Economic healthcare costs of Clostridium difficile infection: a systematic review.

Clostridium difficile infection (CDI) is the leading cause of infectious diarrhoea in hospitalised patients. CDI increases patient healthcare costs due to extended hospitalisation, re-hospitalisation, laboratory tests and medications. However, the economic costs of CDI on healthcare systems remain uncertain. The purpose of this study was to perform a systematic review to summarise available studies aimed at defining the economic healthcare costs of CDI. We conducted a literature search for peer-reviewed studies that investigated costs associated with CDI (1980 to present). Thirteen studies met inclusion and exclusion criteria. CDI costs in 2008 US dollars were calculated using the consumer price index. The total and incremental costs for primary and recurrent CDI were estimated. Of the 13, 10 were from the USA and one each from Canada, UK, and Ireland. In US-based studies incremental cost estimates ranged from $2,871 to $4,846 per case for primary CDI and from $13,655 to $18,067 per case for recurrent CDI. US-based studies in special populations (subjects with irritable bowel disease, surgical inpatients, and patients treated in the intensive care unit) showed an incremental cost range from $6,242 to $90,664. Non-US-based studies showed an estimated incremental cost of $5,243 to $8,570 per case for primary CDI and $13,655 per case for recurrent CDI. Economic healthcare costs of CDI were high for primary and recurrent cases. The high cost associated with CDI justifies the use of additional resources for CDI prevention and control.

Measuring health state preferences for hemophilia: development of a disease-specific utility instrument.

Generic and disease-specific instruments have been used to assess health-related quality of life (HRQoL) in hemophilia. However, HRQoL measures also need to reflect patient preferences for various hemophilia health states. The goal of this project was to develop a disease-specific utility instrument that measures patient preferences for various health states unique to hemophilia. The visual analog scale (VAS) and the standard gamble (SG) methods were used. Study participants (n = 128) were tested and stratified into paediatric and adult groups. Test-retest reliability was demonstrated for both instruments, with r = 0.91 for the VAS and r = 0.79 for the SG. When comparing results by age group, statistically significant differences were observed between paediatric and adult participants with the SG instrument (P = 0.045), with older participants taking more risk overall. However, no significant differences based on age were seen when using the VAS (P = 0.636). Statistically significant differences were observed between the VAS and SG instruments within both the paediatric and adult groups (P < 0.0001). In general, the SG yielded higher preference scores than the VAS for the majority of health states. Results derived from the SG instrument indicate that age can influence patients' preferences regarding their state of health. This can have implications for considering treatment options based on the mean age of the population under consideration. Both instruments demonstrated reliability and validity indicating that they could be used to assess patient preferences in hemophilia. However, preference score differences indicate that the two measures may not be interchangeable.

Early treatment cost in epilepsy and how it varies with seizure type and frequency.

The purpose of this paper is to describe the temporal pattern of healthcare cost in two population-based samples of new cases of epilepsy from two different regions of the US, and show how it varies with seizure type and frequency. Epilepsy-related healthcare cost from onset through 4 years of follow-up was determined for two population-based incident samples from Houston, TX and Rochester, MN. Cases were identified over the period 1987-1991 and followed through 1994. Annual use and cost was calculated for the first through fourth year of treatment for each person in the combined samples to examine the temporal pattern of early treatment cost. A multivariate model was estimated to examine how seizure type and seizure frequency affect early treatment cost while controlling for location, age, gender, and ethnicity. Our estimates indicate high initial healthcare cost at onset for most patients followed by lower cost in subsequent years. The mean annual epilepsy-related healthcare cost per patient was $3157 for the first year, $702 for the second year, $471 for year three, and $411 for year four. Cost was significantly higher for groups whose seizures continued and were relatively frequent, but was not significantly different for groups with partial seizures as compared with primary generalized seizures. There was a 2.2-fold difference in 4-year cost between patients with a single seizure at onset and those having recurrent seizures at the rate of more than one per month, controlling for seizure type, age, gender, and ethnicity.

The cost of epilepsy in the United States: an estimate from population-based clinical and survey data.

PURPOSE: To provide 1995 estimates of the lifetime and annual cost of epilepsy in the United States using data from patients with epilepsy, and adjusting for the effects of comorbidities and socioeconomic conditions. METHODS: Direct treatment-related costs of epilepsy from onset through 6 years were derived from billing and medical chart data for 608 population-based incident cases at two sites in different regions of the country. Indirect productivity-related costs were derived from a survey of 1,168 adult patients visiting regional treatment centers. Direct costs separate the effects of epilepsy and comorbidity conditions. Indirect costs account for the effects of other disabilities and socioeconomic conditions on foregone earnings and household activity. The estimates were applied to 1995 population figures to derive national projections of the lifetime and annual costs of the disorder. RESULTS: The lifetime cost of epilepsy for an estimated 181,000 people with onset in 1995 is projected at $11.1 billion, and the annual cost for the estimated 2.3 million prevalent cases is estimated at $12.5 billion. Indirect costs account for 85% of the total and, with direct costs, are concentrated in people with intractable epilepsy. CONCLUSIONS: Direct costs attributable to epilepsy are below previous estimates. Indirect costs adjusted for the socioeconomic conditions of patients are above previous estimates. Findings indicate that epilepsy is unique in the large proportion of costs that are productivity-related, justifying further investment in the development of effective interventions.

A framework for assessing the effectiveness, efficiency, and equity of behavioral healthcare.

OBJECTIVE: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research. STUDY DESIGN: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance. PATIENTS AND METHODS: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions. RESULTS: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance. CONCLUSIONS: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment.

Economic implications of an early postoperative enteral feeding protocol.

OBJECTIVE: To study the cost-effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections. DESIGN: A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset. SUBJECTS/SETTING: Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18-month period. INTERVENTION: Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care. OUTCOMES: A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups. STATISTICAL ANALYSIS: Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent-samples t tests. Nonparametric Mann-Whitney rank sum tests were used to determine the cost significance of a nosocomial infection. RESULTS: The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group. CONCLUSION: An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost-effective.

Methodological issues in estimating the cost of epilepsy.

Changes in treatment alternatives and the emphasis on cost containment and managed care have increased the interest in information on the cost of epilepsy. The last comprehensive cost study in the USA was in 1975. That study estimated the national cost of epilepsy at $3.6 billion for 2.1 million cases. On a per patient basis the 1975 figure represents $7440 in 1995 US dollars, $1150 (15%) for direct treatment-related costs and $6290 (85%) for indirect employment-related costs. Since then, various cost-of-illness (COI) studies in the USA and other countries have offered estimates ranging from $6000 to $15000 per patient per year, with percentages of direct and indirect cost varying greatly. To assist those interested in interpreting or producing cost information, this paper reviews the state of research on the cost of epilepsy and discusses several methodological issues. A comprehensive study begun in 1993 to update the 1975 estimates for the USA is also described. Recommendations are provided to stimulate discussion about the best methods to use in future research.

Managed care and community-oriented care: conflict or complement?

Motivated by the need for fundamental change, reform of the health care delivery system is continuing despite the recent failure of national initiatives. One aspect of this reform is the restructuring of managed care systems to include low-income, at-risk populations in their health delivery program: It is a move that threatens current "safety-net" providers, which already serve these populations with programs that combine public health and traditional primary care. This paper explores this potential conflict by providing a brief history and comparison of the main features of the community-oriented primary care (COPC) and health maintenance organization (HMO) models. The authors provide a frame-work that contrasts the structure, process, and outcome characteristics of these two models, delineating key similarities and differences. The frame-work is used in profiling a service delivery system model that integrates the two systems and in discussing issues related to operationalizing the proposed integration.

Equity of health care in Australia.

This paper examines the equity characteristics of health care financing and delivery in Australia and compares its performance with recent findings on systems in Europe and the United States. Vertical equity of finance is evaluated with income and payment concentration indices derived from published survey data on taxes and expenditure by income decile. Horizontal equity of health care delivery is assessed with standardized expenditure concentration coefficients for three measures of health status and four types of health services, derived from household survey data on health care utilization, health status, income and demographics. Health cover is available to the entire population. Results show the financing system is slightly progressive despite the fact that 30% of payment comes from private sources, which are regressive. The equity index compares favorably to many European countries and is much better than the U.S. which has a regressive financing system. The Australian system fares less well in terms of equity of health care delivery. Several features favor privately insured higher income persons in use of health care and this is reflected, for some health status measures and types of service, in inequity favoring the better off. This contrasts with inequity favoring the less well off in many European countries and the U.S. This analysis provides a benchmark for monitoring the equity of the Australian system and provides information on the equity of a mixed private and public financing system that covers the entire population. This is relevant to the U.S. which is moving in this direction by extending private cover to the uninsured and to European countries that are increasing private sector involvement in health care financing.

Cost of epilepsy in the United States: a model based on incidence and prognosis.

A model of the clinical course of epilepsy from onset until remission or death has been developed for six prognostic groups, including survival, use and cost of medical care, and time lost from work and housekeeping. The model has been used to generate preliminary estimates of the lifetime cost of epilepsy for a cohort of persons diagnosed in 1990 in the United States. The distribution of incident cases among prognostic groups is derived from epidemiologic studies of prognosis in epilepsy. Direct cost is estimated by multiplying nationally representative unit costs by the expected type and frequency of medical care use. The latter were derived by an expert panel, based on inferences from existing literature and on their own clinical experiences. Indirect cost is estimated based on lost earnings associated with projections of restricted activity days, excess unemployment, and excess mortality. Total lifetime cost in 1990 dollars of all persons with epilepsy onset in 1990 was estimated at $3.0 billion, with indirect cost accounting for 62% of the total. Cost per patient ranged from $4,272 for persons with remission after initial diagnosis and treatment to $138,602 for persons with intractable and frequent seizures. Antiepileptic drug (AED) treatment is the most costly category of service. Different assumptions about the amount and type of drug administration cause major changes in overall cost estimates.

Screening for diabetic retinopathy. The wide-angle retinal camera.

OBJECTIVE: To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS: Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physician's assistant through dilated pupils using direct ophthalmoscopy, a single 45 degrees retinal photograph without pharmacological dilation, and a set of three dilated 45 degrees retinal photographs) were compared with a reference standard of stereoscopic 30 degrees retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identified from a laboratory list of elevated serum glucose values were recruited from a DOD medical center. RESULTS: The subjects (352) had complete exams excluding the exam by the physician's assistant that was added later. The sensitivities, specificities, and positive and negative likelihood ratios are as follows: ophthalmologist 0.33, 0.99, 72, 0.67; photographs without pharmacological dilation 0.61, 0.85, 4.1, 0.46; dilated photographs 0.81, 0.97, 24, 0.19; and physician's assistant 0.14, 0.99, 12, 0.87. CONCLUSIONS: Fundus photographs taken by the 45 degrees camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy. Physician extenders can effectively perform the photography with minimal training but would require more training to perform adequate eye exams. In this older population, many patients did not obtain adequate nonpharmacological dilation for use of the 45 degrees camera.

Cost-effectiveness of alternative methods for diabetic retinopathy screening.

OBJECTIVE: To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologist's exam and an ophthalmic exam by a physician's assistant or nurse practitioner technician, for detecting nonproliferative and proliferative diabetic retinopathy. RESEARCH DESIGN AND METHODS: Comparison of 45-degrees fundus photographs with and without pharmacological pupil dilation taken by technicians and interpreted by experts, direct and indirect ophthalmoscopy by ophthalmologists, and direct ophthalmoscopy by technicians with seven-field stereoscopic fundus photography (reference standard). Costs were estimated from market prices and actual resource use. The study included 352 patients attending outpatient diabetes and general-medicine clinics at VA and DOD facilities. RESULTS: Medical system costs per true positive were: 45-degrees photos with dilation, $295; 45-degrees photos without dilation, $378; ophthalmologist, $390; and technician, $794. Patient costs per true positive were: 45-degrees photos with dilation, $139; 45-degrees photos without dilation, $171; ophthalmologist, $306; and technician, $1009. Cost-effectiveness is sensitive to program size due to high fixed cost of the camera methods but not to prevalence. Cost-effectiveness of the technician exam is strongly affected by its sensitivity. CONCLUSIONS: Primary-care screening with retinal photographs through pharmacologically dilated pupils for diabetic retinopathy is an appropriate and cost-effective alternative to screening by an ophthalmologist in this setting. Ophthalmologists are scarce, primary-care physicians are extremely busy, and large clinics allow fixed equipment costs to be spread across many patients.

Screening for patients with alcohol problems: severity of patients identified by the CAGE.

Primary care physicians are well situated to identify patients with substance abuse problems and motivate them to seek appropriate assistance, but active programs are the exception. A study in a community setting was undertaken to assess the CAGE (the first letters of key words in a series of four questions about drinking: cut down; annoyed; guilty; and eye-opener), instrument in the routine screening for alcohol problems in both new and established patients. The screening process identified subjects for a pilot evaluation of a motivational interview designed to encourage problem-solving behavior. This article focuses on the screening results and the use of the CAGE instrument. During June and July of 1990, 687 patients of two primary care physicians belonging to a large group practice were asked to complete a health questionnaire that included the CAGE. Those who responded affirmatively to at least two of the four CAGE questions were requested to participate in follow-up assessment of problems associated with alcohol and health. The type and severity of alcohol problems experienced by patients who scored positive on the CAGE are described. Prevalence of a positive score on the CAGE was 8.6 percent with males, smokers, and blue collar and unemployed persons being more likely to score positive. The positive predictive value was .68. Primarily, persons with moderate alcohol problems were identified. Results show that the CAGE instrument is a useful screening device for identifying those with mild to moderate substance abuse problems, increasing the opportunity for intervention prior to serious medical complications. The instrument is easily administered, and has demonstrated relatively high levels of sensitivity and specificity. When combined with assessment and motivational interviews, the CAGE shows promise in the secondary prevention of substance abuse and related health problems.

Identifying families at high risk of cardiovascular disease: alternative work site approaches.

By examining coverage, concordance, and costs, this project evaluated four methods of cardiovascular disease (CVD) risk screening at a work site with 1821 central office employees of an energy company in Houston, Tex. Screening methods included a health risk appraisal mail questionnaire (HRA), an HRA plus brief physical assessment, an analysis of medical claims data, and an analysis of absenteeism data. Coverage ranged from 99% of employees for the absenteeism method to about 30% for the HRA method. Combining the first three screening methods, 18% of families had at least one member with a CVD or related diagnosis or one of four major CVD risk factors. The absenteeism method yielded 12.1% of the central office employees with 9 or more days absent. Although the absenteeism method identified high-cost families, only 9% had a heart disease or related diagnosis. This lack of concordance also occurs with other methods. For example, only 9.4% of families identified with the claims data were also identified by the HRA. Therefore, the methods identify different groups of high-risk families. Findings are discussed in relation to costs and other factors important to firms' selection of screening methods.

Pregnancy and medical cost outcomes of a self-help prenatal smoking cessation program in a HMO.

The results of a randomized clinical trial of a prenatal self-help smoking cessation program are reported in terms of the pregnancy and cost outcomes. The study population were the socioeconomically and ethnically diverse members of a large health maintenance organization (HMO) who reported that they were smoking at the time of their first prenatal visit. The intervention consisted predominantly of printed materials received through the mail. Compared with the usual care control group, women assigned to the self-help program were more likely to achieve cessation for the majority of their pregnancy (22.2 percent versus 8.6 percent), gave birth to infants weighing on average 57 grams more, and were 45 percent less likely to deliver a low birth weight infant. An economic evaluation of the self-help program was conducted from the perspective of the sponsoring HMO. Based upon the expenditures associated with the neonates' initial hospital episode, the intervention had a benefit-cost ratio of 2.8:1. These findings provide strong evidence to support widespread incorporation of smoking cessation interventions as a standard component of prenatal care.

Economic considerations in technology assessment: the case of genetic disease.

This paper describes economic issues pertinent to health care technology assessment. Of interest are the allocation of resources between health and other sectors of the economy, between alternative services within the health sectors, and the costs of producing the services that are selected. These issues are discussed and then illustrated by reference to a specific area of health care technology: screening for and intervention against genetic diseases. It is concluded that investments in screening programs for Tay Sachs disease and Down Syndrome are allocatively efficient. Indications are that such investments are also efficient for interventions against Neural Tube Defects; however, there are complex ethical issues involved. There are many genetic diseases for which screening tests have yet to be developed. As such tests become available, each will have to be evaluated on its own merits relative to alternative health sector investments.

The role of health practices, health status, and prior health care claims in HMO selection bias.

To examine selection bias in terms of demographics, self-reported health practices, professionally evaluated health status, and prior health care utilization by employees and dependents, we examined health insurance choice between traditional insurance and a health maintenance organization (HMO) by central office employees of a large southwestern utility company. The HMO attracted a relatively younger and female population compared with the traditional plan. We found no difference in health practices and health status measures between the two groups. Consistent with recent studies, the HMO group experienced lower health claims cost the year prior to enrollment compared with persons who remained in the traditional plan. This difference was largely due to dependents' utilization-a factor that should be examined in future studies and considered by those structuring insurance premiums for HMOs and traditional plans.