospital costs. Econometric problems with the model are demonstrated, and instead a two-part model shows both age and proximity to death to have significant effects on quarterly hospital costs. Cost predictions, calculated with bootstrapped 95% confidence intervals, further demonstrate that while age may significantly affect quarterly costs, these cost changes are small compared to the tripling of quarterly costs that occurs with approaching death in the last year of life. The analyses show the importance of model selection to properly assess the determinants of health-care expenditures.

Aged↗