The Direct Medical Costs of Undiagnosed Chronic Obstructive Pulmonary Disease

Objective:  To estimate the costs of undiagnosed chronic obstructive pulmonary disease (COPD) by describing inpatient, outpatient, and pharmacy utilization in the years before and after the diagnosis.
Methods:  A total of 6864 patients who were enrolled in the Lovelace Health Plan for at least 12 months during the study period (January 1, 1999 through December 31, 2004) were identified. The first date that utilization was attributed to COPD was considered the first date of diagnosis. Each COPD case was matched to up to three age- and sex-matched controls. All utilization and direct medical costs during the study period were compiled monthly and compared based on the time before and after the initial diagnosis.
Results:  Total costs were higher by an average of $1182 per patient in the 2 years before the initial COPD diagnosis, and $2489 in the 12 months just before the initial diagnosis, compared to matched controls. Most of the higher cost for undiagnosed COPD was attributable to hospitalizations. Inpatient costs did not increase after the diagnosis was made, but approximately one-third of admissions after the diagnosis were attributed to respiratory disease. Outpatient and pharmacy costs did not differ substantially between cases and matched controls until just a few months before the initial diagnosis, but remained 50% to 100% higher than for controls in the 2 years after diagnosis.
Conclusions:  Undiagnosed COPD has a substantial impact on health-care costs and utilization in this integrated managed care system, particularly for hospitalizations.     

Assessment of Total Economic Burden of Chronic Hepatitis B (CHB)-Related Diseases in Beijing and Guangzhou, China

Objective:  To estimate the total annual cost due to Chronic Hepatitis B (CHB)-related diseases imposed on each patient and his/her family in Beijing and Guangzhou, China.
Methods:  Economic burden of CHB-related diseases (CHB, compensated cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma) were examined. A retrospective cohort of 328 patients in Beijing and 271 in Guangzhou were identified to obtain their socioeconomic status, utilization and costs of treatment, and work loss days due to illness with a structured questionnaire. Costs of hospitalization were extracted from databases of two hospitals in Beijing and Guangzhou Social Insurance Information System, respectively. The outpatient expenditure per patient was measured through the rate of outpatient visits and average cost per visit reported by the patients, while the inpatient cost was calculated through annual rate of hospitalization and average expenditure for different types of hospitals. Self medication and direct nonmedical cost were also reported. The Human Capital Approach was employed to measure the work loss cost.
Results:  The total annual cost per patient for CHB, compensated cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma were US$1636, US$2722, US$4611, and US$6615 in Beijing, and US$1452, US$2065, US$4290 and US$6054 in Guangzhou, respectively.
Conclusion:  This study confirms that CHB-related diseases impose a substantial economic burden on patients, families, and the society in China urban areas. The study demonstrates increasing health-care costs related to disease progression and provides useful information on cost of treatment and work loss for different disease states, which can be further utilized in cost-effectiveness evaluation.     

Service Utilization and Health-Care Costs in the Advanced Elderly

Objectives:  Despite their increasing importance, the advanced elderly are often neglected in service utilization and costing studies. The purpose of this study was to analyze from societal perspective service utilization and direct health-care costs and its predictors in the advanced elderly population.
Methods:  A bottom-up costing study was conducted using a cross-sectional primary care sample aged 75+ (n = 452) in Germany. The main instruments were a questionnaire of service utilization and costs administered by an interviewer and the chronic disease score (CDS). Predictors were derived by means of multivariate regression models.
Results:  Respondents caused mean direct costs of €3730 (95% CI 3203–4257) in prices of 2004/2005. This included inpatient care 34%, pharmaceuticals 29%, outpatient physician services 15%, nursing care 10%, medical supply and dentures 6%, outpatient nonphysician providers 5%, assisted living 1%, and transportation 2%. A shift from lower to middle education and a one-point increase in CDS were associated with an increase of €1678 (95% CI 250–3369) and €482 (95% CI 316–654), respectively. Total mean direct costs did not differ significantly between sexes. Ischemic heart disease and diabetes mellitus were associated with excess costs of €711 and €290, both being not significant. Altogether 55% of the respondents accounted for 90% of total direct costs.
Conclusions:  Advanced elderly used a wide range of health services. Our study still underestimates the true costs to society. Further research should focus on economic evaluation of new health-care programs for this increasingly important age group.     

Health-Care Costs of Pediatric Clients Developing Adverse Events during Treatment with Antipsychotics

Objective:  To examine the differences over time in health-care costs associated with incident adverse events in children and adolescents treated with antipsychotic agents compared to an untreated control sample.
Method:  A retrospective cohort design evaluating South Carolina's Medicaid medical and pharmacy claims between January 1996 and December 2005 was employed for 4140 children and adolescents prescribed antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications. The main outcome measures were total health-care costs and emergency, inpatient, and outpatient services use.
Results:  Patients with the focal adverse medical conditions incurred significantly higher total care costs (34% higher, on average, over 8–9 years) compared with those without these conditions ( F  = 710.08; P  < 0.0001) or to children not treated with psychotropic medications ( F  = 2855.54; P  < 0.0001). Patients with incident adverse events associated with antipsychotic treatment had significantly higher rates/time under Medicaid coverage of outpatient, emergency, and inpatient services utilization than the control sample patients, controlling for preexisting conditions, receipt of multiple psychotropic medications, and individual risk factor differences for males, adolescents, and non-African Americans.
Conclusions:  The development of adverse medical conditions related to antipsychotic medication use in children and adolescents is significantly associated with higher total costs of health care and to utilization of outpatient, emergency, and inpatient services over time.     

Economic Evaluation of Universal Infant Vaccination with 7vPCV in Hong Kong

Objectives:  The purpose of this study was to evaluate the clinical and economic benefits of routine infant vaccination with seven-valent pneumococcal conjugate vaccine (7vPCV) in Hong Kong.
Methods:  A decision-analytic model was populated with local age-specific incidence data to simulate the expected health outcomes resulting from 7vPCV vaccination of a birth cohort of 57,100 children compared with an unvaccinated cohort over a 10-year horizon. Primary analyses were conducted from a payer perspective, using local inpatient and outpatient costs associated with the treatment of pneumococcal disease. Vaccine efficacy rates were consistent with results from pivotal clinical trials. The reduction in adult invasive pneumococcal disease (IPD) and associated cost avoidance due to the indirect effect of vaccination were estimated in line with published overseas rates.
Results:  Universal 7vPCV vaccination was estimated to prevent 524 cases of IPD and more than 2580 cases of otitis media in the birth cohort over a 10-year period, leading to a reduction of HK$28.7 million (US$3.7 million) in direct medical costs. Additional cost savings from the indirect prevention of 919 adult cases of IPD during this time period also resulted. Overall, 7vPCV vaccination was estimated to have an incremental cost per life-year gained of HK$50,456 (US$6460) from a payer perspective or HK$46,308 (US$5929) when both direct and indirect costs were included.
Conclusion:  With reference to the World Health Organization's threshold for cost-effectiveness, results from this study indicate that routine infant vaccination with 7vPCV is a cost-effective intervention because of the added cost savings resulting from the indirect effect of vaccination on adult disease.     

The Health and Economic Consequences of Moderate Alcohol Consumption in Germany 2002

Objective:  Moderate alcohol consumption is associated with both positive and negative health effects. This study aims to estimate the positive and negative consequences on mortality, years of potential life (YPL), quality-adjusted life-years (QALYs), resource utilization, and societal costs attributable to moderate alcohol consumption in Germany in 2002.
Methods:  The concept of attributable risks and a prevalence-based approach was used to calculate age- and sex-specific alcohol attributable mortality and resource utilization for a wide range of disorders, and avoided mortality and resource utilization for diabetes mellitus, coronary heart disease, stroke, and cholelithiasis. The literature provided prevalence of moderate alcohol consumption in Germany by age and sex and relative risks. Direct costs were calculated using routine utilization and expenditure statistics. Indirect costs were calculated using the human capital approach.
Results:  Due to moderate alcohol consumption, 14,457 lives, 205,691 YPL, and 179,964 QALYs were lost, whereas 29,918 lives, 300,382 YPL, and 258,284 QALYs were gained. Up to an age of 55 to 60 (62.5–67.5) years, more lives were lost than gained among men (women), whereas in older age groups more lives were gained than lost. Moderate alcohol consumption caused €3049 million of direct and €2630 million of indirect costs, whereas €2094 million of direct and €2604 million of indirect costs were avoided.
Conclusion:  Despite considerable uncertainty, moderate alcohol consumption seems to result in an overall net effect of gained lives, YPL, and QALYs, realized among the elderly, but overall increased societal costs. Thus, moderate alcohol consumption should still be seen critical, especially among youths.     

The Direct Cost and Incidence of Systemic Fungal Infections

Objectives: In this study we determined the incidence and direct inpatient and outpatient costs of systemic fungal infections (candidiasis, aspergillosis, cryptococcosis, histoplasmosis) in 1998.
Methods: Using primarily the National Hospital Discharge Survey (NHDS) for incidence and the Maryland Hospital Discharge Data Set (MDHDDS) for costs, we surveyed four systemic fungal infections in patients who also had HIV/AIDS, neoplasia, transplant, and all other concomitant diagnoses. Using a case-control method, we compared the cases with controls (those without fungal infections with the same underlying comorbidity) to obtain the incremental hospitalization costs. We used the Student's t -test to determine significance of incremental hospital costs. We modeled outpatient costs on the basis of discharge status to calculate the total annual cost for systemic fungal infections in 1998.
Results: For 1998, the projected average incidence was 306 per million US population, with candidiasis accounting for 75% of cases. The estimated total direct cost was $2.6 billion and the average per-patient attributable cost was $31,200. The most commonly reported comorbid diagnoses with fungal infections (HIV/AIDS, neoplasms, transplants) accounted for only 45% of all infections.
Conclusion: The cost burden is high for systemic fungal infections. Additional attention should be given to the 55% with fungal disease and other comorbid diagnoses.     

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

Objective. To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997.
Data Sources. Medicaid administrative data from Iowa aggregated at the county level.
Study Design. Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program.
Principal Findings. We estimated that the PCCM program was associated with a savings of $66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses.
Conclusions. Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.     

The Health Value and Cost of Care for Major Depression

Background:  Trade-offs between costs and outcomes are a reality of health-care decisions. Cost-effectiveness analyses can guide choices toward interventions with the most health benefit for the least cost but are limited because generic measures of health value are infrequently available in the literature and are expensive to collect.
Objective:  We report on the application of a new approach to estimate the health value of alternative treatment patterns. We apply this approach to common treatment patterns for major depression, and we generate estimates of the change in health value that is attributable to a particular treatment. We also obtain estimates of treatment costs and report cost/health value ratios. We used a modified expert panel approach to estimate the change in health value attributable to different patterns of treatment. We used claims and pharmacy data to define usual care treatment patterns and estimate costs.
Results:  The lowest cost and most frequent treatment, 1 to 3 psychotherapy visits, produces minimal improvement. Treatments that include an antidepressant medication provide more health benefit per unit cost than all other treatments and adding a medication follow-up visit provides a lot of benefit for minimal cost.
Conclusions:  We demonstrate the application of a new approach to estimate the health value of common depression treatment practices in the United States. Our results suggest cost-effective targets for quality improvement efforts by identifying ways in which treatment for depression could cost less to get to a given outcome. Because our approach uses a generic health outcome measure, it can be applied to other conditions, permitting comparisons of benefit across diseases.     

Estimating the costs of substance abuse to the Medicaid hospital care program.

OBJECTIVES. The purpose of this study was to develop a model, using the epidemiologic tool of attributable risk, for estimating the cost of substance abuse to Medicaid. METHODS. Based on prior substance-use and morbidity research, population attributable risks for substance abuse-related diseases were calculated. (These risks measure the proportion of total disease cases attributable to smoking, drinking, and drug use.) The risks for each disease were applied to Medicaid hospital discharges and days on the 1991 National Hospital Discharge Survey that had these diseases as primary diagnoses. The cost of these substance abuse-related days were added to Medicaid hospital costs for direct treatment of substance abuse. RESULTS. More than 60 medical conditions involving 1100 diagnoses were identified, at least in part, as attributable to substance abuse. Factoring these substance abuse-related conditions into hospital costs, 1 out of 5 Medicaid hospital days, or 4 million days, were spent on substance abuse-related care in 1991. In 1994, this would account for almost $8 billion in Medicaid expenditures. CONCLUSIONS. The use of tobacco, alcohol, and drugs contributes significantly to hospital costs. To address rising costs, substance abuse treatment and prevention should be an integral part of any health care reform effort.     

Cost–Benefit Analysis of Preventing Nosocomial Bloodstream Infections among Hemodialysis Patients in Canada in 2004

Objectives:  Hemodialysis-associated bloodstream infection (BSI) is a significant public health problem because the number of hemodialysis patients in Canada had doubled from 1996 to 2005.Our study aimed to determine the costs of nosocomial BSIs in Canada and estimate the investment expenses for establishing infection control programs in general hospitals and conduct cost–benefit analysis.
Materials and Methods:  The data from the Canadian Nosocomial Infection Surveillance Program was used to estimate the incidence rate of nosocomial BSI. We used Canadian Institute of Health Information data to estimate the extra costs of BSIs per stay across Canada in 2004. The cost of establishing and maintaining an infection control program in 1985 was estimated by the US Centers for Disease Control and Prevention and converted into 2004 Canadian costs. The possible 20% to 30% reduction of total nosocomial BSIs was hypothesized.
Results:  A total of 2524 hemodialysis-associated BSIs were projected among 15,278 hemodialysis patients in Canada in 2004. The total annual costs to treat BSIs were estimated to be CDN$49.01 million. Total investment costs in prevention and human resources were CDN$8.15 million. The savings of avoidable medical costs after establishing infection control programs were CDN$14.52 million. The benefit/cost ratio was 1.0 to 1.8:1.
Conclusion:  Our study provides evidence that the economic benefit from implementing infection control programs could be expected to be well in excess of additional cost postinfection if the reduction of BSI can be reduced by 20% to 30%. Infection control offered double benefits: saving money while simultaneously improving the quality of care.     

Comparing Methodologies for the Allocation of Overhead and Capital Costs to Hospital Services

Background:  Typically, little consideration is given to the allocation of indirect costs (overheads and capital) to hospital services, compared to the allocation of direct costs. Weighted service allocation is believed to provide the most accurate indirect cost estimation, but the method is time consuming.
Objective:  To determine whether hourly rate, inpatient day, and marginal mark-up allocation are reliable alternatives for weighted service allocation.
Methods:  The cost approaches were compared independently for appendectomy, hip replacement, cataract, and stroke in representative general hospitals in The Netherlands for 2005.
Results:  Hourly rate allocation and inpatient day allocation produce estimates that are not significantly different from weighted service allocation.
Conclusions:  Hourly rate allocation may be a strong alternative to weighted service allocation for hospital services with a relatively short inpatient stay. The use of inpatient day allocation would likely most closely reflect the indirect cost estimates obtained by the weighted service method.     

Medical costs of fourteen occupational illnesses in the United States in 1999

OBJECTIVES: This study estimated the annual medical costs associated with 14 occupational illnesses in the United States in 1999. METHODS: National data sets collected by the National Center for Health Statistics, the Health Care Financing Administration, and the Agency for Healthcare Research and Quality were aggregated and analyzed. The cost assessment began with estimates of national health expenditures. These included categories for hospital care, professional services, nursing homes, and medical products, including drugs, administration, public health activities, research and construction. The total disease burden was assessed from estimates of hospital days and number of outpatient visits. The occupational disease burden was assessed by multiplying the total disease burden by a given percentage of the proportionate attributable risk for the disease in question. The occupational burden was then combined with costs for each disease. Adjustments were made for unique inpatient and outpatient costs. RESULTS: In the preferred model, the 14 diseases generated USD 14.5 billion in medical costs in 1999. Roughly USD 10.7 billion was attributed to men and USD 3.8 billion to women. The diseases generating the most costs were as follows: circulatory diseases in the age group 24-64 years (USD 4.7 billion), cancer (USD 4.3 billion), chronic obstructive pulmonary disease (USD 2.2 billion), and asthma (USD 1.5 billion). A sensitivity analysis generated alternative estimates. An upper age limit of 74 years increased the circulatory disease estimate by USD 3.7 billion. The range of the sensitivity analysis was USD 9.6-19.7 billion. CONCLUSION: This study significantly improves over the methodology of previous literature. Our methods were transparent. Occupational illnesses were a major contributor to the total cost of medical care.     

Estimating the economic impact of secondhand smoke on the health of a community

PURPOSE: This study provides a model to estimate the health-related costs of secondhand smoke exposure at a community level. MODEL DEVELOPMENT: Costs of secondhand smoke-related mortality and morbidity were estimated using national attributable risk values for diseases that are causally related to secondhand smoke exposure for adults and children. Estimated costs included ambulatory care costs, hospital inpatient costs, and loss of life costs based on vital statistics, hospital discharge data, and census data. APPLICATION OF THE MODEL: The model was used to estimate health-related costs estimates of secondhand smoke exposure for Marion County, Indiana. Attributable risk values were applied to the number of deaths and hospital discharges to determine the number of individuals impacted by secondhand smoke exposure. RESULTS: The overall cost of health care and premature loss of life attributed to secondhand smoke for the study county was estimated to be $53.9 million in 2000-$10.5 million in health care costs and $20.3 million in loss of life for children compared with $6.2 million in health care costs and $16.9 million in loss of life for adults. This amounted to $62.68 per capita. CONCLUSIONS: This method may be replicated in other counties to provide data needed to educate the public and community leaders about the health effects and costs of secondhand smoke exposure.     

Large Impact of Antidiabetic Drug Treatment and Hospitalizations on Economic Burden of Diabetes Mellitus in The Netherlands during 2000 to 2004

Objective:  To estimate the burden of diabetes mellitus (DM) and its complications in The Netherlands.
Methods:  The PHARMO Record Linkage System comprised among others linked drug dispensing, hospital and clinical laboratory data from approximately 2.5 million individuals in The Netherlands. Patients with DM (type 1 and type 2) were included in the study cohort from 2000 to 2004 if they used antidiabetic drugs or had HbA1c ≥ 6.5 mmol/L or had a hospitalization for DM or a diabetic complication in the measurement year or in the preceding year. Controls, defined as subjects without a diagnosis of DM and/or subjects not prescribed glucose-lowering medication, were 1:1 matched to patients with diabetes, on birth year, zip code, and gender. Complications (hospitalizations and dispensings for cardiovascular disease/eye problems/amputations) were classified into stages. Complications attributed to DM were estimated as complication stages 1 and 2 among patients minus those among controls. Drug costs were extrapolated to The Netherlands by direct standardization.
Results:  Among the total population in The Netherlands, the prevalence of DM increased from 2.8% in 2000 to 4.0% in 2004. Severe cardiovascular complications attributed to DM increased from 18,000 to 39,000 patients. Per DM patient the cost of direct treatment attributed to DM increased from €974 in 2000 to €1283 in 2004. Per 100 members of the total population, this increase was from €2764 in 2000 to €5140 in 2004. Most of these costs (65% in 2004) were because of hospitalizations.
Conclusion:  Drug treatment, hospitalizations, and cost attributed to diabetes mellitus have almost doubled between 2000 and 2004, but so did the "background" costs in the general population, perhaps because of preventive efforts.     

Implications of Controlling for Comorbid Conditions in Cost-of-Illness Estimates: A Case Study of Osteoarthritis from a Managed Care System Perspective

Objectives: Current methods for estimating the cost of illness inconsistently control for the effect of comorbid conditions. This analysis examines the implications of controlling for comorbid conditions on the estimated cost of illness. These implications are illustrated using the cost of osteoarthritis as an example.
Methods and Data: Medical claims data from 1996 were obtained for inpatient, outpatient, and pharmacy services for members in four United HealthCare health plans. Total annual costs for osteoarthritis (OA) were compared to costs among an equal number of comparison members. Multivariate regression analysis was used to compare the natural log of costs between the OA and comparison groups under two alternative controls for comorbid conditions: no controls, and controls for all conditions.
Results: Controlling for no or all comorbid conditions resulted in estimates of the annual cost of members with OA that ranged between 261% and 151% of the cost of members without OA, respectively.
Conclusions: Existing cost-of-illness estimates may seriously underestimate the true cost by including statistical controls for all comorbid conditions, or seriously overestimate the true cost by failing to control for enough comorbid conditions. In the case of OA, the range of potential bias is substantial.     

The economic burden of human papillomavirus infection-associated diseases in the Republic of Korea, 2002–2015

BackgroundThis prevalence-based, cost-of-illness study estimated the health care costs of human papillomavirus (HPV) infection-associated diseases in the era before the introduction of organized HPV vaccination for 12-year-old girls in 2016, South Korea.MethodsThe claims data provided by the National Health Insurance Service was used to estimate the prevalence of HPV-associated diseases and their direct medical costs, including costs related to hospitalizations, outpatient visits, and medications.ResultsA total of 1.3 million men and women used medical services for HPV-attributed diseases between 2002 and 2015. Among women, the most common diseases attributable to HPV were cervical dysplasia (64.4%), anogenital warts (12.9%), cervical carcinoma in situ (10.7%) and cervical cancer (2.6%), whereas anogenital warts (80.6%), benign neoplasms of larynx (14.3%), and anal cancers (8.9%) were most common among men. In 2015, the healthcare cost attributable to HPV was 124.9 million US dollars (USD) representing 69.0% of the annual cost of all HPV-associated diseases. At a cost of 75.1 million USD, cervical cancer contributed the largest economic burden in 2015 followed by cervical dysplasia (19.4 million USD) and cervical carcinoma in situ (10.7 million USD). These three conditions represented 58.2% of the total annual cost of all HPV-associated diseases, while 84.2% of the total annual cost was attributable to HPV. Annual health care costs increased from 42.6 million USD in 2002 to 180.9 million USD in 2015.ConclusionThe healthcare costs associated with HPV-related diseases in Korea are substantial and increased between 2002 and 2015 mainly caused by increased number of patients. Expanding the target age for HPV vaccination of girls and introducing HPV vaccination for boys are possible ways of reducing the economic burden of HPV-associated disease and should be considered.     

How Do Type 2 Diabetes Mellitus-Related Chronic Complications Impact Direct Medical Cost in Four Major Cities of Urban China?

Objective:  The purpose of this study was to evaluate the direct medical costs of type 2 diabetes mellitus with or without complications, and to determine the economic impact of complications on type 2 diabetic patients.
Methods:  We performed a cross-sectional study of prevalent type 2 diabetes carried out in four major cities of China. The study populations were 1530 outpatients and 524 inpatients from clinics or wards of a total of 20 hospitals, using a two-phase subject enrolment process, by face-to-face interview with a unique questionnaire.
Results:  The annual direct medical cost per patient was estimated to be 4800 Chinese Yuan (CNY) in median or 10,164 CNY in mean. There is a difference between annual direct medical costs for patients with or without complications (6056 vs. 3583 CNY; P  < 0.001). It is also significantly different for the pay-out-of-pocket proportions ( P  = 0.015) between the patients with (44.6%) and without complications (40.4%). The direct medical cost varied significantly among the four cities ( P  < 0.001). Patients who simultaneously suffered microvascular and macrovascular diseases had higher direct medical cost (7600) than those with macrovascular (6000) ( P  = 0.012) and microvascular disease (5364) ( P  < 0.001), and those without both (3600) ( P  < 0.001). The correlation was statistically significant between the number of complications and direct medical costs ( P  < 0.001).
Conclusions:  The high economic burden raised by diabetes and its complications challenges the Chinese health-care system. It implicates an urgent need of intervention to prevent the development of long-term complications among the diabetic population, especially on the development of complications in high-cost body system.