Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis.

BACKGROUND: Chest pain is a common clinical problem, but up to 30% of patients who present with chest pain lack coronary disease. Subsequent investigation often reveals an esophageal source for the pain, with gastroesophageal reflux disease identified most frequently. Controversy exists regarding whether to establish the cause or to empirically treat as reflux. OBJECTIVE: To assess the cost-effectiveness of empirical treatment in patients with noncardiac chest pain. METHODS: Decision analysis was used to compare a strategy of empirical treatment as reflux using an H-blocker or proton pump inhibitor with initial investigation for gastrointestinal causes over a period of up to 16 weeks and over a period of more than a year. The prototype patient was an outpatient with chest pain and a normal coronary angiogram. Gastrointestinal investigations included an upper gastrointestinal tract series, endoscopy, manometry, 24-hour pH monitoring, and provocation tests. The main outcome measure was direct medical costs per case treated from a third-party payer perspective. RESULTS: Total medical costs were $2,187 per case treated for the initial investigation arm and $849 for the empirical treatment arm in the 8- to 16-week model. One-way sensitivity analyses revealed that the model was robust; the treatment arm was less expensive in all cases. At just over a year empirical treatment remained dominant. CONCLUSIONS: An initial therapeutic trial with antisecretory agents for patients with noncardiac chest pain is cost-effective compared with investigation for gastrointestinal causes in the short term of weeks, with cost savings persisting beyond a year.

More or less?: Methods to compare VA and non-VA health care costs.

OBJECTIVE: To examine past comparisons of the costs of the Veterans Health Administration (VA) and of non-VA providers to determine lessons and data requirements for future cost comparisons, particularly those assessing VA efficiency and to determine whether VA should purchase care from non-VA providers. CONCEPTUAL FRAMEWORK: Over the past two decades, researchers have tried to establish how VA costs compare to those of non-VA health care delivery systems. Existing studies of overall acute care costs address one of two distinct questions: How do VA costs compare to costs in private sector hospitals? and Would it cost more to have VA patients treated in nonfederal hospitals? For both questions, the major factors underlying differences in health care costs are variations in outputs, input prices, and levels of efficiency. Health care cost comparisons across systems must also wrestle with accounting differences. CONCLUSIONS: That review finds no convincing evidence that VA has been significantly more or less efficient than nonfederal hospitals in delivering care. However, VA costs do appear to have been significantly lower than fee-for-service charges that the federal government might have to pay if veterans were treated in private sector hospitals for the same diagnoses. Future comparisons of costs in the era of managed care will require better diagnostic and population data to control for observable and unobservable case-mix differences. They should also include measures of the quality of outcomes. Finally, consistent accounting practices, particularly in the treatment of capital costs, are needed.

Health services research and policy studies.

Health services research in rheumatology is producing important studies that have implications for the provision of care in a changing health care environment. This paper reviews studies relating to issues surrounding the delivery of care to patients, patients' access to medical care, how to provide more cost-effective medical care, and who should be providing medical care. The increasing use of managed medical care provides researchers with the opportunity to examine how changes in medical care delivery affect patient outcomes and the cost of the care that is provided. Policy makers need to be made aware of the research being conducted in health services so that they make informed policy decisions.

Health care research and policy studies.

Health economic studies in rheumatology have never been of greater policy importance, but unfortunately there are only a small number of researchers examining issues in this area. This paper reviews studies relating to economics and rheumatology as well as some important methodologic issues relating to conducting such studies. The topics covered include cost-identification analysis, physician variation, specialty versus subspecialty care, utility assessment, decision analysis, quality of life, time preferences and discounting, and sensitivity analysis. More than ever, now is the time to provide policy makers with evidence that rheumatologists provide medical care that is not only the finest from a medical perspective but the most cost effective from society's perspective.

The total costs of drug therapy for rheumatoid arthritis. A model based on costs of drug, monitoring, and toxicity.

OBJECTIVE: We created a model to estimate the total medication costs of treating patients with rheumatoid arthritis with 6 second-line agents for the first 6 months of treatment. METHODS: Drug costs were obtained from a survey of pharmacies; monitoring costs were calculated from utilization information obtained in a survey of rheumatologists; toxicity costs were obtained using decision trees to represent the evaluation and treatment of potential toxicities. Monitoring and toxicity costs were estimated using costs from the Boston University Medical Center or, for hospitalizations, using appropriate diagnosis-related group categories. The sum of the 3 components determined the total medication costs. RESULTS: The least expensive medication was penicillamine, at $10.62/week, and the most expensive was injectable gold, at $30.89/week. In terms of monitoring costs, methotrexate had the highest costs associated with necessary laboratory tests and office visits. Hydroxychloroquine had the lowest monitoring costs for office visits, and oral gold had the lowest for laboratory costs. Hematologic toxicities were the largest component of toxicity costs for all 6 medications, and renal toxicities were costly for patients taking oral gold, penicillamine, and injectable gold. Total medication costs revealed oral gold as the least expensive medication and injectable gold as the most expensive. The combination of monitoring and toxicity costs accounted for more than 60% of the total costs for all medications except injectable gold. In all cases, the cost of treating toxicities was the smallest of the 3 components. CONCLUSION: When calculating the costs of drug therapy, it is important to consider not only the price of the drug, but also the costs of monitoring and treating the toxicities that might occur. Failure to do so will result in underestimating the true costs of treatment with these medications.

The cost-effectiveness of liver biopsy in rheumatoid arthritis patients treated with methotrexate.

OBJECTIVE: To assess the cost-effectiveness of liver biopsy in monitoring rheumatoid arthritis (RA) patients for methotrexate (MTX)-induced cirrhosis. METHODS: A decision analytic model was used to compare a strategy of no biopsy versus strategies of biopsy after 5 years or 10 years of MTX treatment. RESULTS: Biopsy after 5 years of MTX treatment had a cost-effectiveness ratio of $1,891,830 per year of life saved, while biopsy after 10 years of treatment had a cost-effectiveness ratio of $52,374 per year of life saved. Sensitivity analyses revealed that the cost-effectiveness of biopsy was most dependent on the probability of cirrhosis. CONCLUSION: Liver biopsy to monitor for MTX-induced cirrhosis in RA patients is not cost effective after 5 years of treatment, and even biopsy after 10 years has a high cost.

The costs of rheumatoid arthritis.

The economic costs associated with rheumatoid arthritis (RA), a chronic, systemic, inflammatory disorder that affects many joints, are high, approximating those of coronary heart disease. The estimated prevalence of RA in the US is 0.9%. Incidence increases with age, and is highest among women in the fourth to sixth decades of life. The primary impact of RA is due to the significant morbidity associated with this disease. Mortality is increased among a poorly defined subgroup of RA patients. The average level of disability among RA patients is moderate, but 6.5 to 12% of patients are severely disabled. Between one- and two-thirds of previously employed patients have a reduced work capacity. Treatment primarily involves the use of nonsteroidal anti-inflammatory drugs and disease modifying antirheumatic drugs. Rehabilitation measures and orthopaedic surgery are also used. Total annual direct costs of RA (total charges) have been calculated to be $US5275 and $US6099 (1991 dollars) per patient. Lifetime medical care charges were estimated at $US12,578 per patient (1991 dollars). The direct costs of RA are substantial, but indirect costs have been calculated to be much higher because of extensive morbidity. The difference between the direct and indirect costs of RA is decreasing because salary increases have not kept pace with rising healthcare costs. The latter are increasing rapidly in RA because of the use of new technology, surgical procedures, and the greater use of drugs with frequent monitoring requirements and significant toxicity. Because intangible costs such as pain form a substantial part of the overall costs of RA but are difficult to evaluate, cost estimates inevitably underestimate the impact of the disease on individuals and society.

Health care research and policy studies.

Health care research in rheumatology has traditionally underemphasized economic studies, but the advent of health care reform makes this type of research more important than ever. This paper reviews studies relating to economics and rheumatology as well as methodologic issues relating to the conduct of such studies. The topics covered include data collection in health services research, problems in the use of traditional measures of health-related quality of life and rheumatology, cost-effectiveness analyses, cost studies, studies documenting changes in utilization, and the merits of using contingent valuation methods as the outcome variable in rheumatologic cost-effectiveness studies. It is important for researchers in rheumatology to continue investigation into the most efficient means of providing care to our patients.

Subspecialty training: is it financially worthwhile?

OBJECTIVE: To determine the financial return of additional training in a cognitive-oriented medical subspecialty (rheumatology) and in a procedure-oriented medical subspecialty (gastroenterology) relative to general internal medicine. DESIGN: Analysis of existing data to compare lifetime discounted earnings of physicians in different medical specialties. PARTICIPANTS: General internists, gastroenterologists, and rheumatologists were surveyed. MAIN OUTCOME MEASURES: Using data from surveys conducted by Medical Economics and the American College of Rheumatology, we constructed lifetime earnings streams that allowed the calculation of the net present values of discounted lifetime earnings in general internal medicine, gastroenterology, and rheumatology. Net present values of lifetime earnings were calculated for each group at two discount rates. Sensitivity analyses were done to estimate how changes in relative income would affect calculations of the net present values. MAIN RESULTS: The average net incomes before taxes for general internists, gastroenterologists, and rheumatologists in 1988 were $115,825, $201,875, and $118,056, respectively. At 5% and 10% discount rates, the net present values of the estimated career earnings stream for additional training in gastroenterology relative to general internal medicine were + $1,101,863 and + $512,952, respectively; for additional training in rheumatology relative to general internal medicine, the respective values were - $84,748 and - $92,467. If the incomes of general internists were decreased by 3% and the incomes of gastroenterologists were decreased by 25% to reflect the effect of potential changes due to the resource-based relative value scale (RBRVS), or if gastroenterology training were increased to 3 years and rheumatology fellowship stipends were increased by 30%, large differences would still exist between the groups. CONCLUSION: Gastroenterologists have an extremely large return on their additional investment in training, but rheumatologists have a negative return. When considered exclusively as a financial decision, fellowship training in a cognitive-oriented medical subspecialty such as rheumatology is a poor investment. Even major changes in reimbursement policies will not affect the relative pecuniary attractiveness of procedure-oriented medical subspecialties.