Developing and applying a costing tool for hypertension and related cardiovascular disease: Attributable costs to salt/sodium consumption

This paper proposes a costing tool for hypertension and cardiovascular disease by adapting cost‐of‐illness methodologies to estimate the attributable burden of excessive salt intake on cardiovascular disease. The methodology estimates the changes in blood pressure that result from each gram change in salt intake and links diet to the direct and indirect costs of cardiovascular diseases (CVD), such as coronary heart disease, stroke, hypertensive disease, aortic aneurysm, heart failure, pulmonary embolism, and rheumatic heart, using the relative risks of disease and the prevalence of salt consumption in the population. The methodology includes (a) identifying major diseases and conditions related to excessive salt intake and relevant economic cost data available, (b) quantifying the relationship between the prevalence of excessive salt intake and the associated risk of disease morbidity and mortality using population attributable risks (PAR), (c) using PARs to estimate the share of total costs directly attributed to excessive salt intake, and (d) undertaking a sensitivity analysis of key epidemiological and economic parameters. The costing tool has estimated that, in 2013, US$ 102.0 million (95% uncertainty interval—UI: US$ 96.2‐107.8 million) in public hospitalizations could be saved if the average salt intake of Brazilians were reduced to 5 g/d, corresponding to 9.4% (95% UI: 8.9%‐9.9%) of the total hospital costs by CVDs. This methodology of cost of illness associated with salt consumption can be adapted to estimate the burden of other dietary risk factors and support prevention and control policies in Brazil and in other countries.     

Methods for the costing process in the field of economic evaluation of a rehabilitation program for patients with chronic obstructive lung diseases

Studies in health economics especially economic evaluations of health care technologies and programmes are getting more and more important. However, in Germany there are no established, validated and commonly used instruments for the costing process. For the economic evaluation of a rehabilitation programme for patients with chronic lung diseases such as asthma and chronic bronchitis we developed methods for identification, measurement and validation of resource use during the inpatient rehabilitation programme and during the outpatient follow-up period. These methods are based on methodological considerations as well as on practical experience from conducting a pilot study. With regard to the inpatient setting all relevant diagnostic and therapeutic resource uses could be measured basing on routine clinical documentation and validated by using the cost accounting of the clinic. For measuring the use of resources during the follow-up period in an outpatient setting no reliable administrative data are accessible. Hence, we compared a standardised retrospective patient questionnaire used in a 20-minute interview (n = 50) and a cost diary for the continuing documentation by the patient over a period of 4 weeks (n = 50). Both tools were useful for measuring all relevant resource uses in sufficient detail, but because of higher participation rates and lower dropouts the structured interview appears to be more suitable. Average total costs per month were 1591 DM (interview), respectively 1867 DM (cost diary). Besides productivity loss, costs for medication and GP visits caused the relatively highest resource uses. Practicable instruments were developed for the costing process as part of an economic evaluation in a German rehabilitation setting for pulmonary diseases. After individual modification, these could also be used for different indications and in other institutional settings.     

Costs of a home-based rehabilitation program for older adults after lower limb orthopedic surgery: a pilot study

Little is known about the cost of home-based rehabilitation programs in Quebec, Canada. The objective of this pilot project was to test a cost estimation methodology in the context of rehabilitation services delivered at home and to provide preliminary data on the costs for lower limb orthopedic surgery patients. This pilot study examined a short-term home care program for adults, aged 65 and over who returned home after lower limb surgery and required rehabilitation services. Efficacy was determined as the functional autonomy changes between admission and discharge from home rehabilitation program, as measured by the functional autonomy measurement system (SMAF). Costs of professionals, including direct and indirect time related to the intervention, were also determined in order to document cost-effectiveness of the program. Eighteen subjects were recruited. From those, 14 had complete data available for the analysis. The result shows that costs related to the combined natural improvement and the effect of the home-based rehabilitation program were CAN dollars 419 per unit of change of functional autonomy. The results of this pilot study confirm the feasibility of the cost estimation methodology for a home-based rehabilitation program.     

Implementation of a community‐based hypertension control program in Matanzas,Cuba

Increased blood pressure is a leading risk factor for death worldwide, and improving the control of hypertension is a major health goal to reduce non‐communicable disease. Thus, in 2016, as part of a regional effort between the Pan American Health Organization and Cuban Ministry of Public Health to reduce cardiovascular risk and disease, a community demonstration project was implemented to enhance hypertension control. The intervention project was in a population of 25 868 people served by the Carlos Verdugo Martínez Polyclinic in Matanzas, Cuba. The project implemented interventions currently recommended in the World Health Organization HEARTS modules, including a standardized clinical training program with certification for blood pressure measurement, routine screening for hypertension in clinics and in the community, a simple directive pharmacologic treatment algorithm, and a registry with performance reporting and feedback. Qualitative and quantitative program monitoring and evaluation was established. In a 2010 national survey, the prevalence of hypertension and the rate of hypertension control were estimated to be 31% and 36%, respectively. Following less than one year of the full implementation of the program, the prevalence of hypertension, proportion of the hypertensive population registered as having hypertension, proportion of those drug‐treated who were controlled, and estimated population rate of control were 30%, 90%, 68%, and 58%, respectively. Based on these positive results, the program has been expanded to include another demonstration program initiated in a second region. In addition, preliminary efforts to disseminate and scale‐up aspects of the program to the full Cuban population have started.     

Financial impact of a home intravenous antibiotic program on a medicare managed care program.

This study quantitates cost savings achieved by a home intravenous antibiotic (HIVA) program in a Medicare managed health care program. In 1998, 66 treatment courses of HIVA therapy were administered for a total of 1542 patient-days of therapy. The calculated cost of HIVA therapy included the actual costs of drugs, supplies, nursing and therapists' salaries, and laboratory studies. Savings were calculated based on the average daily direct variable cost (DDVC) for hospital acute unit or skilled nursing facility (SNF) care associated with the patient's discharge diagnosis-related-group. The number of days on HIVA therapy was assumed to equal the number of days in the hospital acute unit or hospital-based SNF. The average cost per day of HIVA therapy was $122, whereas average DDVC of hospital acute unit care was $798, and the average DDVC of SNF care was $541. In 1 year, the HIVA program saved our health care system $646,000-$834,000, which demonstrates that HIVA programs are powerful tools to reduce costs in Medicare managed health care programs.     

Cost Analysis of Tests for the Detection of Schistosoma mansoni Infection in Children in Western Kenya

Financial resources tend to be limited in schistosomiasis endemic areas, forcing program managers to balance financial and scientific considerations when selecting detection assays. Therefore, we compared the costs of using single stool Kato-Katz, triplicate stool Kato-Katz, and point-of-contact circulating cathodic antigen (POC-CCA) assays for the detection of Schistosoma mansoni infection. Economic and financial costs were estimated from the viewpoint of a schistosomiasis control program using the ingredients approach. Costs related to specimen collection, sample processing and analysis, and treatment delivery were considered. Analysis inputs and assumptions were tested using one-way and two-way sensitivity analysis. The total per-person cost of performing the single Kato-Katz, triplicate Kato-Katz, and POC-CCA was US$6.89, US$17.54, and US$7.26, respectively. Major cost drivers included labor, transportation, and supplies. In addition, we provide a costing tool to guide program managers in evaluating detection costs in specific settings, as costs may vary temporally and spatially.     

Cost of allogeneic blood transfusion

Blood is a scarce and costly resource to society. Therefore, it is important to understand the costs associated with blood, blood components, and blood transfusions. Previous studies have attempted to account for the cost of blood but, because of different objectives, perspectives, and methodologies, they may have underestimated the true (direct and indirect) costs associated with transfusions. Recognizing these limitations, a panel of experts in blood banking and transfusion medicine gathered at the Cost of Blood Consensus Conference to identify a set of key elements associated with whole blood collection, transfusion processes, follow-up, and to establish a standard methodology in estimating costs. Activity-based costing (ABC), the proposed all-inclusive reference methodology, is expected to produce standard and generalizable estimates of the cost of blood transfusion, and it should prove useful to payers, buyers, and society (all of whom bear the cost of blood). In this article, we argue that the ABC approach should be adopted in future cost-of-transfusion studies. In particular, we address the supply and demand dilemma associated with blood and blood components; evaluate the economic impact of transfusion-related adverse outcomes on overall blood utilization; discuss hemovigilance as it contributes not to the expense, but also the safety of transfusion; review previous cost-of-transfusion studies; and summarize the ABC approach and its utility as a methodology for estimating transfusion costs.     

Cost effectiveness of a smoking cessation program in patients admitted for coronary heart disease.

BACKGROUND: Smoking cessation is probably the most important action to reduce mortality after a coronary event. Smoking cessation programs are not widely implemented in patients with coronary heart disease, however, possibly because they are thought not to be worth their costs. Our objectives were to estimate the cost effectiveness of a smoking cessation program, and to compare it with other treatment modalities in cardiovascular medicine. METHODS: A cost-effectiveness analysis was performed on the basis of a recently conducted randomized smoking cessation intervention trial in patients admitted for coronary heart disease. The cost per life year gained by the smoking cessation program was derived from the resources necessary to implement the program, the number needed to treat to get one additional quitter from the program, and the years of life gained if quitting smoking. The cost effectiveness was estimated in a low-risk group (i.e. patients with stable coronary heart disease) and a high-risk group (i.e. patients after myocardial infarction or unstable angina), using survival data from previously published investigations, and with life-time extrapolation of the survival curves by survival function modeling. RESULTS: In a lifetime perspective, the incremental cost per year of life gained by the smoking cessation program was euro 280 and euro 110 in the low and high-risk group, respectively (2000 prices). These costs compare favorably to other treatment modalities in patients with coronary heart disease, being approximately 1/25 the cost of both statins in the low-risk group and angiotensin-converting enzyme inhibitors in the high-risk group. In a sensitivity analysis, the costs remained low in a wide range of assumptions. CONCLUSIONS: A nurse-led smoking cessation program with several months of intervention is very cost-effective compared with other treatment modalities in patients with coronary heart disease.     

Cost savings threshold analysis of a capacity-building program for HIV prevention organizations

Although the incidence of HIV each year remains steady, prevention funding is increasingly competitive. Programs need to justify costs in terms of evaluation outcomes, including economic ones. Threshold analyses set performance standards to determine program effectiveness relative to that threshold. This method was used to evaluate the potential cost savings of a national capacity-building program for HIV prevention organizations. Program costs were compared with the lifetime treatment costs of HIV, yielding an estimate of the HIV infections that would have to be prevented for the program to be cost saving. The 136 persons who completed the capacity-building program between 2000 and 2003 would have to avert 41 cases of HIV for the program to be considered cost saving. These figures represent less than one tenth of 1% of the 40,000 new HIV infections that occur in the United States annually and suggest a reasonable performance standard. These data underscore the resources needed to prevent HIV.     

Reducing maintenance and repair costs in an interventional pulmonology program

BACKGROUND: In the current economic climate, hospitals and academic institutions demand that medical departments function in an efficient and cost-effective manner. Detailed business plans are necessary to build new clinical programs, and institutions have learned that new programs are associated with significant costs for purchasing and maintaining equipment. We report our experience with repairs to equipment before and after starting our interventional pulmonary (IP) program, and with the effect of an educational program on reducing these costs. METHODS: We retrospectively studied the costs of equipment repair in the 3 years preceding and in the 5 years following the development of an IP program in our institution, a university-based tertiary referral center. We also studied the effect of an educational program that was designed to enhance the skills of physicians and technical staff in handling the equipment. RESULTS: The cost of repairs to the equipment during the 3 years prior to the development of the IP program was $42 (US dollars) per procedure. In the initial 3 years following the start of the IP program, the yearly average cost rose 21% to $51 per procedure. After the introduction of the educational program, the yearly repair costs decreased by 84% to $8 per procedure. Based on our experience, we estimate that a reasonable budget for the cost of repairs is $50 per procedure. CONCLUSIONS: An educational program was effective in dramatically decreasing the costs of equipment repair after initiating an IP program. This is the first study to offer budgetary guidelines for equipment repair in an IP program and to demonstrate that an educational program can effectively reduce costs.     

The cost-effectiveness of etanercept in patients with severe ankylosing spondylitis in the UK

OBJECTIVES: To examine the costs and benefits associated with long-term etanercept (ETN) treatment in patients with severe ankylosing spondylitis (AS) in the UK in accordance with the BSR guidelines. METHODS: A mathematical model was constructed to estimate the costs and benefits associated with ETN plus non-steroidal anti-inflammatory drugs (NSAIDs) compared with NSAIDs alone. Individual patient data from Phase III RCTs was used to inform the proportion and magnitude of initial response to treatment and changes in health-related quality of life. A retrospective costing exercise on patients attending a UK secondary care rheumatology unit was used to inform disease costs. Published evidence on long-term disease progression was extrapolated over a 25-yr horizon. Uncertainty was examined using probabilistic sensitivity analyses. RESULTS: Over a 25-yr horizon, ETN plus NSAIDs gave 1.58 more QALYs at an additional cost of 35,978 pounds when compared with NSAID treatment alone. This equates to a central estimate of 22,700 pounds per QALY. The incremental cost per QALYs using shorter time periods were 27,600 pounds, 23,600 pounds and 22,600 pounds at 2, 5 and 15 yrs, respectively. Using a 25-yr horizon, 93% of results from the probabilistic analyses fall below a threshold of 25,000 pounds per QALY. CONCLUSIONS: This study demonstrates the potential cost-effectiveness of ETN plus NSAIDs compared with NSAIDs alone in patients with severe AS treated according to the BSR guidelines in the UK.     

To the hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.     

Cost effectiveness of a two-year home exercise program for the treatment of knee pain

OBJECTIVE: To assess the cost effectiveness of a 2-year home exercise program for the treatment of knee pain. METHODS: A total of 759 adults aged > or = 45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using self-reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included. RESULTS: Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were pound 112 for the exercise program and pound 61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the no-exercise groups (mean difference pound 225; 95% confidence interval pound 218, pound 232; P < 0.001). CONCLUSION: Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.     

Economic advantage of a community-based malaria management program in the Brazilian Amazon.

In the Brazilian Amazon, travel costs to centralized malaria clinics for diagnosis and treatment can approach 20% of one's monthly salary. A program was established in a mining town for community-based dipstick test diagnosis and treatment. An economic analysis was performed that compared expected costs under the old program to the observed costs of the new one. Data were obtained through interviews, government reports, clinic and hospital records, and community records. There was a 53% reduction (by 1,219 visits) of clinic visits but a doubling of malaria hospitalization admissions (to 191). The new program had an overall annual savings of $60,900 ($11.8K-$160K, sensitivity limits), a 77% reduction of the old program's cost. The benefit-to-cost ratio was 9:1, where benefits were patients' savings from travel and lost wages and costs were government drug, diagnostic, training, and monitoring expenses. A community-based program incorporating dipstick tests for malaria management can have economic advantages.     

The state of costing research for HIV interventions in sub-Saharan Africa

The past decade has seen a growing emphasis on the production of high-quality costing data to improve the efficiency and cost-effectiveness of global health interventions. The need for such data is especially important for decision making and priority setting across HIV services from prevention and testing to treatment and care. To help address this critical need, the Global Health Cost Consortium was created in 2016, in part to conduct a systematic search and screening of the costing literature for HIV and TB interventions in low- and middle-income countries (LMIC). The purpose of this portion of the remit was to compile, standardise, and make publicly available published cost data (peer-reviewed and gray) for public use. We limit our analysis to a review of the quantity and characteristics of published cost data from HIV interventions in sub-Saharan Africa. First, we document the production of cost data over 25 years, including density over time, geography, publication venue, authorship and type of intervention. Second, we explore key methods and reporting for characteristics including urbanicity, platform type, ownership and scale. Although the volume of HIV costing data has increased substantially on the continent, cost reporting is lacking across several dimensions. We find a dearth of cost estimates from HIV interventions in west Africa, as well as inconsistent reporting of key dimensions of cost including platform type, ownership and urbanicity. Further, we find clear evidence of a need for renewed focus on the consistent reporting of scale by authors of costing and cost-effectiveness analyses.     

The Tuscan Mobile Simulation Program: a description of a program for the delivery of in situ simulation training

Simulation has become a critical aspect of medical education. It allows health care providers the opportunity to focus on safety and high-risk situations in a protected environment. Recently, in situ simulation, which is performed in the actual clinical setting, has been used to recreate a more realistic work environment. This form of simulation allows for better team evaluation as the workers are in their traditional roles, and can reveal latent safety errors that often are not seen in typical simulation scenarios. We discuss the creation and implementation of a mobile in situ simulation program in emergency departments of three hospitals in Tuscany, Italy, including equipment, staffing, and start-up costs for this program. We also describe latent safety threats identified in the pilot in situ simulations. This novel approach has the potential to both reduce the costs of simulation compared to traditional simulation centers, and to expand medical simulation experiences to providers and healthcare organizations that do not have access to a large simulation center.     

Cost-benefit analysis of the tsutsugamushi disease prevention program in South Korea

The purpose of this research was to evaluate the economic value of the tsutsugamushi disease prevention program and to suggest whether to abolish or expand this program. A cost-benefit analysis was conducted to evaluate the economic feasibility of this prevention program. We collected cost data from 25 public health centers (PHCs) and the medical insurance data for all tsutsugamushi patients. We estimated the costs and benefits of the program using a macro-costing method. The estimated total cost was $1.22 million with a governmental cost of $697,000 and a cost of $521,000 to the PHCs. After the prevention program was implemented, $581 were salvaged from medical costs, $46 from non-medical costs, and $847 from productivity loss due to the reduced number of patients, with an estimated $6.66 million per year in total benefits of the program. The ratio of benefit to cost was found to be 5.5, making the economic value of the program significant. The net benefit should increase if the tsutsugamushi disease prevention program is continued and the implementation period is expanded to 10 years.