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PubMed1998

The Ontario Prehospital Advanced Life Support (OPALS) Study: rationale and methodology for cardiac arrest patients.

The Ontario Prehospital Advanced Life Support Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period. The study will evaluate the incremental benefit of rapid defibrillation and prehospital Advanced Cardiac Life Support measures for cardiac arrest survival and the benefit of Advanced Life Support for patients with traumatic injuries and other critically ill prehospital patients. This article describes the OPALS study with regard to the rationale and methodology for cardiac arrest patients.

Cost-Benefit Analysis↗
PubMed1990

Principles of cost-effective resource allocation in health care organizations.

Cost-effectiveness analysis (CEA) is a method of economic evaluation that can be used to assess the efficiency with which health care technologies use limited resources to produce health outputs. However, inconsistencies in the way that such ratios are constructed often lead to misleading conclusions when CEAs are compared. Some of these inconsistencies, such as failure to discount or to calculate incremental ratios correctly, reflect analytical errors that, if corrected, would resolve the inconsistencies. Others reflect fundamental differences in the viewpoint of the analysis. The perspectives of different decision-making entities can properly lead to different items in the numerator and denominator of the cost-effectiveness (C/E) ratio. Producers and consumers of CEA need to be more conscious of the perspectives of analysis, so that C/E comparisons from a given perspective are based upon a common understanding of the elements that are properly included.

Cost-Benefit Analysis↗
PubMed1999

Calculating the direct costs of urinary incontinence: a new test instrument.

OBJECTIVES: To develop a universally applicable test instrument to measure the total direct costs of urinary incontinence, including personal costs and treatment costs, i.e. the Dowell-Bryant Incontinence Cost Index (DBICI), and to study the construct validity and test-retest reliability of the instrument. PATIENTS AND METHODS: In a prospective observational study, 100 consecutive community-dwelling ambulatory women who presented with stress, urge or mixed incontinence were asked to complete the DBICI questionnaire on two occasions, 7 days apart, before any treatment. The construct validity of the DBICI was ascertained by correlation with other standard measures of urinary incontinence severity; (i) a visual analogue scale (VAS) to assess the impact of leakage upon lifestyle; (ii) frequency-volume charts (voids/24 h, leaks/week); (iii) urine loss during a standard 1 h pad test; and (iv) two disease-specific quality of life questionnaires. The test-retest reliability was measured by comparing the two test results and the construct validity of the individual subsets (personal and treatment) of the DBICI similarly assessed. RESULTS: Ninety-seven women completed the baseline assessment and 84 completed the re-test. The median (interquartile range) total direct incontinence cost (in Au$) was 12. 89 (5.26-22.67) per week, which comprised the median personal costs of 5.61 (1.68-10.36) and the median treatment costs of 4.96 (1.22-13. 37). The total direct incontinence cost was significantly correlated with the severity of urinary leakage on a 1 h pad test (Kendall's rank correlation, P=0.01), with the VAS impact score (P<0.001) and with the number of leaks/week (P=0.005). The correlation between the personal cost subset and other quantitative measures was also highly significant. Test-retest analysis of the personal costs subset revealed that this subset was robust and satisfied the statistical criteria of repeatability. CONCLUSIONS: The DBICI gives a detailed measure of the direct economic costs of urinary incontinence in ambulatory home-dwelling women, with the construct validity confirmed by the significant correlation with other quantitative measures of incontinence. By substituting local prices into the test format, the index should be useful in other countries. In the current climate of economic rationalization, such an index should be a part of future urinary incontinence research.

Adult↗
PubMedDate not supplied

Diabetes in Canada: direct medical costs of major macrovascular complications.

OBJECTIVES: To estimate direct medical costs of managing major macrovascular complications in diabetic patients. METHODS: Costs were estimated for acute myocardial infarction (AMI) and ischemic stroke by applying unit costs to typical resource use profiles. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, provincial physician and laboratory fee schedules, provincial formularies, government reports, and peer-reviewed literature. For each complication, the event costs per patient are those associated with resource use specific to the acute episode and any subsequent care occurring in the first year. State costs are the annual costs per patient of continued management. All costs are expressed in 1996 Canadian dollars. RESULTS: Acute hospital care accounts for approximately half of the first year management costs ($15,125) of AMI. Given the greater need for postacute care, acute hospital care has less impact (28%) on event costs for stroke ($31,076). The state costs for AMI and stroke are $1544 and $8141 per patient, respectively. CONCLUSIONS: Macrovascular complications of diabetes potentially represent a substantial burden to Canada's health care system. As new therapies emerge that may reduce the incidence of some diabetic complications, decision makers will need information to make critical decisions regarding how to spend limited health care dollars. Published literature lacks Canadian-specific cost estimates that may be readily translated into patient-level cost inputs for an economic model. This paper provides two key pieces of the many needed to understand the scope of the economic burden of diabetes and its complications for Canada.

Adult↗
PubMedDate not supplied

The cost-effectiveness of alternative therapeutic strategies for the management of chronic hepatitis B in Poland.

OBJECTIVE: The aim of the study was to estimate the cost-effectiveness of alternative therapeutic strategies for the management of chronic hepatitis B (CHB) in Poland. METHODS: The model for the Polish health-care context was based on clinical data from the literature and local data on health-care resource utilization and unit costs. Costs and effects of a population of CHB patients were modeled using four scenarios, which attempt to reflect real-life practice in which patients may receive any of the treatment options available and in which a proportion of patients may still receive no treatment because therapy is not suitable. Strategies A and B assumed the availability of both treatment options: the first choice of treatment is in A, lamivudine, and in B, interferon alpha (IFN-alpha). In strategy C, the only approved treatment is IFN-alpha, and in strategy D, the patients receive no antiviral treatment. The outcome measures were HBeAg seroconversion and nonprogression to cirrhosis-the surrogate marker with predictive value for improved survival. Only direct medical costs were analyzed. The payer's perspective and time horizon of 1 year were adopted. One-way sensitivity analysis and extreme scenario analysis were performed. RESULTS: The best results in terms of seroconversion and nonprogression to cirrhosis were achieved for strategy A, costs were lowest for strategy D, and strategies B and C were dominated by strategy A. The incremental cost/effectiveness ratio (ICER) comparing strategy A with strategy D was 57,855 Polish new zloty (PLN) per extra seroconversion and 79,550 PLN per cirrhosis case avoided. CONCLUSIONS: Cirrhosis reduces estimated life expectancy by 37.76 years and by 20 years among 30- and 50-year-olds, respectively. The ICER for strategies A and D was 2105 PLN and 3978 PLN per life-years gained for the population at ages 30 and 50, respectively, and was below the suggested threshold for cost-effectiveness, based on treatment costs for 1 year of hemodialysis in Poland (62,400 PLN). Changing the value of key drivers for sensitivity analysis did not have a significant effect on the ICER.

Antiviral Agents↗
PubMed1999

Outcome assessment--TISS as a tool to evaluate cost-effectiveness of immunological treatment.

Nursing costs more than any other element of intensive care. Nurses are allocated exclusively to the ICU, and their use can therefore be accurately monitored. The amount of nursing work in the ICU is intimately associated with the severity of illness of the patients. Consequently, the density of nursing staff in the ICU can be used as a measure of cost, and the Therapeutic Intervention Scoring System (TISS) is a reliable tool for measuring their workload. TISS is therefore often used to compare the costs of alternative courses of care; it covers direct costs of care, but it should not be used as a proxy for total costs in the ICU. The users of TISS should consider the limitations of the scoring system in some aspects of its development, as well as the general nature of the definitions of the items included. The careful enunciation of the more generally defined items has therefore to be considered when it is used in a research project that compares small samples.

Cardiac Surgical Procedures↗
PubMed2003

Pharmacoeconomic analysis of thiopurine methyltransferase polymorphism screening by polymerase chain reaction for treatment with azathioprine in Korea.

OBJECTIVES: To evaluate the value of genotype-based dosing by polymerase chain reaction (PCR)-based polymorphism screening in terms of cost-effectiveness for treatment with azathioprine in Korea. METHODS: Decision analysis was employed to compare a genotype-based dosing strategy with the conventional weight-based dosing strategy using a hypothetical cohort composed of rheumatoid arthritis and systemic lupus erythematosus patients. The time horizon was set up as 1 yr. Direct medical costs were used. Data used were obtained from previous reports, except for PCR and admission costs, which were from real cases. Cost-effectiveness analysis was conducted from a societal perspective. Outcomes were measured as a total expected cost and an incremental cost-effective ratio. RESULTS: In the base case model, total expected cost and the probability of not dropping out owing to serious adverse events of the conventional weight-based dosing and the genotype-based dosing strategy were 1339 x 10(3) Korean won (1,117 US dollars) and 1109 x 10(3) Korean won (926 US dollars), and 97.06 and 99.90%, respectively. CONCLUSIONS: Our model suggests that a genotype-based dosing strategy through PCR-based thiopurine methyltransferase (TPMT) polymorphism screening is less costly and more effective than the conventional weight-based dosing strategy in Korea, as it was associated with a marked reduction in the number of serious adverse events.

Antirheumatic Agents↗
PubMed2001

Decision analysis for the cost-effective management of recurrent colorectal cancer.

OBJECTIVE: To determine whether the use of [(18)F]2-fluoro-2-deoxyglucose positron emission tomography (FDG PET) in addition to computed axial tomography (CT) is helpful in managing recurrent colorectal cancer (CRC). SUMMARY BACKGROUND DATA: There is no consensus on a management algorithm for CRC. However, when recurrence is suspected, CT is generally used for further evaluation and staging of disease. METHODS: The authors used decision trees based on theoretical models to assess the cost-effectiveness of a CT + FDG PET strategy for the diagnosis and management of recurrent CRC compared with a CT-alone strategy. These theoretical models focus on patients with hepatic recurrence who are potentially curable through surgical hepatic resection. The population entering the decision trees consisted of patients with CRC who had undergone surgical resection of their primary CRC and who were suspected of having recurrence based on elevated levels of carcinoembryonic antigen. RESULTS: The CT + FDG PET strategy was found to be cost-effective for managing patients with elevated carcinoembryonic antigen levels who were candidates for hepatic resection. The CT + FDG PET strategy was higher in mean cost by $429 per patient but resulted in an increase in the mean life expectancy of 9.527 days per patient. CONCLUSIONS: These results show, through rigorous decision tree analysis, the potential cost-effectiveness of FDG PET in the management of recurrent CRC. The decision trees can be used to model various features of the management of recurrent CRC, including the cost-effectiveness of other newly emerging technologies.

Colorectal Neoplasms↗
PubMedDate not supplied

Process-based costing.

Understanding how quality improvement affects costs is important. Unfortunately, low-cost, reliable ways of measuring direct costs are scarce. This article builds on the principles of process improvement to develop a costing strategy that meets both criteria. Process-based costing has 4 steps: developing a flowchart, estimating resource use, valuing resources, and calculating direct costs. To illustrate the technique, this article uses it to cost the care planning process in 3 long-term care facilities. We conclude that process-based costing is easy to implement; generates reliable, valid data; and allows nursing managers to assess the costs of new or modified processes.

Cost Allocation↗
PubMedDate not supplied

A model for quantifying quality initiatives in intensive care.

A balance should exist in health care organizations between the focus on cost containment and quality improvement efforts. This is particularly important in relation to critical care in that intensive care units (ICUs) absorb a significant proportion of the hospital's budget. The purpose of this article is to present a model that can be used to quantify the financial value to the institution of quality ICU outcomes achieved as a result of implementation of ventilator bundle initiatives. This one-bed ICU model illustrates the value of improving the care for one patient and cost, quantifying the outcomes that result through a focus on cost savings, revenue enhancement, and cost avoidance.

Bed Occupancy↗
PubMed1992

A cost-savings analysis of the use of a predictive instrument for coronary-care-unit admission decisions.

The predictive instrument for acute ischemic heart disease is one of several clinical decision aids developed to reduce unnecessary coronary-care-unit (CCU) admissions. Previous cost analyses of such decision aids have been based on hospital charges; however, estimates based on hospital charges significantly overstate true cost savings to hospitals. The actual savings for a hospital that wants to implement the predictive instrument depend on the hospital's cost structure, the competitiveness of its medical care, and its payor mix.

Boston↗
PubMed2005

A cost-benefit analysis of external hip protectors in the nursing home setting.

OBJECTIVES: To estimate potential cost savings generated by a program of hip protectors in the nursing home from a Medicare perspective. DESIGN: A state-transition Markov model considering short-term and long-term outcomes of hip protectors for a hypothetical nursing home population, stratified by age, sex, and functional status. Costs, transition probabilities between health states, and estimates of hip protectors' effectiveness were derived from published secondary data. SETTING: Nursing home facilities in the United States. PARTICIPANTS: Hypothetical cohort of permanent nursing home residents aged 65 and older without a previous hip fracture. INTERVENTION: Program of hip protectors reimbursed by Medicare. MEASUREMENTS: Number of fractures, life years, and dollars saved. RESULTS: Three pairs of hip protectors replaced annually would result in a weighted average lifetime absolute risk reduction for hip fracture of 8.5%, with net lifetime savings to Medicare of 223 dollars per resident. When the annual cost of hip protectors is less than 151 dollars per person, relative risk of fracture is less than or equal to 0.65 with hip protectors, or adherence is greater than 42%, hip protectors are cost saving to Medicare over a wide range of assumptions. Extrapolating these results to the estimated population of U.S. nursing home residents without a previous hip fracture, Medicare could save 136 million dollars in the first year of a hip-protector reimbursement program. CONCLUSION: From a Medicare perspective, hip protectors are a cost-saving intervention in the nursing home setting when hip protector effectiveness is less than or equal to 0.65 over the remaining lifetime of subjects.

Aged↗
PubMedDate not supplied

Preoperative correlates of the cost of coronary artery bypass graft surgery: comparison of results from three hospitals.

This article furthers our understanding of the cost of coronary artery bypass graft (CABG) surgery by analyzing the extent to which preoperative correlates of cost differ among hospitals. A total of 2828 patient who underwent bypass surgery at 3 hospitals (2 teaching and 1 nonteaching) were analyzed. The preoperative correlates of direct variable cost (marginal cost) were determined by ordinary least squares regression. Age, urgent/emergent surgical priority, previous CABG, and chronic obstructive pulmonary disease (COPD) were significant contributors (P < .05) to cost in all hospitals, but overall, there were many differences. The major contributor to cost was non-white race (31.3%) at teaching hospital A, previous CABG (30.5%) at teaching hospital B, and preop insertion of intra-aortic balloon pump (IABP) (35.9%) at the nonteaching hospital. The number of significant risk factors also differed. Preoperative characteristics that contribute to cost can be quite different among hospitals and therefore results from one hospital cannot be broadly generalized to others.

Age Factors↗
PubMed2004

Evaluating the cost-effectiveness of orthodontic provision.

The assessment of orthodontic provision is important to determine if treatment was necessary and undertaken appropriately. The ICON objectively quantifies orthodontic treatment need, complexity and outcome and is a valuable occlusal index in the assessment effectiveness of orthodontic care. It is possible to develop cost-effectiveness models by analysing the costs and effectiveness of orthodontic treatment. Several methods are illustrated to compare the orthodontic provision of specialist orthodontists.

Cost of Illness↗
PubMed2000

Cost-effectiveness of radiofrequency ablation for supraventricular tachycardia.

BACKGROUND: Radiofrequency ablation is an established but expensive treatment option for many forms of supraventricular tachycardia. Most cases of supraventricular tachycardia are not life-threatening; the goal of therapy is therefore to improve the patient's quality of life. OBJECTIVE: To compare the cost-effectiveness of radiofrequency ablation with that of medical management of supraventricular tachycardia. DESIGN: Markov model. DATA SOURCES: Costs were estimated from a major academic hospital and the literature, and treatment efficacy was estimated from reports from clinical studies at major medical centers. Probabilities of clinical outcomes were estimated from the literature. To account for the effect of radiofrequency ablation on quality of life, assessments by patients who had undergone the procedure were used. TARGET POPULATION: Cohort of symptomatic patients who experienced 4.6 unscheduled visits per year to an emergency department or a physician's office while receiving long-term drug therapy for supraventricular tachycardia. TIME HORIZON: Patient lifetime. PERSPECTIVE: Societal. INTERVENTIONS: Initial radiofrequency ablation, long-term antiarrhythmic drug therapy, and treatment of acute episodes of arrhythmia with antiarrhythmic drugs. OUTCOME MEASURES: Costs, quality-adjusted life-years, life-years, and marginal cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS: Among patients who have monthly episodes of supraventricular tachycardia, radiofrequency ablation was the most effective and least expensive therapy and therefore dominated the drug therapy options. Radiofrequency ablation improved quality-adjusted life expectancy by 3.10 quality-adjusted life-years and reduced lifetime medical expenditures by $27 900 compared with long-term drug therapy. Long-term drug therapy was more effective and had lower costs than episodic drug therapy. RESULTS OF SENSITIVITY ANALYSIS: The findings were highly robust over substantial variations in assumptions about the efficacy and complication rate of radiofrequency ablation, including analyses in which the complication rate was tripled and efficacy was decreased substantially. CONCLUSIONS: Radiofrequency ablation substantially improves quality of life and reduces costs when it is used to treat highly symptomatic patients. Although the benefit of radiofrequency ablation has not been studied in less symptomatic patients, a small improvement in quality of life is sufficient to give preference to radiofrequency ablation over drug therapy.

Adult↗
PubMed2001

Foot care economics--cost burden to diabetic patients with foot complications: a study from southern India.

OBJECTIVE: To estimate the direct cost burden of diabetic patients with foot complications. METHODS: An illustrative sample of 270 subjects with type two diabetes were seen at the clinic selected for the study. Among them 164 were without any complication (Group I) and 106 patients were with foot complications (Group II). In the latter group 83 (Group IIA) required in-patient (IP) care and 23 (Group IIB) required out-patient (OP) care. Annual expenses on medical care were estimated by a questionnaire method. Validation of the questionnaire data was verifying the amount spent by checking up the bills. RESULT: Group I spent Rs.4373 (US $ 104 Approx.), Group II spent Rs.15450 (US $ 343 Approx.), Group IIA spent Rs.7200 (US $ 171 Approx.) and Group IIB spent Rs.16910 (US $ 403 Approx.) in the study year. In the total sample of 270 subjects 61% were without foot problems, 22% had foot problems requiring OP treatment only (Group IIA), and 78% had foot problems requiring IP treatment (Group IIB). CONCLUSION: Group IIB spent significantly greater percentage of their income than Group IIA, and both groups spent greater percentage of their income than Group I. All differences were statistically significant.

Cost of Illness↗