Effect of Evidence-Based Acute Pain Management Practices on Inpatient Costs

Objectives. To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost.
Data Sources/Study Setting. Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures.
Study Design. Experimental design and observational "as-treated" and instrumental variable (IV) methods.
Data Collection/Extraction Methods. Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts.
Principal Findings. The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention.
Conclusions. A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost.     

How HIV treatment advances affect the cost-effectiveness of prevention.

OBJECTIVE: The cost-effectiveness of an HIV prevention program depends, in part, on its potential to avert HIV-related medical care costs. Recent advances in antiretroviral therapy have made HIV/AIDS treatment both more effective and more costly, which might make HIV prevention either more or less cost-effective. The objective of the present study was to explicate the relationship between the effectiveness and costs of HIV treatment and the cost-effectiveness of HIV prevention programs. METHODS: A basic analytic framework was used to compare the cost-effectiveness of HIV prevention interventions with respect to different HIV/AIDS medical care scenarios. Algebra was used to calculate a cost-effectiveness threshold that distinguishes prevention programs that become more cost-effective when therapeutic advances simultaneously increase or decrease the cost and effectiveness of treatment from those that become less cost-effective. Recent estimates of the costs and consequences of combination antiretroviral therapy were used to illustrate the calculation method. RESULTS: The advent of combination antiretroviral therapies for HIV has increased the cost-effectiveness of some, but not all, HIV prevention interventions. CONCLUSIONS: Whether a particular prevention program becomes more or less cost-effective as a consequence of advancements in the medical treatment of HIV/AIDS depends upon the specific characteristics of both the program and the therapy.     

Optimal investment in a portfolio of HIV prevention programs.

OBJECTIVES: In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes. METHODS: The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior. RESULTS: The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit. CONCLUSIONS: The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.     

PIC4 Cost-Effectiveness of Piperacillin-Tazobactam Versus Ceftazidime in Patients with Febrile Neutropenia

Several models of colorectal cancer (CRC) screening cost-effectiveness have been published. Most of them are based on US costs of parameters/tests used.
OBJECTIVE: The purpose of this analysis was to provide a model to compare several screening programs using cost data related on Italian reimbursement system, both for ambulatorial and for hospital services.
METHODS: Four screening programs were assessed in comparison with nonscreening: annual fecal occult blood test alone (FOBT), flexible sigmoidoscopy every five years (FS), FOBT and FS combined, and one-time colonoscopy (CO). The analysis was carried out by considering a 10-year screening period. Effectiveness data were derived from recent literature; cost-effectiveness was defined as "cost per cancer prevented" (CCP) and "cost per cancer death prevented" (CCDP). Computer analysis was performed using algebraic formula. Data robustness was tested with sensitivity analysis of main variables: patient compliance, cost of cancer care, and cost of CO complication. Maximization analysis was carried out on a risk population (selected screening).
RESULTS: CO had the greatest impact on CRC mortality, followed by FS+FOBT, FS, and FOBT. CO also resulted in the most cost-effective program, both for CCP and for CCDP, followed by FOBT+FS, FS, and FOBT for all the compliance levels considered. Sensitivity analysis reinforced these results. Maximization analysis amplified both efficacy and cost-effectiveness of CO as a test for selected screening.
CONCLUSION: This model, even with the limitation linked to cost assumption problems, seems to be useful for authorities that will organize general population CRC screening programs.     

Applying Cost Analysis Methods to School-Based Prevention Programs

In order to efficiently allocate scarce prevention resources, policymakers need information about the economic costs of school-based substance use prevention programs. The objective of this paper is to outline economic cost analysis methods and demonstrate their applicability to school-based prevention programs. As an example, the paper focuses on estimating the economic cost of ALPHA, an intensive school-based substance use prevention program. The cost of ALPHA is compared to the costs of 3 elementary school programs that were alternatives to ALPHA. We collected cost information for 3 years, using a cost questionnaire that was completed by program and school budget officers and school principals. The program costs obtained from these sources were modified to conform to well-established economic cost analysis principles.     

Cost and cost-effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base?

Many donors and countries are striving to respond to the HIV/AIDS epidemic by implementing prevention programmes. However, the resources available for providing these activities relative to needs are limited. Hence, decision-makers must choose among various types of interventions. Cost information, both measures of cost and cost-effectiveness, serves as a critical input into the processes of setting priorities and allocating resources efficiently. This paper reviews the cost and cost-effectiveness evidence base of HIV/AIDS prevention programmes in low- and middle-income countries (LMICs). None of the studies found have complete cost data for a full range of HIV/AIDS prevention programmes in any one country. However, the range of studies highlight the relative emphasis of different types of HIV/AIDS prevention strategies by region, reflecting the various modes of transmission and hence, to a certain extent, the stage of the epidemic. The costing methods applied and results obtained in this review give rise to questions of reliability, validity and transparency. First, not all of the studies report the methods used to calculate the costs, and/or do not provide all the necessary data inputs such that recalculation of the results is possible. Secondly, methods that are documented vary widely, rendering different studies, even within the same country and programme setting, largely incomparable. Finally, even with consistent and replicable measurement, the results as presented are generally not comparable because of the lack of a common outcome measure. Therefore, the extent to which the available cost and cost-effectiveness evidence base on HIV/AIDS prevention strategies can provide guidance to decision-makers is limited, and there is an urgent need for the generation of this knowledge for planning and decision-making.     

Evolution of HIV/AIDS prevention programs--United States, 1981-2006

When the first cases of what would become known as acquired immunodeficiency syndrome (AIDS) were reported in 1981, the magnitude of the epidemic and the numbers of deaths were unimaginable. During the next 25 years, an unprecedented mobilization of individual, community, and government resources was directed at stopping the epidemic. CDC currently supports a wide range of human immunodeficiency virus (HIV) prevention activities in the United States, including 1) collection of behavioral and HIV/AIDS case surveillance data that document trends in the epidemic and risk behaviors; 2) programs conducted by state, territorial, and local health departments, community-based and national organizations, and education agencies; 3) capacity building to improve HIV-prevention programs; 4) program evaluation to monitor the delivery and outcomes of prevention services; and 5) research leading to new strategies for preventing transmission of HIV/AIDS. Since 1994, local and state health departments have allocated resources to specific programs and populations through local community planning processes that involve health department staff, prevention providers, and members of affected communities. A three-pronged approach has been developed, consisting of 1) prevention activities directed at persons at high risk for contracting HIV; 2) HIV counseling, testing, and referral services; and 3) prevention activities directed at improving the health of persons living with HIV and preventing further transmission.     

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.     

HIV/AIDS prevention in the Nepalese context

With their numbers now approaching almost 30 million, Nepalese feature importantly in the South Asian demography. Yet, it has been only 60 years since Nepal gained international recognition as a nation-state. Nepal at present is one of the world's poorest countries and is in dire need of development, especially in the area of health. Given the current civil instability coupled with rapid modernization, the health and well-being of the Nepalese people have been increasingly affected by newer threats, such as HIV/AIDS. The present study discusses the uniqueness of the Nepalese context in relation to HIV/AIDS prevention. The authors suggest that HIV/AIDS prevention programs in Nepal should now focus more on adolescents from rural regions. The authors also suggest the ways one may approach the task of developing a prevention program targeting rural youths.     

Examining variation in treatment costs: a cost function for outpatient methadone treatment programs

OBJECTIVES: To estimate a hybrid cost function of the relationship between total annual cost for outpatient methadone treatment and output (annual patient days and selected services), input prices (wages and building space costs), and selected program and patient case-mix characteristics. DATA SOURCES: Data are from a multistate study of 159 methadone treatment programs that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project between 1998 and 2000. STUDY DESIGN: Using least squares regression for weighted data, we estimate the relationship between total annual costs and selected output measures, wages, building space costs, and selected program and patient case-mix characteristics. PRINCIPAL FINDINGS: Findings indicate that total annual cost is positively associated with program's annual patient days, with a 10 percent increase in patient days associated with an 8.2 percent increase in total cost. Total annual cost also increases with counselor wages (p<.01), but no significant association is found for nurse wages or monthly building costs. Surprisingly, program characteristics and patient case mix variables do not appear to explain variations in methadone treatment costs. Similar results are found for a model with services as outputs. CONCLUSIONS: This study provides important new insights into the determinants of methadone treatment costs. Our findings concur with economic theory in that total annual cost is positively related to counselor wages. However, among our factor inputs, counselor wages are the only significant driver of these costs. Furthermore, our findings suggest that methadone programs may realize economies of scale; however, other important factors, such as patient access, should be considered.     

Estimating the cost of unmet HIV-prevention needs in the United States

BACKGROUND: Although new HIV infection cases have dropped from over 160,000 per year in the mid-1980s to 40,000 per year in the 1990s, HIV incidence has been relatively unchanged for a decade. This number of annual incident infections suggests that substantial, unmet HIV-prevention needs continue to fuel the HIV epidemic in the United States. OBJECTIVES: This study estimates the cost of addressing the unmet HIV-prevention needs in the United States and establishes a performance standard by estimating the number of HIV infections that would have to be prevented in order for these programs to be considered cost saving to society. METHODS: Standard methods of cost and threshold analysis were employed in this study. Interventions needed to address unmet behavioral risks include services to reduce sexual risk of HIV infection, services to provide access to sterile syringes for people who cannot stop injecting drugs, HIV counseling and testing, and intensive preventive services to help HIV-seropositive people avoid transmitting the virus to others. RESULTS: If brief interventions are utilized to address sexual behavior risk, the total program cost (over and above current resource levels) is just over $817 million; and if more expensive multisession, small-group interventions are used, the costs increase to over $1.85 billion. However, even the higher-cost program has a threshold of only 12,000 infections that must be prevented in order for the program to be considered a cost saving to society. CONCLUSIONS: Addressing the remaining unmet HIV-preventive needs in the United States will require a substantial commitment of resources. However, even a greatly expanded HIV-preventive program in the United States could pay for itself through savings in averted medical care costs.     

The indirect cost of AIDS

AIDS afflicts mainly people aged 15-45 years. The syndrome seriously threatens the social and economic development, and even political stability, of nations by depriving them of citizens in their most productive years. AIDS now dominates public health programs and health services in several countries and may eventually dominate in many more. As the number of AIDS cases rises steeply over the next few years, the economic, social, political, and cultural impact will be difficult to control. AIDS deserves special attention. The spread of AIDS, HIV, sex education, risk groups, desired interventions, and saving costs are discussed. Public health surveillance for HIV is critical in areas where an extensive spread of the virus has not yet occurred. Nongovernmental organizations can play a vital role in prevention, care, and community support programs.     

Cost Implications of Organizing Nursing Home Workforce in Teams

Objective. To estimate the costs associated with formal and self-managed daily practice teams in nursing homes.
Data Sources/Study Setting. Medicaid cost reports for 135 nursing homes in New York State in 2006 and survey data for 6,137 direct care workers.
Study Design. A retrospective statistical analysis: We estimated hybrid cost functions that include team penetration variables. Inference was based on robust standard errors.
Data Collection. Formal and self-managed team penetration (i.e., percent of staff working in a team) were calculated from survey responses. Annual variable costs, beds, case mix-adjusted days, admissions, home care visits, outpatient clinic visits, day care days, wages, and ownership were calculated from the cost reports.
Principal Findings. Formal team penetration was significantly associated with costs, while self-managed teams penetration was not. Costs declined with increasing penetration up to 13 percent of formal teams, and increased above this level. Formal teams in nursing homes in the upward sloping range of the curve were more diverse, with a larger number of participating disciplines and more likely to include physicians.
Conclusions. Organization of workforce in formal teams may offer nursing homes a cost-saving strategy. More research is required to understand the relationship between team composition and costs.     

Cell phone usage among adolescents in Uganda: acceptability for relaying health information

The increase in cell phone use has manifested a growing interest in using this technology for health promotion. The portability and 'always on' features of the cell phone, along with increasing capability for the devices to carry and transfer data suggest that they will reach more people than computers and the Internet in coming years. Self-reported quantitative survey data from 1503 secondary school students in Mbarara, Uganda collected in 2008-2009 suggest that 27% currently have cell phones and about half (51%) of all students and 61% of those who owned a cell phone believe that they would access a text messaging-based HIV prevention program if it were available. Other forms of program delivery modality (e.g. Internet, religious organizations, schools) were preferred to text messaging however. We are in need of effective HIV prevention programs that can reach large audiences at low cost and are culturally relevant for the East African context. Researchers are encouraged to consider translation of effective HIV prevention programs for cell phone delivery in Africa.     

Catching Up on Health Outcomes: The Texas Medication Algorithm Project

Objective. To develop a statistic measuring the impact of algorithm-driven disease management programs on outcomes for patients with chronic mental illness that allowed for treatment-as-usual controls to "catch up" to early gains of treated patients.
Data Sources/Study Setting. Statistical power was estimated from simulated samples representing effect sizes that grew, remained constant, or declined following an initial improvement. Estimates were based on the Texas Medication Algorithm Project on adult patients (age≥18) with bipolar disorder ( n =267) who received care between 1998 and 2000 at 1 of 11 clinics across Texas.
Study Design. Study patients were assessed at baseline and three-month follow-up for a minimum of one year. Program tracks were assigned by clinic.
Data Collection/Extraction Methods. Hierarchical linear modeling was modified to account for declining-effects. Outcomes were based on 30-item Inventory for Depression Symptomatology—Clinician Version.
Principal Findings. Declining-effect analyses had significantly greater power detecting program differences than traditional growth models in constant and declining-effects cases. Bipolar patients with severe depressive symptoms in an algorithm-driven, disease management program reported fewer symptoms after three months, with treatment-as-usual controls "catching up" within one year.
Conclusions. In addition to psychometric properties, data collection design, and power, investigators should consider how outcomes unfold over time when selecting an appropriate statistic to evaluate service interventions. Declining-effect analyses may be applicable to a wide range of treatment and intervention trials.     

Efficiency of Interventions in HIV Infection, 1994–2004

The pandemic caused by HIV is one of the fastest growing health problems in the world today. Given the limited resources available to healthcare systems in many of the most heavily affected countries, it is crucially important to know the effectiveness, efficiency, equity, and acceptability of the interventions being implemented to contain this pandemic. This review examines the peer-reviewed literature on the efficiency of prevention, treatment and care interventions published between 1994 and 2004, findings reported by these studies, and methods used. The results varied by geographical setting and population studied.Some interventions were clearly cost effective including: prevention efforts and testing programs among vulnerable populations; blood screening in high-income nations and in sub-Saharan Africa; providing antiretroviral drugs and other interventions to expectant mothers and infants; treating certain opportunistic infections; and providing combination anti-retroviral therapy. However, most studies were set in the US, while only one in six dealt with sub-Saharan Africa. Few studies could be identified from continental Asia and none from Latin America. Three-quarters of all papers focused on hospital or primary care settings, with only prevention studies regularly evaluating community-based interventions. There is a paucity of primary data and thus, outcomes or costs were frequently modeled, using data from multiple sources in the absence of context-specific data.Establishing multicenter prospective monitoring systems on the use, cost and outcome of HIV service provision in middle and lower income countries may provide data to fill some of the large gaps which exist in the literature on interventions in these countries. The resulting gaps in the current scientific literature limits the ability for it to guide policy makers in those settings where the epidemic is most intense. Increased research in such settings and dissemination of their findings is urgently required, especially given the need for intensified prevention strategies to complement the scaling up of HIV treatment and care services in these countries.     

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.     

The Impact of the Prospective Payment System for Skilled Nursing Facilities on Therapy Service Provision: A Transaction Cost Approach

Objective. To examine skilled nursing facilities (SNFs) "make-or-buy" decisions with respect to rehabilitation therapy service provision in the 1990s, both before and after implementation of Medicare's Prospective Payment System (PPS) for SNFs.
Data Sources. Longitudinal On-line Survey Certification and Reporting (OSCAR) data (1992–2001) on a sample of 10,241 freestanding urban SNFs.
Study Design. We estimated a longitudinal multinomial logistic regression model derived from transaction cost economic theory to predict the probability of the outcome in each of four service provision categories (all employed staff, all contract, mixed, and no services provided).
Principal Findings. Transaction frequency, uncertainty, and complexity result in greater control over therapy services through employment as opposed to outside contracting. For-profit status and chain affiliation were associated with greater control over therapy services. Following PPS, nursing homes acted to limit transaction costs by either exiting the rehabilitation market or exerting greater control over therapy services by managing rehabilitation services in-house.
Conclusions. The financial incentives associated with changes in reimbursement methodology have implications that extend beyond the boundaries of the health care industry segment directly affected. Unintended quality and access consequences need to be carefully monitored by the Medicare program.     

HIV prevention cost-effectiveness: a systematic review

Background

After more than 25 years, public health programs have not been able to sufficiently reduce the number of new HIV infections. Over 7,000 people become infected with HIV every day. Lack of convincing evidence of cost-effectiveness (CE) may be one of the reasons why implementation of effective programs is not occurring at sufficient scale. This paper identifies, summarizes and critiques the CE literature related to HIV-prevention interventions in low- and middle-income countries during 2005-2008.

Methods

Systematic identification of publications was conducted through several methods: electronic databases, internet search of international organizations and major funding/implementing agencies, and journal browsing. Inclusion criteria included: HIV prevention intervention, year for publication (2005-2008), setting (low- and middle-income countries), and CE estimation (empirical or modeling) using outcomes in terms of cost per HIV infection averted and/or cost per disability-adjusted life year (DALY) or quality-adjusted life year (QALY).

Results

We found 21 distinct studies analyzing the CE of HIV-prevention interventions published in the past four years (2005-2008). Seventeen CE studies analyzed biomedical interventions; only a few dealt with behavioral and environmental/structural interventions. Sixteen studies focused on sub-Saharan Africa, and only a handful on Asia, Latin America and Eastern Europe. Many HIV-prevention interventions are very cost effective in absolute terms (using costs per DALY averted), and also in country-specific relative terms (in cost per DALY measured as percentage of GDP per capita).

Conclusion

There are several types of interventions for which CE studies are still not available or insufficient, including surveillance, abstinence, school-based education, universal precautions, prevention for positives and most structural interventions. The sparse CE evidence available is not easily comparable; thus, not very useful for decision making. More than 25 years into the AIDS epidemic and billions of dollars of spending later, there is still much work to be done both on costs and effectiveness to adequately inform HIV prevention planning.