Clinical and economic impact of multiple gated acquisition scan monitoring during anthracycline therapy.

The clinical and economic impacts of monitoring cardiac function in patients given doxorubicin have yet to be determined, especially in relation to patient age, cumulative doxorubicin dose, and the relative efficacies of doxorubicin-based vs alternative regimens. We developed a decision analysis model that includes these factors to estimate the incremental survival benefit and cost-effectiveness of using multiple gated acquisition scans to measure left-ventricular ejection fraction before and during doxorubicin chemotherapy. Probability distributions for the incidences of abnormal left-ventricular ejection fraction findings and congestive heart failure were derived from a retrospective review of 227 consecutive cases at The University of Michigan Medical Center and published findings. Multiple gated acquisition-scan monitoring minimally improved the probability of 5-year survival (<1.5% in the base--case scenario). For patients who received up to 350 mg m(-2) of doxorubicin, multiple gated acquisition-scan screening had an incremental cost of $425 402 per life saved for patients between the ages of 15--39. This incremental cost markedly decreased to $138 191, for patients between the ages of 40--59, and to $86 829 for patients older than 60 years. The small gain in 5-year survival probability secondary to multiple gated acquisition scan monitoring doubled for all age groups when the average cumulative dose for doxorubicin reached 500 mg m(-2). Variations in the cure rate differences between the doxorubicin and alternative regimens had insignificant effects on the improvement in 5-year survival rates from multiple gated acquisition-scan screening. The use of multiple gated acquisition scans for pretreatment screening appears to be more cost-effective for patients who are 40 years or older, when cumulative doxorubicin dose is 350 mg m(-2) or less.

Aspirin as an adjunct to screening for prevention of sporadic colorectal cancer. A cost-effectiveness analysis.

BACKGROUND: Aspirin may decrease colorectal cancer incidence, but its role as an adjunct to or substitute for screening has not been evaluated. OBJECTIVE: To examine the potential cost-effectiveness of aspirin chemoprophylaxis in relation to screening. DESIGN: Markov model. DATA SOURCES: Literature on colorectal cancer epidemiology, screening, costs, and aspirin chemoprevention (1980-1999). TARGET POPULATION: General U.S. population. TIME HORIZON: 50 to 80 years of age. PERSPECTIVE: Third-party payer. INTERVENTION: Aspirin therapy in patients screened with sigmoidoscopy every 5 years and fecal occult blood testing every year (FS/FOBT) or colonoscopy every 10 years (COLO). OUTCOME MEASURES: Discounted cost per life-year gained. RESULTS OF BASE-CASE ANALYSIS: When a 30% reduction in colorectal cancer risk was assumed, aspirin increased costs and decreased life-years because of related complications as an adjunct to FS/FOBT and cost $149 161 per life-year gained as an adjunct to COLO. In patients already taking aspirin, screening with FS/FOBT or COLO cost less than $31 000 per life-year gained. RESULTS OF SENSITIVITY ANALYSIS: Cost-effectiveness estimates depended highly on the magnitude of colorectal cancer risk reduction with aspirin, aspirin-related complication rates, and the screening adherence rate in the population. However, when the model's inputs were varied over wide ranges, aspirin chemoprophylaxis remained generally non-cost-effective for patients who adhere to screening. CONCLUSIONS: In patients undergoing colorectal cancer screening, aspirin use should not be based on potential chemoprevention. Aspirin chemoprophylaxis alone cannot be considered a substitute for colorectal cancer screening. Public policy should focus on improving screening adherence, even in patients who are already taking aspirin.

National estimates of the quantity and cost of informal caregiving for the elderly with dementia.

OBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia. DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443). SETTING: National population-based sample of the community-dwelling elderly. MAIN OUTCOME MEASURES: Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status. RESULTS: After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars. CONCLUSION: The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Beyond managed long-term care: paying for home care based on risk of adverse outcomes.

Evaluations of home care for chronically ill elderly people have shown disappointing results for many years. Improvements in outcomes have been slight and costs high. We offer a system for setting budget targets based upon effectiveness of home care in mitigating certain adverse outcomes, the risk of those outcomes those outcomes. We believe that such a budgeting system will encourage improved measurement of outcomes and more rigorous justification for expenditures. Moreover, such a system is designed to reallocate resources to higher-risk patients and those more likely to benefit, focusing caregiving on specific outcomes and improving those outcomes.

Preference diversity and the breadth of employee health insurance options.

OBJECTIVE: To examine the effect of worker heterogeneity, firm size, and establishment size on the breadth of employer health insurance offerings. DATA SOURCES: The data were drawn from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey of 22,000 business establishments selected randomly from ten states. STUDY DESIGN: The analysis was cross-sectional, using ordered probit models to relate the breadth of plan offerings to firm characteristics. PRINCIPAL FINDINGS: Firms with more diverse workforces offered a more diverse set of health insurance options. Firm and establishment size independently influenced the breadth of plan offerings. CONCLUSIONS: Employers are responsive to worker heterogeneity when determining the breadth of their health insurance offerings. However, diseconomies of scale in the purchase and administration of health insurance appear to limit the extent to which small employers can accommodate diverse worker preferences.

A benefit-based copay for prescription drugs: patient contribution based on total benefits, not drug acquisition cost.

Several managerial mechanisms have been used by managed care organizations to affect prescription drug utilization and related expenditures. Some efforts have focused on monitoring clinical conditions, drug use, and compliance, whereas other efforts have focused on consumer cost sharing and changing product-mix. Efforts focusing on improving quality of care by identifying untreated patients or by enhancing compliance can lead to appropriately increased drug costs, although perhaps with reduced overall medical expenditures. In contrast, the mechanisms implemented to constrain drug costs raise concerns regarding missed opportunities to enhance clinical outcomes, and the possibility of higher medical expenditures. Cost sharing plays a critical role in defining the pharmaceutical benefit. To balance the demands for access to pharmaceuticals with pressures to constrain costs, levels of cost sharing must be set in a manner that achieves appropriate clinical and financial outcomes. Modern multitier systems often base patient contributions on drug acquisition cost, and often do not consider medical necessity as a coverage criterion. Using an alternative approach, the benefit-based copay, patient contributions are based on the potential for clinical benefit, taking into consideration the patient's clinical condition. For any given drug, patients with a high potential benefit would have lower copays than patients with a low potential benefit. Implementation of such a system would provide a financial incentive for individuals to prioritize their out-of-pocket drug expenditures based on the value of their medications, not their price.

Heterogeneity of risk in a managed home health care population.

OBJECTIVE: To examine the distribution of risk and the correlation between risks in a home care population with regard to several important adverse outcomes. BACKGROUND: Researchers and policy makers have long recognized the heterogeneity of home care populations. Most research in this area focuses on identifying predictors of adverse outcomes. The degree of the heterogeneity of risks is much more poorly understood. Yet understanding the degree of risk heterogeneity at the population level is important because it has implications for the extent to which the level of care should vary among recipients. STUDY SETTING: Patients enrolled in the Arizona Health Care Cost Containment System (AHCCCS) program, between the December 1992 and April 1998. OUTCOME MEASURES: Estimating the risk for nursing home placement, hospitalization, death, and functional decline. METHODS: Estimating discrete time hazard models. From these models the predicted risk for each outcome is estimated and the distribution and correlation of predicted risks is examined. Model fit is assessed through split sample techniques and by examining the ratio of predicted to actual outcomes for selected sub-groups. RESULTS: The estimates reveal a wide variation in predicted risk. The ratio of predicted risk at the 90th percentile relative to the 10th percentile ranges from 4.99 for nursing home admission to 6.65 for hospitalization. The distributions of predicted risks are all skewed, particularly the distributions for death and nursing home admission. Predicted nursing home risk is highly correlated with the predicted risk for death (rho = 0.71). The predicted risk for hospitalization is not strongly correlated with the predicted risk for either death or nursing home admission. CONCLUSION: The wide variation in risk among home care patients suggests that efficient allocation of resources would require variation in spending and targeting of services based on patient characteristics. Greater research regarding the effectiveness of home care for different sub-populations is called for.

Estimating the cost of informal caregiving for elderly patients with cancer.

PURPOSE: As the United States population ages, the increasing prevalence of cancer is likely to result in higher direct medical and nonmedical costs. Although estimates of the associated direct medical costs exist, very little information is available regarding the prevalence, time, and cost associated with informal caregiving for elderly cancer patients. MATERIALS AND METHODS: To estimate these costs, we used data from the first wave (1993) of the Asset and Health Dynamics (AHEAD) Study, a nationally representative longitudinal survey of people aged 70 or older. Using a multivariable, two-part regression model to control for differences in health and functional status, social support, and sociodemographics, we estimated the probability of receiving informal care, the average weekly number of caregiving hours, and the average annual caregiving cost per case (assuming an average hourly wage of $8.17) for subjects who reported no history of cancer (NC), having a diagnosis of cancer but not receiving treatment for their cancer in the last year (CNT), and having a diagnosis of cancer and receiving treatment in the last year (CT). RESULTS: Of the 7,443 subjects surveyed, 6,422 (86%) reported NC, 718 (10%) reported CNT, and 303 (4%) reported CT. Whereas the adjusted probability of informal caregiving for those respondents reporting NC and CNT was 26%, it was 34% for those reporting CT (P <.05). Those subjects reporting CT received an average of 10.0 hours of informal caregiving per week, as compared with 6.9 and 6.8 hours for those who reported NC and CNT, respectively (P <.05). Accordingly, cancer treatment was associated with an incremental increase of 3.1 hours per week, which translates into an additional average yearly cost of $1,200 per patient and just over $1 billion nationally. CONCLUSION: Informal caregiving costs are substantial and should be considered when estimating the cost of cancer treatment in the elderly.

Decomposing pharmaceutical cost growth in different types of health plans.

OBJECTIVE: To decompose pharmaceutical spending growth into price and quantity components and to compare growth across different types of health plans. STUDY DESIGN: Retrospective analysis of pharmaceutical claims for active employees of a large national employer from 1996 to 1998, who were enrolled in traditional fee-for-service plans, health maintenance organizations (HMOs), and preferred provider organizations. OUTCOME MEASURES: Outcomes measures included total cost growth, price growth, and quantity growth. Quantity growth was divided into growth in use of existing products and in use of newly introduced products. For existing products, quantity growth was further decomposed into growth in the number of prescriptions and change in the mix of prescriptions. RESULTS: During the study period, HMOs had the greatest cost growth. This differential cost growth was largely attributable to changes in utilization as opposed to changes in prices, which were similar among types of health plans. Introduction of new products contributed 15 to 20 percentage points to cost growth in each setting. Differences in cost growth were largely attributed to differences in the growth rate of spending on existing products. For existing products, the impact of increases in the number of prescriptions was much greater in the HMOs, while the impact of changes in the mix of prescriptions was only mildly greater in the HMOs. CONCLUSIONS: Pharmaceutical cost growth was largely attributable to changes in utilization as opposed to changes in prices. Changes in utilization patterns were complex and differed across types of health plans.

The explosion in paid home health care in the 1990s: who received the additional services?

OBJECTIVE: Public expenditures for home health care grew rapidly in the 1990s, but it remains unclear to whom the additional services were targeted. This study tests whether the rapidly increasing expenditures were targeted to the elderly with high levels of disability and low levels of social support, 2 groups that have historically been higher users of paid home health and nursing home services. METHODS: The Asset and Health Dynamics Study, a nationally representative, longitudinal survey of people > or = 70 years of age (n = 7,443), was used to determine the association of level of disability and level of social support with the use of paid home care services in both 1993 and 1995. Multivariable regression models were used to adjust for sociodemographics, recent hospital or nursing home admissions, chronic medical conditions, and receipt of informal care from family members. RESULTS: Those with higher levels of disability received more adjusted weekly hours of paid home care in both 1993 and 1995. In 1993, users of paid home care with the least social support (unmarried living alone) received more adjusted weekly hours of care than the unmarried elderly living with others (24 versus 13 hours, P < 0.01) and the married (24 versus 18 hours, P = 0.06). However, by 1995, those who were unmarried and living with others were receiving the most paid home care: 40 versus 26 hours for the unmarried living alone (P < 0.05) and 24 hours for the married (P < 0.05). CONCLUSIONS: The recent large increase in formal home care services went disproportionately to those with greater social support. Home care policy changes in the early 1990s resulted in a shift in the distribution of home care services toward the elderly living with their children.

Helicobacter pylori screening for individuals requiring chronic NSAID therapy: a decision analysis.

INTRODUCTION: Although it is incontrovertible that Helicobacter pylori causes peptic ulcer disease, controversy persists regarding the impact of H. pylori infection on the incidence of NSAID-related complications and whether H. pylori eradication reduces the rate of adverse events. METHODS: A symptom-driven decision analytic model was developed to compare the clinical and economic impact of H. pylori screening compared to a strategy of no H. pylori testing for individuals requiring chronic NSAID therapy. In the principal analysis, it was assumed that untreated H. pylori infection increased the ulcer risk by 50% and that successful eradication reduced the risk of adverse events to that of uninfected patients. Patients' ulcer risk and the protective effect of H. pylori eradication were evaluated using sensitivity analysis. RESULTS: When compared to no H. pylori testing, H. pylori screening led to fewer symptomatic ulcers (no test, 5.4; H. pylori test, 4.6 per 100 patient years) and ulcer complications (no test, 2.6; H. pylori test, 2.3 per 100 patient years) and a higher cost per patient (no test, $435; H. pylori test, $556). The incremental cost attributable to the H. pylori screening strategy to prevent a symptomatic and complicated ulcer was $16,805 and $31,842, respectively. The clinical and cost-effectiveness advantage of H. pylori screening improved as patients' ulcer risk increased or the protective effect of H. pylori eradication was enhanced. CONCLUSIONS: Based upon the available evidence, H. pylori screening has the potential to reduce NSAID-related adverse events for average-risk patients at an incremental cost. Until controlled investigations definitively quantify the effect of H. pylori eradication on clinically significant NSAID-related adverse events, a compelling argument can be made for H. pylori testing for chronic NSAID users at increased risk of ulcer disease.

Ownership, competition, and the adoption of new technologies and cost-saving practices in a fixed-price environment.

Advances in medical technology have been implicated as the primary cause of rising health care expenditures. It is not yet known whether the increasing prevalence of managed care mechanisms, particularly capitation, will change substantially incentives for acquiring and using cost-increasing innovations. We examined the decisions of dialysis units (a set of providers that has faced capitation and real decreases in payment for several decades) with respect to use of cost-increasing technologies that enhance quality of care, cost-cutting practices that reduce quality of care, and amenities desired by patients that are unrelated to quality of care. We found that the dialysis payment system does not appear to have blocked access to a number of new, quality-enhancing technologies that were developed in the 1980s. However, facilities made adjustments along other valuable margins to facilitate adoption of these technologies; use of new technologies varied with numerous facility, regulatory, and case-mix characteristics including ownership, chain membership, size, market competition, and certificate of need programs. Interestingly, the trade-offs made by for-profit and nonprofit facilities when faced with fixed prices appeared quite different. For-profits tended to deliver lower technical quality of care but more amenities, while nonprofits favored technical quality of care over amenities. Our findings may have implications for the response of other types of health care providers to capitation and increasing economic constraints.

Willingness to pay for a quality-adjusted life year: in search of a standard.

Cost-benefit analysis (CBA) provides a clear decision rule: undertake an intervention if the monetary value of its benefits exceed its costs. However, due to a reluctance to characterize health benefits in monetary terms, users of cost-utility and cost-effectiveness analyses must rely on arbitrary standards (e.g., < $50,000 per QALY) to deem a program "cost-effective." Moreover, there is no consensus regarding the appropriate dollar value per QALY gained upon which to base resource allocation decisions. To address this, the authors determined the value of a QALY as implied by the value-of-life literature and compared this value with arbitrary thresholds for cost-effectiveness that have come into common use. A literature search identified 42 estimates of the value of life that were appropriate for inclusion. These estimates were classified by method: human capital (HK), contingent valuation (CV), revealed preference/job risk (RP-JR) and revealed preference/non-occupational safety (RP-S), and by U.S. or non-U.S. origin. After converting these value-of-life estimates to 1997 U.S. dollars, the life expectancy of the study population, age-specific QALY weights, and a 3% real discount rate were used to calculate the implied value of a QALY. An ordinary least-squares regression of the value of a QALY on study type and national origin explained 28.4% of the variance across studies. Most of the explained variance was attributable to study type; national origin did not significantly affect the values. Median values by study type were $24,777 (HK estimates), $93,402 (RP-S estimates), $161,305 (CV estimates), and $428,286 (RP-JR estimates). With the exception of HK, these far exceed the "rules of thumb" that are frequently used to determine whether an intervention produces an acceptable increase in health benefits in exchange for incremental expenditures.

Patient, physician, and payer perceptions and misperceptions of willingness to pay for diagnostic certainty.

Little is known about the value patients, physicians, and payers place on intangible attributes of care. Differences in valuations among these groups and misperceptions of value of intangible attributes to other groups can contribute to conflicts about treatment recommendations or coverage decisions. We surveyed patients, physicians, and managed care executives to assess their willingness to pay (WTP) for diagnostic certainty for peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). To determine if patients, physicians, and payers accurately perceive each other's valuations of diagnostic certainty, participants were also asked to estimate the WTP of each of the other types of respondents. Patients were most likely, and executives least likely, to value diagnostic certainty. For PUD, 84% of patients, 61% of physicians, and 43% of executives expressed a positive WTP. Median WTP was low for all three groups ($1-9 for patients and physicians; $0 for payers). Physicians and executives both correctly predicted patient WTP. For GERD, 87% of patients, 52% of physicians, and 29% of executives expressed a positive WTP. Executives underestimated patient WTP. For both diseases, physicians' WTP was overestimated by patients and underestimated by executives. The inconsistency in the value that patients, physicians, and managed care executives place on diagnostic certainty indicates the potential for conflict over practice guidelines or access to services. WTP surveys can provide information to aid in anticipating and addressing areas of disagreement.

Pharmaceutical cost growth under capitation: a case study.

Rising drug spending has generated concern among purchasers and policymakers. This paper compares drug cost growth in a capitated system with that in managed care systems that generally did not place physicians directly at risk for drug spending. We focus on cost growth because a substantial body of literature indicates that managed care interventions that reduce the level of costs may not influence the rate of cost growth. Drug cost growth under capitation initially was below that of other systems but still above targeted rates. Over time the capitation rates rose, the amount of risk transferred to physicians declined, and spending growth accelerated.

Optimal health insurance: the case of observable, severe illness.

We explore optimal cost-sharing provisions for insurance contracts when individuals have observable, severe diseases with a discrete number of medically appropriate treatment options. Variation in preferences for alternative treatments is unobserved by the insurer and non-contractible. Interest in such situations is increasingly common, exemplified by disease carve-out programs and shared decision-making (SDM) tools. We demonstrate that optimal insurance charges a copay to patients choosing the high-cost treatment and provides consumers of the low-cost treatment a cash payment. A simulation of the effect of such a policy, based on prostate cancer, indicates a substantial reduction in moral hazard.

HEDIS measures and managed care enrollment.

This article examines the relationship between 1996 health plan enrollment and both HEDIS-based plan performance ratings and individual HEDIS measures. Data were obtained from a large firm that collected, aggregated, and disseminated plan performance ratings to its employees. Plan market share regressions are estimated controlling for out-of-pocket price and model type in addition to the plan ratings and HEDIS measures. The results suggests that employees did not respond strongly to the provided ratings. There are several potential explanations for the lack of response, including difficulty understanding the ratings and never having seen them. In addition, employees may base their plan choices on information that is obtained from their own past experience, friends, family, and colleagues. The pattern of results suggests that such information is important. Counterintuitive signs most likely reflect an inverse correlation between some HEDIS ratings (or measures) and attributes employees observe informally.

Willingness to pay for diagnostic certainty: comparing patients, physicians, and managed care executives.

Cost-effectiveness analyses routinely ignore the value of diagnostic certainty. Moreover, no previous study has compared this value among different stakeholders. We surveyed 25 patients, 28 physicians, and 23 managed care executives to compare their willingness to pay for diagnostic information for peptic ulcer disease. Patients (84%) were most likely, and executives (43%) least likely, to be willing to pay at least $1 (median willingness to pay < $50). Differences in willingness to pay among stakeholders indicate potential for conflicts over access to tests. Although nearly all patients valued diagnostic certainty, its value was generally small and insufficient to change the cost-effectiveness ranking of treatment alternatives.

Clinical and economic effects of population-based Helicobacter pylori screening to prevent gastric cancer.

BACKGROUND: Helicobacter pylori infection has been identified as a risk factor for certain types of gastric cancer. However, the extent to which H. pylori eradication decreases the risk of gastric cancer is unknown, raising the question of whether population-based H. pylori screening should be undertaken. OBJECTIVE: To compare clinical and economic effects of H. pylori screening, with and without confirmatory testing, with no screening to prevent gastric cancer. DESIGN: Decision analysis incorporating a Markov simulation. PATIENTS: Simulated cohorts of men and women with varying risk of gastric cancer. INTERVENTION: Three strategies were evaluated: (1) no screening; (2) H. pylori serologic testing, treat those positive for H. pylori, no follow-up testing; and (3) H. pylori serologic testing, treat those positive for H. pylori, followed by a test to confirm H. pylori eradication, retreat those who test positive. In the principal analysis, the risk of gastric cancer after H. pylori eradication was assumed to be similar to that for those without H. pylori infection. Scenarios with less optimistic assumptions regarding risk reduction of cancer were evaluated. MAIN OUTCOME MEASURES: Gastric cancer rates, discounted cost per life-year saved. RESULTS: If H. pylori eradication reduced the risk of cancer to that of people never infected, both H. pylori intervention strategies reduced gastric cancer rates so that each yielded at least 12 additional life-years per 1000 40-year-old white men screened when compared with no screening. Helicobacter pylori serologic testing without posttreatment confirmatory testing resulted in the lowest cost per additional life-year saved (S6264). The cost-effectiveness of the H. pylori screening strategies varied substantially as the level of risk reduction of cancer was varied, but remained cost-effective even at moderate rates (<30%) of excess risk reduction of cancer in all cohorts evaluated. CONCLUSIONS: Population-based H. pylori screening has the potential to produce important health benefits at a reasonable cost at moderate rates of excess risk reduction of cancer. Controlled studies are necessary to confirm and quantify the impact of H. pylori eradication on the risk of gastric cancer.