The economics of daily dialysis.

Research suggests that daily hemodialysis improves clinical outcomes and patient quality of life when compared with conventional hemodialysis; however, little is known about its economic impact. In this article, we review the literature on the costs of daily hemodialysis (n = 170). We also present updated results from an economic model we constructed that compares 1-year treatment costs for short daily in-center, short daily at-home, nocturnal, and conventional hemodialysis. Clinical parameters for the model were drawn from our review of the clinical literature. Resource use during daily hemodialysis was modeled after the experience of 2 ongoing programs in the United States, a short daily program in California (n = 26) and a nocturnal program in Virginia (n = 13). Reports from the literature and our economic model suggest daily hemodialysis might provide better outcomes and savings when compared with conventional hemodialysis. However, larger, longer controlled studies are needed to see if daily dialysis fulfills these promises. We discuss several issues researchers should keep in mind in designing future studies about the economics of daily dialysis.

The case for daily dialysis: its impact on costs and quality of life.

Research suggests daily hemodialysis may improve clinical outcomes. To date, a comprehensive review of its implications on quality of life has not been performed, and little is known about its economic impact. We conducted an economic evaluation comparing short daily or nocturnal hemodialysis with thrice-weekly conventional in-center dialysis. Data on the quality of life and clinical effects of daily dialysis were obtained from more than 60 reports from 13 daily dialysis programs around the world (n = 197). Cost data were derived principally from the US Renal Data System, Centers for Disease Control, and Medicare Payment Advisory Commission. Resource use during daily hemodialysis was modeled after two ongoing programs in the United States. Results suggest that patients feel better and direct treatment costs could be reduced with daily dialysis. Costs are sensitive to assumptions about the effect of daily dialysis on hospital days. Reductions of at least 8% in hospital days are required for these modalities to be cost saving compared with documented reductions of 30% to 100%. Larger well-controlled studies of daily versus conventional dialysis would be helpful to determine whether daily dialysis fulfills these promises. Medicare policy, which limits payment for most patients to three dialysis treatments weekly, poses a disincentive to more widespread adoption among dialysis centers. Given this constraint to broader acceptance, we address several policy options to gain a better understanding of the potential risks and benefits of daily dialysis.

Critical access hospitals: how many rural hospitals will meet the requirements?

Although the Medicare Rural Hospital Flexibility Program (MRHFP), which establishes a new designation for limited-service hospitals called critical access hospitals (CAH), intends to assist small rural hospitals having financial difficulty, it is unclear how many hospitals will qualify for the program. Potential CAHs are identified and the strategic issues that will impact actual participation in the program are discussed. Potential CAHs are identified by applying the legislative criteria for designation to a data set created from both the 1992-1995 Medicare Hospital Cost Report Information System and the 1993 and 1995 Prospective Payment System's Impact files. Descriptive analyses are used to identify potential CAHs by three parameters: distance to nearest hospital, average daily census and operating margin. Results indicate that the majority of potential CAHs have low volume and report poorer operating margins than other rural hospitals. Findings also show that the mileage requirements significantly impact the number of potential CAHs. There is more than a ninefold difference between the 93 hospitals that meet the mileage criterion and the 864 hospitals that might be eligible if certified by the state as "necessary providers," regardless of distance to the nearest hospital. The MRHFP is designed to prevent small, isolated hospitals from closing and thus to ensure continued access to care for rural residents. However, the number of potential CAHs that participate will clearly hinge on the flexibility of the program and the ability of states to determine "necessary providers."

The societal costs of severe to profound hearing loss in the United States.

OBJECTIVE: Severe to profound hearing impairment affects one-half to three-quarters of a million Americans. To function in a hearing society, hearing-impaired persons require specialized educational, social services, and other resources. The primary purpose of this study is to provide a comprehensive, national, and recent estimate of the economic burden of hearing impairment. METHODS: We constructed a cohort-survival model to estimate the lifetime costs of hearing impairment. Data for the model were derived principally from the analyses of secondary data sources, including the National Health Interview Survey Hearing Loss and Disability Supplements (1990-91 and 1994-95), the Department of Education's National Longitudinal Transition Study (1987), and Gallaudet University's Annual Survey of Deaf and Hard of Hearing Youth (1997-98). These analyses were supplemented by a review of the literature and consultation with a four-member expert panel. Monte Carlo analysis was used for sensitivity testing. RESULTS: Severe to profound hearing loss is expected to cost society $297,000 over the lifetime of an individual. Most of these losses (67%) are due to reduced work productivity, although the use of special education resources among children contributes an additional 21%. Lifetime costs for those with prelingual onset exceed $1 million. CONCLUSIONS: Results indicate that an additional $4.6 billion will be spent over the lifetime of persons who acquired their impairment in 1998. The particularly high costs associated with prelingual onset of severe to profound hearing impairment suggest interventions aimed at children, such as early identification and/or aggressive medical intervention, may have a substantial payback.

Vulnerability of rural hospitals to Medicare outpatient payment reform.

Because the Balanced Budget Act (BBA) of 1997 requires implementation of a Medicare prospective payment system (PPS) for hospital outpatient services, the authors evaluated the potential impact of outpatient PPS on rural hospitals. Areas examined include: (1) How dependent are rural hospitals on outpatient revenue? (2) Are they more likely than urban hospitals to be vulnerable to payment reform? (3) What types of rural hospitals will be most vulnerable to reform? Using Medicare cost report data, the authors found that small size and government ownership are more common among rural than urban hospitals and are the most important determinants of vulnerability to payment reform.

Serum progesterone and prognosis in operable breast cancer.

Several studies have now shown that women with operable breast cancer undergoing tumour excision during the luteal phase of the menstrual cycle have a better prognosis than those having surgery during the follicular phase. As part of a prospective study of prognostic factors in breast cancer, blood was taken at the time of surgery. Between 1975 and 1992 this was available from 289 premenopausal women within 3 days of tumour excision. All were treated by either modified radical mastectomy or breast conservation including axillary clearance and the date of last menstrual period (LMP) was known in 239 (80%) cases. Blood samples were assayed for both oestradiol (E2) and progesterone (P). Because of the wide inter-individual variation in E2 levels there was no clear relationship between E2 and LMP. However, using a running mean smoothing technique the expected cyclical variation could be discerned. There was no significant association between E2 and survival. Smoothing of the P data yielded a pattern similar to the normal hormone profile. Those cases with a progesterone level of 4 ng ml-1 or more had a significantly better survival than those with a level < 4 ng ml-1. This was especially clear in node-positive patients (P < 0.01). The possibility of misclassification of menstrual cycle status, because of misreported LMP, has been minimised by applying an independent hormonal measurement (P) of cycle activity. This parameter will also identify women who may be undergoing anovular cycles. Thus this study has confirmed that a raised level of progesterone at the time of tumour excision is associated with an improvement in prognosis for women with operable breast cancer.