Cost-effectiveness analysis: cardiovascular benefits of proton pump inhibitor co-therapy in patients using aspirin for secondary prevention.

BACKGROUND: Many patients with cardiovascular (CV) disease will stop aspirin (ASA) because of ASA-related dyspepsia. Proton pump inhibitor (PPI) co-therapy may reduce ASA-related dyspepsia, enhancing ASA adherence and improving CV outcomes. AIM: To explore the impact of PPI co-therapy on CV outcomes in long-term, low-dose ASA users. METHODS: We modified a previously published Markov model to assess the long-term impact of PPI co-therapy on CV and upper gastrointestinal bleeding (UGIB) outcomes among patients using ASA for secondary CV prevention. UGIB events, recurrent myocardial infarctions (MIs) and incremental cost-effectiveness ratios (ICERs) were measured. The perspective taken was that of a long-term payer. RESULTS: Compared with ASA alone, ASA plus PPI resulted in fewer lifetime UGIB events (3.4% vs. 7.2%) and increased ASA adherence (74% vs. 71%). Increased ASA adherence resulted in fewer recurrent MIs (26 fewer events per 10000 patients). On average, the ASA plus PPI strategy resulted in 38 additional days of life per patient, with the majority of this benefit (61%) because of a reduction in CV mortality (rather than UGIB-related mortality). ASA plus PPI was also more costly than ASA alone, with an ICER of $19000 per life-year saved. Results were sensitive to cost of PPI and impact of PPI on ASA adherence. CONCLUSIONS: Proton pump inhibitor co-therapy has the potential to impact not only GI, but also CV outcomes in patients with CV disease using ASA and such co-therapy is likely to be cost-effective. Future studies should better quantify the CV benefits of PPI co-therapy.

As tests evolve and costs of cancer care rise: reappraising stool-based screening for colorectal neoplasia.

BACKGROUND: Colorectal cancer screening and treatment are rapidly evolving. Aims To reappraise stool-based colorectal cancer screening in light of changing test performance characteristics, lower test cost and increasing colorectal cancer care costs. METHODS: Using a Markov model, we compared faecal DNA testing every 3 years, annual faecal occult blood testing or immunochemical testing, and colonoscopy every 10 years. RESULTS: In the base case, faecal occult blood testing and faecal immunochemical testing gained life-years/person and cost less than no screening. Faecal DNA testing version 1.1 at $300 (the current PreGen Plus test) gained 5323 life-years/100 000 persons at $16 900/life-year gained and faecal DNA testing version 2 (enhanced test) gained 5795 life-years/100 000 persons at $15 700/life-year gained vs. no screening. In the base case and most sensitivity analyses, faecal occult blood testing and faecal immunochemical testing were preferred to faecal DNA testing. Faecal DNA testing version 2 cost $100 000/life-year gained vs. faecal immunochemical testing when per-cycle adherence with faecal immunochemical testing was 22%. Faecal immunochemical testing with excellent adherence was superior to colonoscopy every 10 years. CONCLUSIONS: As novel biological therapies increase colorectal cancer treatment costs, faecal occult blood testing and faecal immunochemical testing could become cost-saving. The cost-effectiveness of faecal DNA testing compared with no screening has improved, but faecal occult blood testing and faecal immunochemical testing are preferred to faecal DNA testing when patient adherence is high. Faecal immunochemical testing may be comparable to colonoscopy every 10 years in persons adhering to yearly testing.

Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States.

BACKGROUND: There is debate about the optimal colorectal cancer screening test, partly because of concerns about colonoscopy demand. AIM: To quantify the demand for colonoscopy with different screening tests, and to estimate the ability of the United States health care system to meet demand. METHODS: We used a previously published Markov model and the United States census data to estimate colonoscopy demand. We then used an endoscopic database to compare current rates of screening-related colonoscopy with those projected by the model, and to estimate the number of endoscopists needed to meet colonoscopy demand. RESULTS: Annual demand for colonoscopy ranges from 2.21 to 7.96 million. Based on current practice patterns, demand exceeds current supply regardless of screening strategy. We estimate that an increase of at least 1360 gastroenterologists would be necessary to meet demand for colonoscopic screening undergone once at age 65, while colonoscopy every 10 years could require 32 700 more gastroenterologists. A system using dedicated endoscopists could meet demand with fewer endoscopists. CONCLUSIONS: Colorectal cancer screening leads to demand for colonoscopy that outstrips supply. Systems to train dedicated screening endoscopists may be necessary in order to provide population-wide screening. The costs and feasibility of establishing this infrastructure should be studied further.

Reappraisal of non-invasive management strategies for uninvestigated dyspepsia: a cost-minimization analysis.

BACKGROUND: The benefits of the Helicobacter pylori test-and-treat strategy are attributable largely to the cure of peptic ulcer disease while limiting the use of endoscopy. AIM: To reappraise the test-and-treat strategy and empirical proton pump inhibitor therapy for the management of uninvestigated dyspepsia in the light of the decreasing prevalence of H. pylori infection, peptic ulcer disease and peptic ulcer disease attributable to H. pylori. METHODS: Using a decision analytical model, we estimated the cost per patient with uninvestigated dyspepsia managed with the test-and-treat strategy ($25/test; H.pylori treatment, $200) or proton pump inhibitor ($90/month). Endoscopy ($550) guided therapy for persistent or recurrent symptoms. RESULTS: In the base case (25%H. pylori prevalence, 20% likelihood of peptic ulcer disease, 75% of ulcers due to H.pylori), the cost per patient is $545 with the test-and-treat strategy and $529 with proton pump inhibitor, and both strategies yield similar clinical outcomes at 1 year. H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H.pylori are important determinants of the least costly strategy. At an H. pylori prevalence below 20%, proton pump inhibitor is consistently less costly than the test-and-treat strategy. CONCLUSIONS: As the H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H. pylori decrease, empirical proton pump inhibitor becomes less costly than the test-and-treat strategy for the management of uninvestigated dyspepsia. Given the modest cost differential between the strategies, the test-and-treat strategy may be favoured if patients without peptic ulcer disease derive long-term benefit from H.pylori eradication.

A national study of the quantity and cost of informal caregiving for the elderly with stroke.

BACKGROUND: As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients. OBJECTIVE: To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke. METHODS: The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated. RESULTS: Of 7,443 respondents, 656 (8.8%) reported a history of stroke. Of those, 375 (57%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke +/- SRHP (p < 0.01). Using the median 1999 home health aide wage (8.20 dollars/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from 3,500 dollars to 8,200 dollars. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to 6.1 billion dollars for stroke-related informal caregiving in the United States. CONCLUSIONS: Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

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.

Respiratory illness caused by picornavirus infection: a review of clinical outcomes.

BACKGROUND: Respiratory infections result from invasion of the respiratory tract, mainly by viruses, and are the leading cause of acute morbidity in individuals of all ages worldwide. During peak season, picornaviruses cause 82% of all episodes of acute nasopharyngitis (the common cold), the most frequent manifestation of acute respiratory infection, and produce more restriction of activity and physician consultations annually than any other viral or bacterial source of respiratory illness. OBJECTIVE: This article reviews the clinical impact and outcomes of picornavirus-induced respiratory infections in specific populations at risk for complications. It also discusses the potential economic impact of the morbidity associated with picornavirus-induced respiratory infection. METHODS: Relevant literature was identified through searches of MEDLINE, OVID, International Pharmaceutical Abstracts, and Lexis-Nexis. The search terms used were picornavirus, rhinovirus, enterovirus, viral respiratory infection, upper respiratory infection, disease burden, economic, cost, complications, asthma, COPD, immunocompromised, elderly otitis media, and sinusitis. Additional publications were identified from the reference lists of the retrieved articles. CONCLUSIONS: Based on the clinical literature, picornavirus infections are associated with severe morbidity as well as considerable economic and societal costs. Future research should focus on identifying patterns of illness and the costs associated with management of these infections. New treatments should be assessed not only in terms of their ability to produce the desired clinical outcome, but also in terms of their ability to reduce the burden of disease, decrease health care costs, and improve productivity.

Cardiologists performing peripheral angioplasties: impact on utilization.

CONTEXT: Angioplasty and stent placement for peripheral arterial occlusive disease has traditionally been performed by radiologists and surgeons. However, cardiologists have recently begun to perform these procedures. It is unknown whether this has affected how often the procedure is done. OBJECTIVE: To assess how the proportion of peripheral angioplastics performed by cardiologists in a geographic area relates to population-based angioplasty rates. DESIGN: Cross-sectional analysis of all U.S. Medicare beneficiaries undergoing peripheral arterial (i.e., renal, iliac, or lower extremity) angioplasty in 1996 using Part B (physician) claims for cardiovascular procedures. Physician specialty was obtained from the American Medical Association's masterfile and Medicare. MEASURES: For each of the 306 U.S. hospital referral regions (HRRs), we calculated the proportion of procedures performed by cardiologists and rates of peripheral arterial angioplasty (adjusted for age, sex, and race). RESULTS: More than 37,000 peripheral arterial angioplastics were performed on Medicare beneficiaries in 1996 (50% for lower extremity, 33% iliac, and 17% renal arterial disease). Cardiologists performed 26% of these procedures overall, including 37% of the renal angioplastics. Few (12%) procedures were done as part of a cardiac catheterization; instead, most were done as a separate procedure. Use of peripheral angioplasty varied more than 14-fold across HRRs (median, 12 procedures per 10,000 beneficiaries; 10th to 90th percentile, 4.1 to 57.9). The mean angioplasty rate in HRRs where cardiologists performed 50% or more of the procedures was almost double that of regions where they performed none (21.9 vs. 12.1 procedures per 10,000 beneficiaries; P < 0.001). CONCLUSIONS: Cardiologists are performing a substantial proportion of peripheral angioplasties. Rates of these procedures are highest in regions where cardiologists do most of the angioplasties.

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.

Endoscopic outcomes analysis.

Endoscopic outcomes analysis has become an increasingly important topic as attempts to measure outcomes, define costs, and compare the relative costs and benefits of different diagnostic and therapeutic procedures have become a major focus of the health care community. This article (1) defines the potential benefits and medical effects of endoscopy; (2) reviews the economic and social pressures fostering the increased focus on health care outcomes research; (3) explores the basic principles, approaches, and paradigms used in health care outcomes analysis; and (4) illustrates how health care outcomes research can help to guide therapeutic approaches, such as endoscopy, in patients with abdominal pain or inflammatory bowel disease.

Cost-effectiveness of saline-assisted hysterosonography and office hysteroscopy in the evaluation of postmenopausal bleeding: a decision analysis.

RATIONALE AND OBJECTIVES: The authors performed this study to evaluate whether hysterosonography (HSG) is a more cost-effective initial diagnostic examination than office hysteroscopy in the evaluation of postmenopausal bleeding (PMB). MATERIALS AND METHODS: A computer model simulated the diagnosis and treatment of PMB in otherwise healthy women. The hypothetical patient who had one episode of PMB precipitating a clinic visit would undergo either HSG or office hysteroscopy as the initial examination. Algorithms were designed such that a finite number of false-negative and false-positive findings would be expected, and clinical decision making would rely on the reported results. Performance characteristics for diagnostic tests and other clinical probabilities were taken from the literature. Costs were based on actual 1997 Medicare reimbursements. The primary clinical outcome considered was the correct diagnosis of any anatomic abnormality that was amenable to definitive treatment. The primary cost outcome considered was the cost per abnormality detected. Sensitivity analysis was performed to examine the effect of varying performance characteristics for diagnostic techniques. RESULTS: HSG and office hysteroscopy correctly depicted 68.1 and 67.6 anatomic abnormalities per 100 patients, respectively. The average cost per abnormality detected was $7,978 with HSG and $8,400 with office hysteroscopy. CONCLUSION: HSG depicted more abnormalities at a lower cost per abnormality, which suggests that it should be the preferred initial diagnostic examination in the setting of PMB.

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.

The role of economic evaluation in infection control.

Given the rise in health care-related expenditures, decision-makers are increasingly relying on both clinical effectiveness and economic efficiency when making health care decisions. The field of infection control is not immune to this rise in cost-consciousness among health care managers. This article clarifies the role of economic evaluation within infection control for both the user and producer of economic evaluations in this field. The strengths and drawbacks of the several different types of economic analysis--cost minimization, cost-effectiveness, cost-benefit, and cost utility analysis--will be discussed. Additionally, the important features of two specific methods used for economic evaluation-decision analytic modeling and economic analysis alongside a clinical trial-will be outlined. Finally, the criteria by which economic analyses should be judged will be provided. As economic evaluation and health services research continue to play an increasingly important role in health care, it will be vital for infection control advocates to partner with individuals from diverse fields to give decision-makers the type of information they need to make choices.

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.

Noninvasive Helicobacter pylori testing for the "test-and-treat" strategy: a decision analysis to assess the effect of past infection on test choice.

BACKGROUND: Clinical guidelines support a noninvasive Helicobacter pylori "test-and-treat" strategy for individuals with uncomplicated dyspepsia. However, consensus is lacking regarding the preferred noninvasive testing method. OBJECTIVE: To use decision analytic modeling to estimate the clinical and economic outcomes associated with noninvasive tests designed to detect either H pylori antibody or active H pylori infection. DESIGN: Decision analytic model. PATIENTS: A simulated patient cohort with uncomplicated dyspepsia. INTERVENTIONS: The simulated dyspepsia cohort underwent antibody testing or testing to detect active H pylori infection (active testing). Individuals testing positive received eradication therapy. MAIN OUTCOME MEASURES: Appropriate and inappropriate treatment prescribed, cost per patient treated, incremental cost per unnecessary treatment avoided. RESULTS: Active testing led to a substantial reduction in unnecessary treatment for patients without active infection (antibody, 23.7; active, 1.4 per 100 patients) at an incremental cost of $37 per patient. The clinical advantage and cost-effectiveness of active testing was enhanced as the percentage of individuals with a positive antibody test result from past, but not current, infection increased. CONCLUSIONS: Active testing for H pylori infection significantly decreases the inappropriate use of antimicrobial therapy when compared with antibody testing. The advantages of active testing should be enhanced as the widespread use of antimicrobial agents increases the proportion of patients with antibody to H pylori, but without active infection.

Management of patients with symptomatic gastroesophageal reflux disease: a primary care perspective.

The availability of antacids and over the counter (OTC) histamine 2 (H2) receptor antagonists provide ample opportunity for individuals with symptomatic reflux to self-medicate before or instead of visiting a physician. Because many patients will not achieve complete relief from OTC products, clinicians will be required to rethink treatment strategies for those who present with persistent reflux symptoms after a trial of low dose H2 receptor antagonists or other antisecretories. Patients with persistent heartburn or regurgitation without evidence of "alarm symptoms" will usually not require a diagnostic study of the upper GI tract. Counseling on lifestyle modifications and empirical antisecretory therapy is indicated in most situations. Proton pump inhibitors have consistently demonstrated superior symptom relief when compared to H2 antagonists for patients with erosive esophagitis and for patients with nonerosive disease. If proton pump inhibitors consistently reduce the need for physician visits and diagnostic testing, they would seem to be a logical first choice pharmaceutical for individuals who fail to improve with OTC H2 antagonists.

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.

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.

Outcomes of initial noninvasive Helicobacter pylori testing in U.S. primary care patients with uninvestigated dyspepsia.

OBJECTIVE: Recent European trials demonstrate that testing and treatment for Helicobacter pylori (H. pylori) is an effective alternative to prompt endoscopy in uninvestigated dyspepsia. The eventual endoscopy rate after H. pylori testing, which is a key determinant of cost-effectiveness, is unknown in the United States. Our aim was to determine the endoscopy rate after H. pylori testing in primary care practice in the United States and to compare outcomes among seropositive and seronegative patients. METHODS: We performed a retrospective review with mean 13 month follow-up of primary care patients with dyspeptic symptoms tested with office-based H. pylori serology. RESULTS: Of 268 adults tested (37+/-11 yr, 58% women), 57 (21%) were seropositive and 49/57 (86%) received eradication therapy. Endoscopy or contrast radiography was performed on 19% of seropositive and 19% of seronegative patients (p = 0.97). Annualized median disease-related expenditures were similar among seropositive and seronegative patients ($228 [$93-$654] vs $366 [$107-$1268], p = 0.19). However, aggregate expenditures were substantially lower than the cost of endoscopy alone ($816 [$296-$970]). On follow-up, seropositive and seronegative patients had similar numbers of primary care visits (2.9+/-3.2 vs 3.5+/-3.6, p = 0.23), prolonged antisecretory medication use (25 vs 33%, p = 0.27), and specialist referrals (23 vs 24%, p = 0.83). CONCLUSION: In a United States center, 81% of primary care patients tested for H. pylori did not undergo endoscopy, and patients incurred significantly lower median expenditures after noninvasive H. pylori testing than the cost of endoscopy alone. Seropositive and seronegative patients experienced comparable outcomes after H. pylori testing.

Acute exacerbation of chronic bronchitis: disease-specific issues that influence the cost-effectiveness of antimicrobial therapy.

BACKGROUND: Acute exacerbation of chronic bronchitis (AECB) is a common condition, with substantial associated costs and morbidity. Research efforts have focused on innovations that will reduce the morbidity associated with AECB. Health care payers increasingly expect that the results of evidence-based economic evaluations will guide practitioners in their choice of cost-effective interventions. OBJECTIVES: To provide a framework on which to base effective and efficient antimicrobial therapy for AECB, we present a concise clinical review of AECB, followed by an assessment of the available data on the economic impact of this disease. We then address several AECB-specific issues that must be considered in cost-effectiveness analyses of AECB antimicrobial interventions. METHODS: Published literature on the clinical and economic impact of AECB was identified using MEDLINE, pre-MEDLINE, HealthSTAR, CINAHL, Current Contents/All Editions, EMBASE, and International Pharmaceutical Abstracts databases. Other potential sources were identified by searching for references in retrieved articles, review articles, consensus statements, and articles written by selected authorities. RESULTS: In evaluating cost-effectiveness analyses of AECB antimicrobial therapy it is critical to (1) use the disease-free interval as an outcome measure, (2) evaluate the sequence of multiple therapies, (3) address the impact of both current and future antibiotic resistance, and (4) measure all appropriate AECB-associated costs, both direct and indirect. CONCLUSIONS: Incorporating these approaches in economic analyses of AECB antimicrobial therapy can help health care organizations make evidence-based decisions regarding the cost-effective management of AECB.