Disability and health care costs in the Medicare population

OBJECTIVE: To determine the effect of activity limitations on health care expenditures. DESIGN: Cross-sectional. SETTING: National survey. PARTICIPANTS: Data from the 1997 Medicare Current Beneficiary Survey (n=9298), a nationally representative sample of community-dwelling Medicare beneficiaries who were older than 64 years of age. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The impact of patient disability on health care costs (inpatient, outpatient, skilled nursing facility, home health, medications). Activity limitations were determined by patient assessment of restrictions in activities of daily living (ADLs). RESULTS: Over 20% (n=6,500,000) of the entire Medicare population had at least 1 health-related activity limitation. Total median health care costs per year (interquartile range [IQR]) increased as the number of these limitation increased (0 ADLs: $1934 [IQR, $801-$4761]; 1-2 ADLs: $4540 [IQR, $1744-$12,937]; 3-4 ADLs: $7589 [IQR, $2580-$23,149]; 5-6 ADLs: $14,399 [IQR, $5425-$33,014]). After adjusting for confounding characteristics including the impact of comorbid illnesses, Medicare enrollees incurred higher health care costs as their number of activity limitations increased (0 ADLs: cost ratio=1.0; 1-2 ADLs: cost ratio=1.4 [95% confidence interval (CI), 1.2-1.6]; 3-4 ADLs: cost ratio=1.6 [95% CI, 1.3-2.0]; 5-6 ADLs: cost ratio=2.3 [95% CI, 1.7-3.2]). The cost increases were because of an increase in the frequency of all events (eg, hospital admissions, outpatient visits) rather than an increase in the intensity or cost of those events. In addition, with increasing activity limitations, there was a significant increase in the proportional impact of home health costs such that, for those with 5 or 6 limitations, home health costs exceeded the cost of outpatient visits. CONCLUSIONS: Activity limitation is an independent risk factor for increased health care costs and appears to be more than just a proxy for chronic illness.     

Measuring the direct healthcare costs of a fall injury event

BACKGROUND: Falls are a leading cause of injury in older adults. Obtaining cost data for a randomized controlled trial aimed at preventing falls was problematic, and an approach was needed to obtain these data on a relatively small sample of women who used healthcare services. APPROACH: The study population was 272 community-dwelling women aged 70 and over who were participants in a fall prevention trial. Fall incident reports and billing records were used to obtain costs associated with outpatient visits, emergency department visits, acute care hospitalizations, nursing home stays, home healthcare visits, rehabilitation visits, and ambulance use. Average time and costs for obtaining fall-related healthcare cost data also were estimated. RESULTS: The mean age of those with falls requiring healthcare utilization was 78.9 years (SD = 5.1 years). Billing records were obtained for 47 of 55 injurious falls (85%). Costs ranged from $63 to $85,984, with a mean cost of $6,606 and a median cost of $658 per fall-related injurious event. The average time it took to collect the data was just over 5 hr per fall, with an estimated data collection cost of $170 per fall. DISCUSSION: The mean cost of falls was higher than seen in other studies, although methods differ. Collecting cost data related to a specific fall injury event directly from study participants was feasible, practical, and relatively inexpensive. Direct costs of injurious falls are greater than have been estimated in previous studies.     

“Home monitoring” for early detection of implantable cardioverter-defibrillator failure

Background  Telemedical ICD monitoring has the potential to enhance patient safety. The “home-monitoring” (HM) feature transmits selected device-related data to a service-center via mobile phone network. In case of a potential emergency situation, event reports are generated automatically. This prospective observational study was designed to test whether HM is effective and reliable in early detection of device failure. Methods  Consecutive patients receiving ICD, CRT-D or CRT pacemaker systems with HM feature were included. Regular follow-up visits were performed 1, 3, 6, 9 and 12 months after implantation in the first year, and every 6 months thereafter. All event reports transmitted by HM were analyzed and severe device-related events (serious lead or device dysfunction, hospitalization, death) were documented including timing, type and mode of detection. Results  Sixty-nine patients were included and followed for 18 ± 9 months. A total of 206 event reports were transmitted, prompted by VF/VT-episodes (n = 193), ineffective ICD shocks (n = 7), abnormal pacing impedance (n = 4) or battery depletion (n = 2). 8 SAEs were observed (RV lead fracture; n = 5, connector defect; n = 1, sensing defect, n = 1, RV lead dislodgement, n = 1). There was no device-related death. 6 out of 8 SAEs were discovered by HM (sensitivity, 75%). Without HM, these events would have been detected with a theoretical delay of 1.9 ± 0.5 months in the first year (3 monthly FU) and 4.9 ± 0.5 months in the following years (6 monthly FU). Conclusions  This pilot study demonstrates that HM enables early detection of ICD failure and appears to enhance patient safety. Melanie Hauck, Alexander Bauer: both authors contributed equally to this work.     

Atrial Automatic Tachycardia-Reversion Pacemakers: Their Economic Viability and Impact on Quality-of-Life

Refractory supraventricular tachyarrhythmias may be both difficult and costly to control medically and can interfere with the patient's lifestyle. Newer treatment modalities are available for their management, and these require comprehensive assessment. We therefore compared costs and selective indices of patient benefit in a group of 17 patients in whom an atrial antitachycardia (Intermedics Intertach 262–12) pacemaker was placed for refractory supraventricular tachyarrhythmias. Prior medical therapy was compared to subsequent automatic antitachycardia pacemaker treatment. The total medical costs (admissions, emergency room visits, office visits, and medication costs) and the number of hospitalizations and medications were compared prior to implantation (F/U 69.3 ± 61 months) and after implantation (F/U 15.3 ± 7.8 months). A detailed quality-of-life questionnaire was also obtained 36.6 ± 11 months after implantation. Results: There were significant per patient differences in total cost before and after implantation: monthly costs were $505 ±$833 before pacemaker implantation and $105 ±$117 monthly afterward (P < 0.005). Pacemaker implantation hospitalization costs were $19,063 ±$8,362. Monthly medication costs averaged $46 before versus $15 after implantation (P < 0.01). The number of medication types also differed with an average 5.5 medication types per patient before versus 1.2 after implantation (P < 0.001). There were 8.6 yearly hospital admissions in the whole group before implantation, versus 4.7 admissions in the group per year thereafter. Patients demonstrated significant improvement in 80% of the quality-of-life parameters studied. Conclusion: Adjunctive atrial automatic tachycardia-reversion pacemaker therapy may be cost-competitive over time when compared to medical therapy alone in patients with refractory supraventricular tachyarrhythmias and appears to improve overall quality-of-life.     

Economic analysis of finasteride: a model-based approach using data from the Proscar Long-Term Efficacy and Safety Study.

Benign prostatic hyperplasia (BPH) is one of the most common medical conditions in older men in the United States. BPH is often associated with a reduction in quality of life and may progress to acute urinary retention (AUR), the inability to pass any urine. Recently, a 4-year placebo-controlled clinical trial known as the Proscar Long-Term Efficacy and Safety Study (PLESS) demonstrated that finasteride use reduces the risk of developing AUR by 57% and the need for BPH-related surgery by 55%. The economic implications of these findings were investigated using a model-based decision-analytic approach to compare finasteride with both watchful waiting and alpha-blocker therapy. The modeling used the longest-term published controlled data concerning alpha-blockers, which were for the alpha-blocker terazosin. The base case considered a 64-year-old man (the mean age of a PLESS patient) with prostatic enlargement on digital rectal examination and moderate-to-severe symptoms of BPH. The model suggested savings in surgical and AUR costs with finasteride versus watchful waiting, with an estimated 25% of total finasteride costs recouped in savings on surgical events avoided in the first year. Over 2 years, the expected cost per patient starting finasteride therapy was $2304, whereas the expected cost per patient starting terazosin was $2334. Analyses also explored the variation in economic results by baseline levels of prostate-specific antigen (PSA), a proxy for prostate volume. For patients with PSA levels > or =1.4 ng/mL, expected 2-year costs with finasteride and terazosin were $2342 and $2479, respectively. For patients with PSA levels > or =3.3 ng/mL, expected 2-year costs with finasteride were $373 less than with terazosin ($2347 vs $2720). Results were robust over a range of model assumptions and cost estimates. The analyses illustrate that all medical interventions, including watchful waiting, have associated costs. Finasteride shows cost offsets compared with watchful waiting and cost savings compared with terazosin over 2 years. Finasteride appears to be more economical in men with higher PSA levels.     

Cost-effectiveness analysis of bevacizumab combined with chemotherapy for the treatment of metastatic colorectal cancer in Japan

BACKGROUND: Rapid progress has been made in the treatment of metastatic colorectal cancer (mCRC). New treatment regimens for mCRC include not only cytotoxic chemotherapy but also targeted monoclonal antibodies, including bevacizumab. However, bevacizumab is an expensive medication, which costs from 300,000 yen to 400,000 yen (US $2500-$3300) per month. OBJECTIVE: The purpose of this cost-effectiveness analysis was to examine the economic efficiency of treating mCRC with bevacizumab plus chemotherapy versus chemotherapy alone in Japan. METHODS: We searched an electronic database (MEDLINE, UpToDate, and American Society of Clinical Oncology [ASCO] Virtual Meeting; key terms: bevacizumab limited to randomized controlled trial; years: 2000 to present [June 29, 2007]) to detect randomized controlled trials (RCTs) that compared chemotherapy alone with chemotherapy plus bevacizumab. To analyze the cost-effectiveness of bevacizumab, we used the Weibull regression model and determined an expected treatment duration at each state using reported survival curves of RCTs. We included only the direct medical costs (2006) of these medications to estimate the expected values of incremental costs; thus, the analysis was conducted from the perspective of the health care payer. The incremental cost-effectiveness ratios (ICERs) were calculated from these expected values of incremental life-years and incremental costs. RESULTS: We identified 5 articles using MEDLINE and 1 trial found on UpToDate and ASCO Virtual Meeting; these data composed the final analysis group. First-line chemotherapy regimens included in this analysis were bevacizumab + 5-fluorouracil/leucovorin (FU/LV), irinotecan/FU/LV (IFL), infusional FU/LV/ oxaliplatin (FOLFOX6), bolus FU/LV/oxaliplatin (bFOL), and capecitabine/oxaliplatin (CAPOX). The only second-line chemotherapy regimen included was FOLFOX4. The ICERs of additional bevacizumab when combined with FU/LV,IFL,FOLFOX6, bFOL, and CAPOX were 17.4 million yen (US $145,000), 11.9 million yen ($99,000), 13.5 million yen ($113,000), 16.9 million yen ($141,000), and 8.5 million yen ($71,000), respectively, per life-year gained; the ICER was 14.1 million yen ($118,000) with second-line FOLFOX4. CONCLUSIONS: In this cost-effectiveness analysis in Japan, the ICERs of bevacizumab + FU/LV combination treatment, IFL, and second-line FOLFOX4 were high compared with other chemotherapies for mCRC. It remains difficult to assess first-line therapies comprising bevacizumab with oxaliplatin-based regimens, especially CAPOX. Further information is needed to assess cost-effectiveness.     

Examining the utility of in-clinic "rescue" therapy for acute migraine

Background.— Management options currently are limited for patients with acute migraine whose symptoms prove refractory to self‐administered therapy. Objective.— To evaluate the clinical utility and cost‐effectiveness of a management program offering in‐clinic “rescue” treatment for patients with acute migraine. Methods.— Two hundred consecutive migraine patients presenting to a university‐based headache clinic were randomized to receive either optimal self‐administered medical therapy for acute migraine (“standard therapy”) or similar therapy plus the option of in‐clinic parenteral drug administration should self‐administered therapy prove ineffective (“rescue therapy”). Patients randomized to the latter group were restricted to a maximum of 2 “rescue visits” per month, and all patients were followed for one year. Patients “rescued” in clinic were contacted by telephone 24 hours following treatment to evaluate their treatment response. The primary analysis involved a comparison of the number of emergency department (ED) visits for headache recorded within each group over the one‐year period of study. For all ED visits in the rescue group and for a randomly selected and equal number of ED visits within the standard group, the direct costs associated with those visits were assessed, and the direct costs of all in‐clinic rescue visits also were recorded and analyzed. Results.— The 2 groups studied were similar in terms of age, gender ratio, migraine subtype, migraine‐related disability status at baseline and type/extent of medical insurance coverage. Over the one‐year study period, the rescue group recorded 423 in‐clinic rescue visits and reported 27 ED visits for headache treatment. The standard therapy group reported 73 ED visits (27 vs 73 visits; P < .01). The total direct costs associated with ED visits were $45,330 for the rescue group (mean $1690 per ED visit) and (by extrapolation from the sample selected) $147,971 for the standard therapy group (mean $2027 per ED visit). The total direct cost of the 423 “rescue visits” was $33,647 (mean $80 per visit). In 79% of the 423 rescue encounters, the patients involved reported no residual functional disability 24 hours following treatment. Of those in the rescue group who sought in‐clinic rescue, 89% reported themselves “very satisfied” with such management. Conclusion.— Providing the alternative of in‐clinic “rescue” for acute migraine refractory to self‐administered therapy offers an attractive alternative for patients and appears to substantially lower use of an ED for headache treatment and the cost associated with that use.     

Reducing the cost of frequent hospital admissions for congestive heart failure: a randomized trial of a home telecare intervention

BACKGROUND: The high cost of caring for patients with congestive heart failure (CHF) results primarily from frequent hospital readmissions for exacerbations. Home nurse visits after discharge can reduce readmissions, but the intervention costs are high. OBJECTIVES: To compare the effectiveness of three hospital discharge care models for reducing CHF-related readmission charges: 1) home telecare delivered via a 2-way video-conference device with an integrated electronic stethoscope; 2) nurse telephone calls; and 3) usual outpatient care. RESEARCH DESIGN: One-year randomized trial. SUBJECTS: English-speaking patients 40 years of age and older with a primary hospital admission diagnosis of CHF. MEASURES: Our primary outcome was CHF-related readmission charges during a 6-month period after randomization. Secondary outcomes included all-cause readmissions, emergency department (ED) visits, and associated charges. RESULTS: Thirty-seven subjects were randomized: 13 to home telecare, 12 each telephone care and 12 to usual care. Mean CHF-related readmission charges were 86% lower in the telecare group ($5850, SD $21,094) and 84% lower in the telephone group ($7320, SD $24,440) than in the usual care group ($44,479, SD $121,214). However, the between-group difference was not statistically significant. Both intervention groups had significantly fewer CHF-related ED visits (P = 0.0342) and charges (P = 0.0487) than the usual care group. Trends favoring both interventions were noted for all other utilization outcomes. CONCLUSIONS: Substantial reductions in hospital readmissions, emergency visits, and cost of care for patients with CHF might be achieved by widespread deployment of distance technologies to provide posthospitalization monitoring. Home telecare may not offer incremental benefit beyond telephone follow-up and is more expensive.     

Alternative Measures of Resource Consumption in Home Care Episodes

Expected changes in home health care reimbursement will require a shift in focus from a visit-based unit to some other yet-to-be-defined unit of resource consumption. Little research has been done to understand other measures of resource consumption, however, especially those examining disciplinary differences. The purpose of this study was to provide empirical evidence on other measures of resource consumption as a way to frame discussions on alternative measures. Information is presented from a study of 102 home health care patients from 10 agencies in Ohio who completed an episode of care and remained at home. While the mean time per visit was similar for all disciplines (46 to 55 minutes), there were differences in the number of visits provided by various disciplines (home care aide services had the highest mean number of visits with 11.8). The mean cost per day for all services was $43.80 while the mean cost per episode was $1,160. Recommendations for further research include similar examinations using a more rigorous sampling methodology and including disparate populations of patients.     

Treatment cost of acute exacerbations of chronic bronchitis.

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients aged > or =65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged <65 years. We calculated a total treatment cost of $1.2 billion for patients aged > or =65 years and $419 million for patients aged <65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $1.1 billion for the 207,540 patients aged > or =65 years, and $408 million for the 73,299 patients aged <65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients aged > or =65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those aged > or =65 years and 237,000 visits for those aged <65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those aged > or =65 years and 4.2 million visits for those aged <65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.     

Costs of postpartum care: examining associations from the Ontario mother and infant survey.

A cross-sectional survey of 1,250 mothers of "normal" newborn infants was conducted to assess mother and infant characteristics as well as the costs of health and social services used in the first 4 weeks after discharge from hospital in the province of Ontario, Canada. Each mother was asked to recall use of services for herself and her infant. This utilization was multiplied by the unit cost of each service and summed to arrive at the total cost of services used. Although re-admission rates were low (1% for mothers, 4% for infants), costs associated with hospital and emergency room care ($194 on average per mother/infant dyad) accounted for the greatest proportion of total health-care costs. Physician or midwife visits, which were received by almost all mothers, were the next most costly service ($128 on average per dyad). Mothers with incomes under $20,000 had more medical costs than those with higher incomes. Costs of community nursing care ($86 on average per dyad) were higher for mothers with more than 5 self-identified learning needs (e.g., infant feeding, infant care and behaviour, emotional changes in self, signs of illness in infant); perception of their own health as poor; perception of inadequate help and support at home; many signs and symptoms of depression; and postpartum hospital stay of 48 hours or less. Costs for social work visits were higher for mothers with depression and mothers with low incomes. Total health and social service costs were double for mothers with family incomes under $20,000 ($788 vs. $399 on average per dyad) and for mothers with clinical depression ($845 vs. $413). Specifically, nursing care costs were greater for mothers with high depression scores ($135 vs. $81).     

The emergency care model: A new paradigm for skilled nursing facilities

The population of individuals age 65 and older is increasing in the United States. One third of these individuals will utilize nursing home care before death. Nursing home residents (“NHR”) average 1.8 emergency department visits annually. Improving the quality of nursing home care is of vital importance. This project describes a new paradigm for the management of acute emergent health issues affecting NHR. The model features a multidisciplinary team coordinated by emergency providers resulting in a 55% reduction in unplanned hospital admissions compared to skilled nursing facility regional data. Additionally, a reduction in ancillary lab costs was observed. Implementation of this paradigm on a national scale could result in a projected cost savings in excess of $10 billion per year for the Center for Medicare and Medicaid Services (“CMS”).     

Home blood pressure monitoring. Effect on use of medical services and medical care costs.

The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BP) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patient's BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8, 1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was $88.76 per patient per year in the Home BP group, 29% less than in the UC group (95% CI: $16.11, $54.74). The annualized cost of implementing the home BP system was approximately $28 per patient during the study year and would currently be approximately $15. After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups. Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings.     

Impact of Chest Pain on Cost of Migraine Treatment With Almotriptan and Sumatriptan

Chest-related symptoms occur with all triptans; up to 41% of patients with migraine who receive sumatriptan experience chest symptoms, and 10% of patients discontinue treatment. Thus, the cost of chest pain-related care was estimated in migraineurs receiving almotriptan 12.5 mg versus sumatriptan 50 mg. A population-based, retrospective cohort study used data to quantify the incidence and costs of chest pain-related diagnoses and procedures. An economic model was constructed to estimate annual cost savings per 1000 patients receiving almotriptan versus sumatriptan based on the reported rates of chest pain. Annual direct medical cost avoided was calculated for a hypothetical health plan covering 1 million lives. Among a cohort of 1390 patients, the incidence of chest pain-related diagnoses increased significantly by 43.6% with sumatriptan ( P =.003). Aggregate costs for chest pain-related diagnoses and procedures increased from $22  713 to $30  234. Payments for inpatient hospital services, costs for primary care visits, and costs for outpatient hospital visits increased by over 100%, 53.1%, and 14.4%, respectively. The model predicted $11  215 in direct medical cost savings annually per 1000 patients treated with almotriptan versus sumatriptan. Annual direct medical costs avoided totaled $194 358, and when applied to recent estimates of 86 million lives currently covered by almotriptan treatment, translates into an annual cost savings of just under $17 million for chest pain and associated care. Thus, using almotriptan in place of sumatriptan will likely reduce the cost of chest pain-related care.     

Remote, Wireless, Ambulatory Monitoring of Implantable Pacemakers, Cardioverter Defibrillators, and Cardiac Resynchronization Therapy Systems: Analysis of a Worldwide Database

Study Objective: To describe the daily routine application of a new telemonitoring system in a large population of cardiac device recipients.
Methods: Data transmitted daily and automatically by a remote, wireless Home Monitoring™ system (HM) were analyzed. The average time gained in the detection of events using HM versus standard practice and the impact of HM on physician workload were examined. The mean interval between device interrogations was used to compare the rates of follow-up visits versus that recommended in guidelines.
Results: 3,004,763 transmissions were made by 11,624 recipients of pacemakers (n = 4,631), defibrillators (ICD; n = 6,548), and combined ICD + cardiac resynchronization therapy (CRT-D) systems (n = 445) worldwide. The duration of monitoring/patient ranged from 1 to 49 months, representing 10,057 years. The vast majority (86%) of events were disease-related. The mean interval between last follow-up and occurrence of events notified by HM was 26 days, representing a putative temporal gain of 154 and 64 days in patients usually followed at 6- and 3-month intervals, respectively. The mean numbers of events per patient per month reported to the caregivers for the overall population was 0.6. On average, 47.6% of the patients were event-free. The mean interval between follow-up visits in patients with pacemakers, single-chamber ICDs, dual chamber ICDs, and CRT-D systems were 5.9 ± 2.1, 3.6 ± 3.3, 3.3 ± 3.5, and 1.9 ± 2.9 months, respectively.
Conclusions: This broad clinical application of a new monitoring system strongly supports its capability to improve the care of cardiac device recipients, enhance their safety, and optimize the allocation of health resources.     

The lifetime risks and costs of nursing home use among the elderly

In this paper, we estimate the risk of an individual of entering a nursing home throughout the aging process. We then estimate the expected lifetime costs of nursing home use both for an individual and for society as a whole. The model is based on double-decrement life-table analysis. Data are taken from a 1977 survey of 4,400 Medicare beneficiaries. At age 65, the upper bound for the lifetime risk of entering a nursing home is 43.1%. The risk of entering a nursing home increases with age until around age 80. At about age 85, the risk begins to decline significantly. At almost all ages, the lifetime risk of entry for females is twice that of males. The expected lifetime costs of nursing home care across all ages are between $10,500 and $13,600. These costs are distributed very unequally. Only 13% of the elderly account for 90% of all nursing home expenditures. Given current life expectancy, the expected annual cost per person over age 65 is between $532 and $760. In the year 2000, the expected annual average costs of nursing home care per elderly person will range from $450 to $650. The decline in the average annual cost per person reflects shifts in the age structure and increased life expectancy. These figures need not represent an unmanageable burden on society's resources. Figures presented here help establish the feasibility and desirability of long-term care risk-sharing arrangements among the elderly, like long-term care insurance, life care communities, and other models.     

Modelled economic evaluation of a virtual emergency department in Victoria

Objective

Virtual ED (VED) can potentially alleviate ED overcrowding which has been a public health challenge. The aim of the present study was to conduct a return-on-investment analysis of a VED programme developed in response to changing healthcare needs in Australia.

Methods

An economic model was developed based on initial patient outcome data to assess the healthcare costs, potential costs saved and return on investment (ROI) from the VED. The VED programme operating as part of Alfred Health Emergency Services. The participants were the first 188 patients accessing the Alfred Health VED. VED is the delivery of emergency assessment and management of specific patients virtually via audio-visual teleconferencing. ROI ratios that compare cost savings with intervention costs.

Results

The mean total operational cost of VED for 79 days for 188 patients was A$344 117 (95% uncertainty interval [UI] $296 800–$392 088). The VED led to a potential A$286 779 (95% UI $241 688–$330 568) healthcare cost saving from reductions in emergency visits and A$97 569 (95% UI $74 233–$123 117) cost saving in ambulance services. The ROI ratio was estimated at 1.12 (95% UI 0.96–1.32).

Conclusions

The VED was cost neutral in a conservatively modelled scenario but promising if any hospital admission could be saved. Ongoing research examining a larger cohort with community follow up is required to confirm this promising result.     

Cost-effectiveness of including cromolyn sodium in the treatment program for asthma: a retrospective, record-based study

The treatment of chronic mild to moderately severe asthma is expensive for families and for society. Controlling the costs of asthma-related medications, physician visits, emergency room visits, and hospital admissions is therefore an important consideration. A retrospective, record-based study was undertaken to determine the costs of treating asthma in patients for whom cromolyn sodium was included in the routine treatment plan (n = 27) and those for whom treatment did not include cromolyn sodium (n = 26). Significant reductions in the number of emergency room visits and hospital admissions were obtained in patients who were treated with cromolyn sodium. The estimated average cost of emergency room visits was $33 a year for the patients given cromolyn sodium compared with $624 a year for patients in the comparison group. The estimated average cost of hospital admissions was reduced by $1,298 for the cromolyn sodium group compared with a $357 reduction for the comparison group. Computed for the entire course of treatment, the average (+/- SD) daily cost of medications for the comparison group was $0.84 +/- $0.37 versus $0.93 +/- $0.25 for the cromolyn sodium treatment group. Thus dramatic savings in costs of emergency room visits and hospitalizations when cromolyn sodium was included in therapy were effected at a small increase in the overall cost of medications. Analyzed visit by visit, the average daily cost of treatment that included cromolyn sodium decreased while that of the comparison group increased. We conclude that including cromolyn sodium in a regular anti-asthma regimen is a cost-effective and therapeutically effective treatment strategy.