Cost Effectiveness and Resource Allocation - Latest Articles

Disproportionate utilization of healthcare resources among veterans with COPD: a retrospective analysis of factors associated with COPD healthcare cost

Kyle Darnell — 2013-06-13T00:00:00Z

Background: COPD is a significant cause of morbidity and mortality in the Veterans Health Administration (VHA). To determine the clinical factors associated with the cost of COPD management, we analyzed the relationship between clinical characteristics and COPD healthcare costs at the Cincinnati VAMC. Methods: We queried the VHA Decision Support System for patients diagnosed with COPD at the Cincinnati VAMC and calculated their VHA COPD-related encounters and costs in FY2008. Patients were ranked by COPD-related cost. We determined the detailed clinical characteristics of patients selected by modified systematic sampling and performed univariate and multivariable ordinary linear regression analysis to determine factors associated with cost. Results: 3263 Veterans had 11,869 encounters with a primary or secondary diagnosis of COPD: 10,032 clinic visits, 505 emergency department (ED) visits, and 1,332 hospitalizations and incurred a total COPD-related healthcare cost of $21.4 M: $2.4 M clinic visits, $0.21 M ED visits, and $18.7 M hospitalizations and $0.89 M for COPD-related prescription costs. When the patients were ranked by VHA healthcare costs, the top 20% of patients accounted for 86% of the total costs and 57% of the total encounters with a primary or secondary diagnosis code of COPD and 90% of the total costs and 75% of the total encounters with a primary diagnosis code of COPD. The clinical characteristics and VHA healthcare costs of 840 of the 3263 unique individuals with COPD were analyzed to determine those characteristics associated with increased COPD-related costs. Univariate analysis showed significant associations with 24 clinical variables; the 4 most highly associated factors were nursing home residence, total hospital admissions, use of oral corticosteroids, and supplemental oxygen (p < 0.001 for all). In multivariate analysis, total number of admissions (p < 0.001), management by a pulmonologist (p < 0.001), number of clinic visits (p < 0.001), use of short acting anticholinergic (p = 0.001), forced expiratory volume in 1 second (FEV1) (p = 0.011), number of prescriptions (p = 0.011), body mass index (BMI) (p = 0.025), and use of inhaled corticosteroid (p = 0.043) were associated with COPD management cost. Conclusion: The total number of admissions, clinic visits, physiologic impairment, BMI, number of medications, and type of provider are strongly associated with the total cost of COPD management. These factors may be used to focus COPD management toward patients with the potential for high utilization of healthcare resources.

Cost-effectiveness of adherence therapy versus health education for people with schizophrenia: randomised controlled trial in four European countries

Anita Patel — 2013-05-25T00:00:00Z

Background: Non-adherence to anti-psychotics is common, expensive and affects recovery. We therefore examine the cost-effectiveness of adherence therapy for people with schizophrenia by multi-centre randomised trial in Amsterdam, London, Leipzig and Verona. Methods: Participants received 8 sessions of adherence therapy or health education. We measured lost productivity and use of health/social care, criminal justice system and informal care at baseline and one year to estimate and compare mean total costs from health/social care and societal perspectives. Outcomes were the Short Form 36 (SF-36) mental component score (MCS) and quality-adjusted life years (QALYs) gained (SF-36 and EuroQoL 5 dimension (EQ5D)). Cost-effectiveness was examined for all cost and outcome combinations using cost-effectiveness acceptability curves (CEACs). Results: 409 participants were recruited. There were no cost or outcome differences between adherence therapy and health education. The probability of adherence therapy being cost-effective compared to health education was between 0.3 and 0.6 for the six cost-outcome combinations at the willingness to pay thresholds we examined. Conclusions: Adherence therapy appears equivalent to health education. It is unclear whether it would have performed differently against a treatment as usual control, whether such an intervention can impact on quality of life in the short-term, or whether it is likely to be cost-effective in some sites but not others.Trial registrationTrial registration: Current Controlled Trials ISRCTN01816159

The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

Francois Dionne — 2013-05-20T00:00:00Z

Background: As fiscal constraints dominate health policy discussions across Canada and globally, priority-setting exercises are becoming more common to guide the difficult choices that must be made. In this context, it becomes highly desirable to have accurate estimates of the value of specific health care interventions.Economic evaluation is a well-accepted method to estimate the value of health care interventions. However, economic evaluation has significant limitations, which have lead to an increase in the use of Multi-Criteria Decision Analysis (MCDA). One key concern with MCDA is the availability of the information necessary for implementation. In the Fall 2011, the Canadian Physiotherapy Association embarked on a project aimed at providing a valuation of physiotherapy services that is both evidence-based and relevant to resource allocation decisions. The framework selected for this project was MCDA. We report on how we addressed the challenge of obtaining some of the information necessary for MCDA implementation. Methods: MCDA criteria were selected and areas of physiotherapy practices were identified. The building up of the necessary information base was a three step process. First, there was a literature review for each practice area, on each criterion. The next step was to conduct interviews with experts in each of the practice areas to critique the results of the literature review and to fill in gaps where there was no or insufficient literature. Finally, the results of the individual interviews were validated by a national committee to ensure consistency across all practice areas and that a national level perspective is applied. Results: Despite a lack of research evidence on many of the considerations relevant to the estimation of the value of physiotherapy services (the criteria), sufficient information was obtained to facilitate MCDA implementation at the local level. Conclusions: The results of this research project serve two purposes: 1) a method to obtain information necessary to implement MCDA is described, and 2) the results in terms of information on the benefits provided by each of the twelve areas of physiotherapy practice can be used by decision-makers as a starting point in the implementation of MCDA at the local level.

A cost function analysis of child health services in four districts in Malawi

Benjamin Johns — 2013-05-10T00:00:00Z

Background: Recent analyses show that donor funding for child health is increasing, but little information is available on actual costs to deliver child health care services. Understanding how unit costs scale with service volume in Malawi can help planners allocate budgets as health services expand. Methods: Data on facility level inputs and outputs were collected at 24 health centres in four districts of Malawi visiting a random sample of government and a convenience sample of Christian Health Association of Malawi (CHAM) health centres. In the cost function, total outputs, quality, facility ownership, average salaries and case mix are used to predict total cost. Regression analysis identifies marginal cost as the coefficient relating cost to service volume intensity. Results: The marginal cost per patient seen for all health centres surveyed was US$ 0.82 per additional patient visit. Average cost was US$ 7.16 (95% CI: 5.24 to 9.08) at government facilities and US$ 10.36 (95% CI: 4.92 to 15.80) at CHAM facilities per child seen for any service. The first-line anti-malarial drug accounted for over 30% of costs, on average, at government health centres. Donors directly financed 40% and 21% of costs at government and CHAM health centres, respectively. The regression models indicate higher total costs are associated with a greater number of outpatient visits but that many health centres are not providing services at optimal volume given their inputs. They also indicate that CHAM facilities have higher costs than government facilities for similar levels of utilization. Conclusions: We conclude by discussing ways in which efficiency may be improved at health centres. The first option, increasing the total number of patients seen, appears difficult given existing high levels of child utilization; increasing the volume of adult patients may help spread fixed and semi-fixed costs. A second option, improving the quality of services, also presents difficulties but could also usefully improve performance.

The value of effective public tuberculosis treatment: an analysis of opportunity costs associated with multidrug resistant tuberculosis in Latvia

Thaddeus Miller — 2013-04-17T00:00:00Z

Background: A challenge to effective protection against tuberculosis is to sustain expensive and complex treatment public programs. Potential consequences of program failure include acquired drug resistance, poor patient outcomes, and potentially much higher system costs, however. In contrast, effective efforts have value illustrated by impacts they prevent. We compared the healthcare costs and treatment outcomes among multidrug-resistant tuberculosis (MDR-TB) and non MDR-TB patients in Latvia to identify benefits or costs associated with both. Methods: We measured and compared costs, healthcare utilization, and outcomes for patients who began treatment through Latvia’s TB control program in 2002 using multivariate regression analysis and negative binomial regression. Results: We analyzed data for 92 MDR-TB and 54 non MDR-TB patients. Most (67%) MDR-TB patients had history of prior tuberculosis treatment. MDR-TB was associated with lower cure rates (71% vs. 91%) and greater resource utilization. MDR-TB treatment cost almost $20,000 more than non MDR-TB. Conclusion: Up to 2/3 of MDR-TB treated in our sample was preventable at a potential savings of over $1.3 million in healthcare resources as well as substantial individual health.

A cost-utility analysis of pregabalin versus venlafaxine XR in the treatment of generalized anxiety disorder in Portugal

Luís Silva Miguel — 2013-04-12T00:00:00Z

Background: Generalized anxiety disorder is characterized by excessive anxiety and worry about several events and activities. The estimated 1-year prevalence for adults is around 2% and the lifetime prevalence could reach more than 6%. The disease is associated with reduced quality of life, being comparable to that of major depressive disorder and to chronic illnesses such as diabetes and arthritis, and high consumption of health care resources. Methods: A previously published patient-level simulation cost-utility model was adapted to the Portuguese context in order to evaluate clinical and economic consequences of using pregabalin in place of venlafaxine XR in the treatment of generalized anxiety disorder. The model predicts the evolution of 1,000 patients with generalized anxiety disorder, simulating their pathway in weekly cycles over one year treatment. This is done by setting a pre-treatment Hamilton Anxiety Scale score and projecting the weekly impact of the pharmacotherapy on this score. The model uses clinical data from an 8-week flexible dose direct comparison clinical trial between the two drugs; utility values based on a Spanish study; and Portuguese economic data, being the resource consumption obtained via an expert panel. Results: Pregabalin patients benefited from 0.738 quality adjusted life years while those on venlafaxine XR achieved 0.712. Moreover, the number of weeks with no or minimal anxiety symptoms was estimated to be 12.9 for pregabalin and only 3.8 for venlafaxine XR. Those clinical gains were achieved at the expense of an extra 715€ per patient, implying an incremental cost per quality adjusted life year of 27,199€ and an incremental cost per week with no or minimal symptoms of 79€. Sensitivity analysis shows that results are robust to main assumptions. Conclusions: Assuming a threshold of 30,000€ per quality adjusted life year, pregabalin is cost-effective in comparison with venlafaxine XR in the treatment of generalized anxiety disorder in Portugal.

Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature

Kathleen Melissa Ke — 2013-04-04T00:00:00Z

ObjectiveTo investigate the cost effectiveness of management of patients within the context of a multidisciplinary team (MDT) meeting in cancer and non-cancer teams in secondary care.DesignSystematic review.Data sourcesEMBASE, MEDLINE, NHS EED, CINAHL, EconLit, Cochrane Library, and NHS HMIC.Eligibility criteria for selecting studiesRandomised controlled trials (RCTs), cohort, case–control, before and after and cross-sectional study designs including an economic evaluation of management decisions made in any disease in secondary care within the context of an MDT meeting.Data extractionTwo independent reviewers extracted data and assessed methodological quality using the Consensus on Health Economic Criteria (CHEC-list). MDTs were defined by evidence of two characteristics: decision making requiring a minimum of two disciplines; and regular meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by teleconferencing. Studies that reported on the costs of administering, preparing for, and attending MDT meetings and/or the subsequent direct medical costs of care, non-medical costs, or indirect costs, and any health outcomes that were relevant to the disease being investigated were included and classified as cancer or non-cancer MDTs. Results: Fifteen studies (11 RCTs in non-cancer care, 2 cohort studies in cancer and non-cancer care, and 2 before and after studies in cancer and non cancer care) were identified, all with a high risk of bias. Twelve papers reported the frequency of meetings which varied from daily to three monthly and all reported the number of disciplines included (mean 5, range 2 to 9). The results from all studies showed mixed effects; a high degree of heterogeneity prevented a meta-analysis of findings; and none of the studies reported how the potential savings of MDT working may offset the costs of administering, preparing for, and attending MDT meetings. Conclusions: Current evidence is insufficient to determine whether MDT working is cost-effective or not in secondary care. Further studies aimed at understanding the key aspects of MDT working that lead to cost-effective cancer and non-cancer care are required.

Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement

Don Husereau — 2013-03-25T00:00:00Z

Economic evaluations of health interventions pose a particular challenge for reporting. There is also a need to consolidate and update existing guidelines and promote their use in a user friendly manner. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement is an attempt to consolidate and update previous health economic evaluation guidelines efforts into one current, useful reporting guidance. The primary audiences for the CHEERS statement are researchers reporting economic evaluations and the editors and peer reviewers assessing them for publication.The need for new reporting guidance was identified by a survey of medical editors. A list of possible items based on a systematic review was created. A two round, modified Delphi panel consisting of representatives from academia, clinical practice, industry, government, and the editorial community was conducted. Out of 44 candidate items, 24 items and accompanying recommendations were developed. The recommendations are contained in a user friendly, 24 item checklist. A copy of the statement, accompanying checklist, and this report can be found on the ISPOR Health Economic Evaluations Publication Guidelines Task Force website (http://www.ispor.org/TaskForces/EconomicPubGuidelines.asp).We hope CHEERS will lead to better reporting, and ultimately, better health decisions. To facilitate dissemination and uptake, the CHEERS statement is being co-published across 10 health economics and medical journals. We encourage other journals and groups, to endorse CHEERS. The author team plans to review the checklist for an update in five years.

Modeling the indirect economic implications of musculoskeletal disorders and treatment

Timothy Dall — 2013-03-15T00:00:00Z

Background: Musculoskeletal disorders impose a substantial economic burden on American society, but few studies have examined the economic benefits associated with treating such disorders. The purpose of this research is to estimate the indirect economic implications of activity limitations associated with musculoskeletal disorders and to quantifying the potential economic gains from elective surgery to treat arthritis of the knee and hip. Methods: Using regression analysis with the National Health Interview Survey (2004-2010 data, n=185,829 adults) we quantify the relationship between severity of activity limitations (walking, sitting, standing, etc.) and employment, household income, missed work days, and receipt of supplemental security income for disability. Activity limitations are combined to create an index similar to the Functional Ability Index from the Short Form 36 Health Questionnaire (SF-36) often used in clinical trials to measure patient functional mobility. This index is included in the regression analyses. We use data from published, prospective clinical trials to establish the improvement in patient functional ability following surgery to treat arthritis of the knee and hip. Results: Improved physical function is associated with higher likelihood of employment, higher household income and fewer missed work days for those who are employed, and reduced likelihood of receiving supplemental security income for disability. The magnitude of the impact and statistical significance vary by activity limitation and severity. Each percentage point increase in the index value is associated with a 2-percentage-point increase in the odds of being employed, a 3-percentage-point-day decline in work days missed and an additional $180 in annual household income if employed, and a 2-percentage-point decline in the odds of receiving supplemental security income for disability. All estimates are statistically significant at the 0.05 level. Conclusions: Using a large, representative sample of non-institutionalized adults in the U.S., we find that physical activity limitations are associated with worse economic outcomes across multiple economic metrics. Combined with estimates of improved functional ability following knee and hip surgery, we quantify some of the economic benefits of surgery for arthritis of the knee and hip. This information helps improve understanding of the societal benefits of medical treatment for musculoskeletal conditions.

Cost-utility analysis of a dance intervention for adolescent girls with internalizing problems

Anna Philipsson — 2013-02-20T00:00:00Z

Background: The increasing prevalence of psychological health problems among adolescent girls is alarming. Knowledge of beneficial effects of physical activity on psychological health is widespread. Dance is a popular form of exercise that could be a protective factor in preventing and treating symptoms of depression. The aim of this study was to assess the cost-effectiveness of a dance intervention in addition to usual school health services for adolescent girls with internalizing problems, compared with usual school health services alone. Methods: A cost-utility analysis from a societal perspective based on a randomized controlled intervention trial was performed. The setting was a city in central Sweden with a population of 130 000. A total of 112 adolescent girls, 13–18 years old, with internalizing problems participated in the study. They were randomly assigned to intervention (n = 59) or control (n = 53) group. The intervention comprised dance twice weekly during eight months in addition to usual school health services. Costs for the stakeholder of the intervention, treatment effect and healthcare costs were considered. Gained quality-adjusted life-years (QALYs) were used to measure the effects. Quality of life was measured with the Health Utility Index Mark 3. Cost-effectiveness ratios were based on the changes in QALYs and net costs for the intervention group compared with the control group. Likelihood of cost-effectiveness was calculated. Results: At 20 months, quality of life had increased by 0.08 units more in the intervention group than in the control group (P = .04), translating to 0.10 gained QALYs. The incremental cost-effectiveness ratio was USD $3,830 per QALY and the likelihood of cost-effectiveness was 95%. Conclusions: Intervention with dance twice weekly in addition to usual school health services may be considered cost-effective compared with usual school health services alone, for adolescent girls with internalizing problems.Trial registrationName of the trial registry: “Influencing Adolescent Girls’ With Creative Dance Twice Weekly”Trial registration number: NCT01523561