An economic overview of prostate carcinoma.

BACKGROUND: In the United States in 2000, 180,400 new cases of prostate carcinoma were expected to occur, with 31,900 men expected to die from this illness. In addition, prostate carcinoma is the cause of over half a million disability-adjusted life-years. This study summarizes the current body of published literature about the economics of prostate carcinoma. METHODS: The authors used a MEDLINE-based literature review for relevant articles from 1990 to the present. RESULTS: The authors' search returned 216 articles, 56 of which met the criteria of interest. Prostate carcinoma is costly to treat, currently averaging above $20,000 per case. Cost of care is directly related to stage of disease and comorbidity. Substantial geographic variation exists, even within small locales, with regard to care patterns and cost. In-hospital mortality, length of stay, and cost are inversely related to case volume. Care rendered in health maintenance organizations is generally less technologically intensive than in the fee-for-service sector. Out of the 18 cost studies examined, 13 were cost-minimization analyses and five assessed cost-effectiveness. From a cost perspective, laparoscopic pelvic node dissection was favored over an open pelvic procedure; 3D conformal radiation therapy was favored over 2D; and radiation therapy was favored over radical prostatectomy. Cost-effectiveness analyses favored the use of metastron, mitroxantone plus prednisone over prednisone alone, flutamine with either medical or surgical castration, and orchiectomy as the androgen suppression therapy. CONCLUSIONS: The literature on the economics of prostate carcinoma is relatively meager. Most cost studies were done on small samples, had short follow-up periods, used charges rather than cost data, and did not include adequate representation of all stages of disease. Additional research is needed.

The economic impact of a multifactorial intervention to improve postoperative rehabilitation of hip fracture patients.

OBJECTIVE: To assess the cost savings associated with a patient education and high-intensity strength intervention to improve rehabilitation after hip fracture. METHODS: Economic analysis conducted alongside a randomized controlled trial, using cost-benefit ratios and net present value statistics. Study subjects were aged over 64 years and were followed for 18 months postsurgery. Resource utilization data were gathered by telephone questionnaire. Medicare reimbursement rates and prevailing costs for services not covered by Medicare were used to convert utilization patterns into costs. Intervention costs were obtained from program records. RESULTS: The cost of the intervention was $722 per patient. Over the followup period, median costs were $11,941 and $21,577 for the intervention and control groups, respectively, yielding an average program benefit of $9,636. Cost-benefit ratios exceeded 4.5, and net present value exceeded $150,974. CONCLUSION: The results indicate that the benefits of the intervention exceeded its costs.

Costeffectiveness of diagnostic tests.

We review the principles underlying cost-effectiveness analysis of diagnostic tests and procedures. We use two clinical examples, diagnostic testing for early multiple sclerosis and for Helicobacter pylori to illustrate the methods of analysis and to show how the results can be useful for physicians or payers of health services in making decisions about provision and use of diagnostic services. Economic assessments of diagnostic tests are inherently more difficult than assessments of therapeutic interventions, mainly because of uncertainty about the relation between diagnosis and end results (outcomes) of care. Nonetheless, because of the increasing importance of diagnostic technology in medicine and healthcare, only with such assessments will the most value be gained from restricted medical resources.

An economic overview of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Relatively few pharmacoeconomic studies have been conducted on this disease. This article reviews available information about the utilisation of healthcare resources and cost of care, and the cost or cost effectiveness of therapeutic interventions reported for this disease. Burden-of-illness data indicate that hospital care, medications and oxygen therapy were the major cost drivers in these studies. Mean annual Medicare expenditures in the US were $US11,841 (2000 values) for patients with COPD compared with $US4,901 for all covered patients. Utilisation was skewed; the most expensive 10% of the Medicare beneficiaries accounted for nearly 50% of total expenditures for this disease. Costs are associated with health status, age, physician specialty, geographic location and type of insurance coverage. Six types of interventions were assessed in the literature--pharmacotherapy, oxygen therapy, home care, surgery, exercise and rehabilitation and health education. The studies used different analytic strategies (e.g. cost-minimisation and cost-effectiveness analyses) and even within the realm of cost-effectiveness analyses, no uniformity existed as to how outcome was measured. Patient severity was not always delineated, and the length of the follow-up period, while quite short, varied. Only 11 of the 34 evaluations were based on randomised controlled trials. Cost-minimisation studies generally found no significant difference in the cost of antimicrobial treatment for first-line, second-line and third-line agents. Studies of bronchodilators indicated that ipratropium bromide alone or in combination with salbutamol (albuterol) was the preferred medication. The major area for achieving cost savings is by reducing hospital utilisation. As the annual rate of hospitalisation is relatively low, large patient samples will be required to demonstrate an economic advantage for a new therapy. The major challenges will be financing such a study, and selecting an outcome measure that satisfies both clinical and economic conventions.

The Collection of Indirect and Nonmedical Direct Costs (COIN) form: a new tool for collecting the invisible costs of androgen independent prostate carcinoma.

BACKGROUND: There are limited data available regarding the cost of care in patients with androgen independent prostate carcinoma (AIPC), and there are no data on the impact of direct nonmedical and indirect costs (DNM/IC). This lack of data, along with the feasibility of collecting DNM/IC, was examined in patients with AIPC who took part in a randomized trial using a newly developed questionnaire, the Collection of Indirect and Nonmedical Direct Costs (COIN) form. METHODS: Patients with AIPC were randomized to one of three treatment arms: 1) strontium only (strontium 4 Mci in Week 1 and Week 12) (STRONT); 2) vinblastine 4 mg/m(2) per week for 3 weeks then 1 week off and estramustine, 10 mg/kg per day (CHEMO); or 3) a combination of treatments outlined in the arms for CHEMO and STRONT (CHEMO/STRONT). Direct medical costs were collected through the hospital billing system. DNM/IC data were obtained prospectively using the COIN form. Cost data were analyzed for a period of 6 months. RESULTS: Twenty-nine patients were randomized, after which the protocol was closed because of poor accrual. The median survival of the patients was 22.3 months. The mean and median total costs for the 20 of 29 patients with complete cost information were $12,647 and $11,257 over 6 months, respectively. DNM/IC represented 11% of the total cost (range, from < 1% to 42%); in 20% of participating individuals, these costs accounted for 35-42% of total costs. Failure to collect complete cost information was due to early death, administrative difficulties, and loss to follow-up. CONCLUSIONS: In this pilot project, the collection of these cost data using the COIN form was feasible and practical and was limited primarily by logistic, not form specific, issues. DNM/IC were found to be a significant proportion of total costs (up to 42%) in selected patients, and this information proved to be a useful addition to the cost analysis. Approximately 98 patients would be required to detect a 20% difference in total costs between arms in a properly powered, randomized trial. Considering the potentially significant impact on total costs, DNM/IC data should be included in future cost-analysis studies of patients with AIPC and other diseases.

Clinical economics of head and neck malignancies.

With the continued increase in medical expenditures and the growing awareness that resources are not limitless, there is increasing pressure to curb health care costs and to establish priorities. As potential solutions are proposed and implemented, there is understandable concern that policy choices may adversely affect both the access to and the quality of care. Economic analyses are one tool used to optimize resource allocation decisions. The primary goal of these analyses is to maximize value and efficiency, not necessarily to decrease spending. The current focus on cost cutting is often associated with a more truncated, nonsocietal perspective (e.g., that of the payer or provider). To be most useful, these analyses must be methodologically rigorous. Standard guidelines, such as those established by Eisenberg, are helpful. As shown in the reports applicable to head and neck malignancies that have been discussed here, many articles published in the clinical literature must be interpreted cautiously, because fundamental methodological concerns (e.g., using costs rather than charges, discounting to a common base year) were frequently not addressed. Economic investigations are one aspect of the broader fields of outcomes and health services research. It is easy to underestimate how greatly economic studies depend on the availability of high quality noneconomic data. In that context, current initiatives in evidence-based medicine (EBM), using the best available evidence (considering for example, the type of trial, the quality of the research, and the credentials of the researcher) to help clinicians practice in situations where doubt may exist in the diagnosis, treatment, or prognosis of patients, will likely grow in importance. Evidence-based clinical practice guidelines and systematic literature reviews are manifestations of this trend. Historically, disease control measures and survival have been the primary and points in clinical cancer studies. Economic analyses and studies evaluating other end points (e.g., function, quality of life) will likely play a larger role in the future in evaluating the diagnosis, treatment, and follow-up of head, neck and other malignancies.

An analysis of smoking patterns among older adults.

UNLABELLED: BACKGROUND, SUBJECTS, AND METHODS: The 1990 Health Promotion and Disease Prevention Supplement to The National Health Interview Survey was used to develop point-prevalence data about smoking for four age groups, 55 to 64, 65 to 74, 75 to 84, and over 84 and to assess the association of sociodemographics, health status, and health beliefs with a respondent's smoking profile. RESEARCH DESIGN: Chi-square and Cohran-Mantel-Haenszel tests were used to investigate prevalence patterns. Odds ratios generated from logistic regressions were used to indicate degree of association. RESULTS: Fifty-three percent of individuals above the age of 54 smoked in the past and 17% smoked in 1990. Among these smokers, 61% tried to quit and 36% noted that their physicians never advised them to quit. Significant age group differences were noted on the various measures of smoking prevalence. Beliefs about the adverse health effects of smoking were associated with a greater likelihood of never smoking, and among smokers, a greater likelihood of being a former smoker. CONCLUSIONS: Analyses of health behaviors among older adults must recognize the diversity within this age group, and measures of health beliefs should be included in subsequent studies of health behaviors among older adults. Physicians must also play a greater role in discussing smoking with their patients and advocating smoking cessation.

Prevalence and correlates of alcohol use among older adults.

BACKGROUND: The 1990 Health Promotion and Disease Prevention supplement to The National Health Interview Survey was used to develop point-prevalence data about drinking for four age groups, 55-64, 65-74, 75-84, and over 84, and to assess the impact of sociodemographics, health status, and health belief variables on light, moderate, and heavy alcohol consumption. The number of observations in the unweighted sample was 12,819, and the weighted sample contained 51,046,521 observations. METHODS: The chi 2 and Cohran-Mantel-Haenszel tests were used to investigate prevalence patterns, and odds ratios were generated from logistic regressions. RESULTS: Eighty percent of the sample had had at least 12 drinks during their lifetime, and 46% reported drinking during the survey year. The modal category for the number of days a respondent drank during the survey was 1-4 days, and the modal amount consumed on days that a person drank was 1-3 drinks. Age, gender, race, education, city size, labor force participation, geographic region, health status, having diabetes, and health beliefs about the adverse effects of excessive drinking and being overweight were associated with alcohol consumption, although their effects were different by drinking level. CONCLUSIONS: Analyses of health behaviors among older adults must recognize the diversity within this age group. Studies of drinking should differentiate between the amount consumed. Health beliefs need to be included in subsequent studies of health behaviors among older adults.

Is managed care good or bad for geriatric medicine?

This article uses clinical vignettes to examine the simultaneous dangers and opportunities that managed care brings to geriatric medicine. While the complex multifactorial syndromes prevalent in older adults might at first glance seem poorly handled under capitation, we argue that the incentives provided under existing delivery systems can be equally perverse. These improper incentives have arisen from (1) the fee-for-service payment mechanism itself, which has spawned a subspecialty culture ill-equipped to deal with the primary care needs of older adults and (2) the fragmentation of funding sources for geriatric care into two major payers (Medicare and Medicaid), encouraging providers to focus on cost shifting rather than the logical integration of services. The result has been a delivery system that provides little impetus to maximize functional status, the central goal of modern geriatric medicine. Because physicians may assume financial risk under global capitation, and because the cost of caring for a frail older adult is inversely related to functional status, managed care offers the potential to align the goals of cost containment with the goals of modern geriatric medicine. Physicians should have a substantive voice in the design and implementation of these systems.

Prevalence and correlates of breast and cervical cancer screening among older women.

OBJECTIVE: To identify and assess differences in cancer screening patterns among women 55-64, 65-74, 75-84, and over 84 years of age. METHODS: Nationally representative data reported in the 1990 Health promotion and Disease Prevention Supplement to the National Health Interview Survey of 28,584,574 women were analyzed secondarily. The dependent variables were a knowledge of breast self-examination, over having had a mammogram, and a Papanicolaou smear within the last 3 years. Independent variables were age and various sociodemographic, health-status, and health-belief measures. RESULTS: More than half (58%) of the women had ever had a mammogram, and of these, 91% had had between one and five mammograms. Over a third (35%) of those who had not had a mammogram attributed the omission to a lack of a recommendation by a physician. Almost half (45%) had had a breast examination by a physician within the last year, and 84% knew how to examine their own breasts. Approximately 87% had a Papanicolaou smear with the last 3 years. Age, race, education, and living in a large city were significantly associated with all three screening measures, but prevalent health beliefs were significantly associated only with breast-cancer screening. CONCLUSION: Lack of mammogram screening in a substantial number of women, attributed to lack of physician recommendation, decreased screening in the older age groups, and the negative association of three screening tests with race and residence in a large city suggest that new interventions are needed by health care providers and the public health community to increase older women's use of effective cancer screening techniques.

Economic considerations in the care of patients with head and neck malignancies.

In an era of cost-consciousness and managed care, quality concerns practice variability attributed to nonmedical factors, and growing attention to outcomes research, there is increasing interest in the economics of malignant disease. This review explores economic issues pertinent to the management of patients with head and neck malignancies. Using economic principles to evaluate medical practice does not uniformly mean that less money should be spent; rather, the intention is to optimize efficiency in the use of limited resources. Accordingly costs are best evaluated in the context of other outcomes of interest. The available economic literature for head and neck tumors is limited; it is often compromised by the use of facility charges as a proxy for true costs and the adoption of a truncated economic perspective. Given the potential health policy implications of such studies, their methodologies and results warrant careful scrutiny. Many opportunities exist for further research.

Assessing cost-effectiveness analyses in rheumatoid arthritis and osteoarthritis.

Economic considerations are now a source of great concern to clinicians and policy analysts. Many cost-effectiveness analyses have been published in the area of arthritis, most with substantial methodologic deficiencies. The goal of this article is to outline a method for evaluating cost-effectiveness assessment within the field of rheumatology. We do so by critically evaluating 6 cost-effectiveness analyses--2 in rheumatoid arthritis and 4 in osteoarthritis--as a basis for appraising the literature and developing future studies.

Cost-effectiveness of infective endocarditis prophylaxis for mitral valve prolapse with or without a mitral regurgitant murmur.

To assess the cost-effectiveness of prevention of infective endocarditis (IE) and to calculate cost-effectiveness of currently recommended regimens in patients with mitral valve prolapse (MVP), data on risk of death, complications, and health-care use, and cumulative incremental health-care costs due to the occurrence of IE were combined with data on the prevalence and manifestations of MVP, estimated years of life lost, and efficacy of antibiotic prophylaxis. Effectiveness and costs of standard endocarditis prophylaxis regimens were calculated per IE case prevented and years of life saved. Under the most likely scenario, oral amoxicillin prophylaxis for all MVP patients would prevent 32 cases of IE per million dental procedures at approximate costs of $119,000 per prevented case and $21,000 per year of life saved. Limiting prophylaxis to patients with mitral murmurs would prevent 80 cases of IE per million procedures at costs of about $19,000 per prevented case and $3,000 per year of life saved. Erythromycin prophylaxis was slightly less expensive than amoxicillin per benefit because of lower cost and lack of drug anaphylaxis, whereas intravenous ampicillin was 7 to 30 times more costly. Sensitivity analyses suggested that erythromycin prophylaxis might be cost-saving under some scenarios, whereas intravenous ampicillin use might cause net loss of life. Thus, prevention with oral antibiotics of the cumulative morbidity and incremental health care costs due to IE in MVP patients is reasonably cost-effective for MVP patients with mitral murmurs.

Clinical and health care cost consequences of infective endocarditis in mitral valve prolapse.

Although mitral valve prolapse (MVP) predisposes to infective endocarditis (IE), both the clinical consequences of IE and the increment in health care costs it imposes on patients with MVP remain uncertain. Accordingly, 21 MVP patients with IE and 41 age- and sex-matched control subjects with initially uncomplicated MVP were followed (95% complete) a mean of 8 years. Outcomes included death, complications, health care use and cumulative incremental costs. More MVP patients with IE died (25 vs 5%, p < 0.05), underwent valve surgery (40 vs 8%, p < 0.01), had heart failure (50 vs 5%, p < 0.01) or embolization (53 vs 11%, p < 0.01), underwent cardiac catheterization (40 vs 13%), and saw their physicians > 2 times per year (88 vs 33%). The cumulative incremental cost of IE (1990 dollars) was $46,132 per case. Thus, IE in patients with MVP causes considerable cumulative morbidity and incremental health care costs.

Refusal of surgery in an insured population.

Among 195 people who did not have recommended elective surgery in which a second opinion was required, virtually all indicated they were not going to have the operation and did not want a second opinion. The extent to which this decision adversely affected their health status and well-being and the extent to which alternate treatments were tried are examined. The findings also highlight the discretionary nature of patient and physician decision making.

Resident medical care utilization patterns in continuing care retirement communities.

This article presents the findings of an evaluation of medical care service utilization by two elderly cohorts: one living in continuing care retirement communities (CCRCs) and the other living in traditional community settings. CCRC residents' overall use of Medicare-covered medical services did not differ significantly from that of the traditional community-residing elders. Both groups incurred annual per capita expenditures of approximately $2,000. In their last year of life, however, CCRC residents displayed significantly lower expenditures for hospital care ($3,854 versus $7,268) but higher expenditures for Medicare or non-Medicare-covered nursing home care ($5,565 versus $3,533).

Impact of work on the quality of life of community-residing young elderly.

Using a random sample of 310 Massachusetts community-residing elderly between the ages of 65 and 74, this study investigates the relationship between employment status and quality of life using a modified version of the Spitzer Uniscale QL index. The odds of reporting the highest quality of life rating, after controlling for socioeconomic and health characteristics, was 3.51:1 for those who worked versus those who did not do so.