Assessing the cost and willingness to pay for voluntary HIV counselling and testing in Kenya

OBJECTIVE: Voluntary counselling and testing (VCT) should be an important component in a country's HIV/AIDS prevention and care strategy. However, the high cost of VCT raises concerns about the affordability of VCT in low-income countries. This study was designed to assess the costs of VCT and to identify potential ways of introducing VCT more affordably. METHODOLOGY: An economic evaluation was performed of VCT services in two rural health centres in Thika District and an urban health centre in Nairobi, Kenya. A contingent valuation study was also performed among VCT clients. Estimates were developed regarding the national cost of offering VCT services in Kenya. RESULTS: VCT added US dollars 6800 per year to the average cost of providing services at each of these three health centres. The evaluation revealed that the incremental cost, from the government's perspective, of adding VCT is approximately 16 dollars per client. The estimated incremental cost per client is significantly less than a previous cost estimate in Kenya which estimated a cost per client of 26 dollars. The difference in cost estimates is in part attributable to the emphasis of this project on integrating VCT services into existing health centres, rather than creating stand-alone sites. The cost of VCT services might be further reduced to as little as 8 dollars per client if a government health worker could perform the counselling. A contingent valuation study indicated that most VCT clients would be willing to pay at least 2 dollars for the service. However, if the full cost of the service were charged to the client, less than 5% of clients indicated they were willing and able to pay for the service. CONCLUSIONS: Integrating services into existing health centres can significantly reduce the cost of VCT. Additional cost reductions may be feasible if health centre staff are hired to perform the counselling. Furthermore, it appears that some level of cost recovery from VCT clients is feasible and can contribute to sustainability, although it is very unlikely that the full cost of the service could be recovered from the clients. The national provision of VCT in all Kenyan health centres is likely to be an affordable option, although additional operational research is required to determine the most appropriate way of scaling up VCT services throughout the country.     

Saving newborn lives in Asia and Africa: cost and impact of phased scale-up of interventions within the continuum of care

BACKGROUND: Policy makers and programme managers require more detailed information on the cost and impact of packages of evidenced-based interventions to save newborn lives, particularly in South Asia and sub-Saharan Africa, where most of the world's 4 million newborn deaths occur. METHODS: We estimated the newborn deaths that could be averted by scaling up 16 interventions in 60 countries. We bundled the interventions in a variety of existing maternal and child health packages according to time period of delivery and service delivery mode, and calculated the additional running costs of implementing these interventions at scale (90% coverage) in sub-Saharan Africa and South Asia. The phased introduction and expansion of interventions was modelled to represent incremental strategies for scaling up neonatal care in developing country health systems. RESULTS: Increasing coverage of 16 interventions to 90% could save 0.59-1.08 million lives in South Asia annually at an additional cost of US dollars 0.90-1.76 billion. In sub-Saharan Africa, 0.45-0.80 million lives saved would cost US dollars 0.68-1.32 billion. Additional costs for increased antenatal interventions are low, but given relatively high baseline coverage and lower impact, fewer additional newborn lives can be saved through this package (5-10%). Intrapartum care has higher impact (19-34% of deaths averted) but is costly (US dollars 1.66-3.25 billion). Postnatal family-community care, with potential for high impact at low cost (10-27%, US dollars 0.38-0.75 billion), has been neglected. A first phase of scaling up care in 36 high (NMR 30-45) and 15 very high (NMR >45) mortality countries would cost approximately US dollars 0.56-1.10 and US dolars 0.09-0.17 billion annually, respectively, and would avert 15-32% and 13-29% of neonatal deaths, respectively, in these countries. Full coverage with all interventions in the 51 high and very high mortality countries would cost US dollars 2.23-4.37 billion, and avert 38-68% of neonatal deaths (1.13-2.05 million), at an extra cost per death averted of US dollars 1100-3900. CONCLUSIONS: Low-cost, effective newborn health interventions can save millions of lives, primarily in South Asia and sub-Saharan Africa. Modelling costs and impact of intervention packages scaled up incrementally as health systems capacity increases can assist programme planning and help policy makers and donors identify stepwise targets for investments in newborn health.     

When does quality‐adjusting life‐years matter in cost‐effectiveness analysis?

PURPOSE: This paper investigates the impact of quality-of-life adjustment on cost-effectiveness analyses, by comparing ratios from published studies that have reported both incremental costs per (unadjusted) life-year and per quality-adjusted life-year for the same intervention. METHODS: A systematic literature search identified 228 original cost-utility analyses published prior to 1998. Sixty-three of these analyses (173 ratio pairs) reported both cost/LY and cost/QALY ratios for the same intervention, from which we calculated medians and means, the difference between ratios (cost/LY minus cost/QALY) and between reciprocals of the ratios, and cost/LY as a percentage of the corresponding cost/QALY ratio. We also compared the ratios using rank-order correlation, and assessed the frequency with which quality-adjustment resulted in a ratio crossing the widely used cost-effectiveness thresholds of 20, 000 US dollars, 50,000 US dollars, and 100,000 US dollars/QALY or LY. RESULTS: The mean ratios were 69,100 US dollars/LY and 103,100 US dollars/QALY, with corresponding medians of 24,600 US dollars/LY and 20,400 US dollars/QALY. The mean difference between ratios was approximately -34,300 US dollars (median difference: 1300 US dollars), with 60% of ratio pairs differing by 10,000 US dollars/year or less. Mean difference between reciprocals was 59 (QA)LYs per million dollars (median: 2.1). The Spearman rank-order correlation between ratio types was 0.86 (p<0.001). Quality-adjustment led to a ratio moving either above or below 50,000 US dollars/LY (or QALY) in 8% of ratio pairs, and across 100,000 US dollars in 6% of cases. CONCLUSIONS: In a sizable fraction of cost-utility analyses, quality adjusting did not substantially alter the estimated cost-effectiveness of an intervention, suggesting that sensitivity analyses using ad hoc adjustments or 'off-the-shelf' utility weights may be sufficient for many analyses. The collection of preference weight data should be subjected to the same scrutiny as other data inputs to cost-effectiveness analyses, and should only be under-taken if the value of this information is likely to be greater than the cost of obtaining it.     

Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services

BACKGROUND: Research has established the societal cost-effectiveness of providing breast and cervical cancer screening to women. Less is known about the cost of motivating women significantly overdue for services to receive screening. METHODS: In this intent-to-treat study, a total of 254 women, aged 52-69, who were overdue for both Pap test and mammography, were randomized to two groups, a tailored, motivational outreach or usual care. For effectiveness, we calculated the percent of women who received both services within 14 months of randomization. We used a comprehensive cost model to estimate total cost, per-participant cost, and the incremental cost-effectiveness of delivering the outreach intervention from the health plan perspective. We also conducted sensitivity analyses around two key parameters, target population size and level of effectiveness. RESULTS: Compared with usual care, outreach (P = 0.006) screened significantly more women. The intervention cost US dollars 167.62 (2000 U.S. dollars) for each woman randomized to outreach, and incremental cost-effectiveness of outreach over usual care was US dollars 818 per additional woman screened. Sensitivity analyses estimated incremental cost-effectiveness between Us dollars 19 and US dollars 90 per additional woman screened. CONCLUSIONS: Larger health plans can likely increase Pap test and mammography services in this population for a relatively low cost using this outreach intervention.     

The cost-effectiveness of improving malaria home management: shopkeeper training in rural Kenya

Home management is a very common approach to the treatment of illnesses such as malaria, acute respiratory infections, tuberculosis, diarrhoea and sexually transmitted infections, frequently through over-the-counter purchase of drugs from shops. Inappropriate drugs and doses are often obtained, but interventions to improve treatment quality are rare. An educational programme for general shopkeepers and communities in Kilifi District, rural Kenya was associated with major improvements in the use of over-the-counter anti-malarial drugs for childhood fevers. The two main components were workshop training for drug retailers and community information activities, with impact maintained through on-going refresher training, monitoring and community mobilization. This paper presents the cost and cost-effectiveness of the programme in terms of additional appropriately treated cases, evaluating both its measured cost-effectiveness in the first area of implementation (early implementation phase) and the estimated cost-effectiveness of the programme recommended for district-level implementation (recommended district programme). The proportion of shop-treated childhood fevers receiving an adequate amount of a recommended antimalarial rose from 2% to 15% in the early implementation phase, at an economic cost of 4.00 US dollars per additional appropriately treated case (2000 US dollars). If the same impact were achieved through the recommended district programme, the economic cost per additional appropriately treated case would be 0.84 US dollars, varying between 0.37 US dollars and 1.36 US dollars in the sensitivity analysis. As with most educational approaches, the programme carries a relatively high initial financial cost, of 11,477 US dollars (0.02 per capita US dollars) for the development phase and 81,450 US dollars (0.17 per capita US dollars) for the set up year, which would be particularly suitable for donor funding, while the annual costs of 18,129 US dollars (0.04 per capita US dollars) thereafter could be contained within the budget of a typical District. To reach the Abuja target of 60% of those suffering from malaria in sub-Saharan Africa having access to affordable and appropriate treatment within 24 hours, improvements in community-based malaria treatment are urgently required. From these results, policymakers can estimate costs for district-scale shopkeeper training programmes, and will be able to assess their relative cost-effectiveness as comparable evaluations become available from home management interventions in the future. Extrapolation of the results using a simple decision tree model to estimate the cost per DALY averted indicates that the intervention is likely to be considered highly cost-effective in comparison with standard benchmarks for interventions in low-income countries.     

The cost-effectiveness of a child nutrition education programme in Peru

This article reports impact and cost results from a health facility-based nutrition education programme targeting children less than 2 years of age in Trujillo, Peru. Key elements of the programme included participative complementary feeding demonstrations, growth monitoring sessions and an accreditation process. Data were collected from six intervention and six control health facilities to measure utilization and costs associated with the intervention. To calculate the unit costs of services, these costs are allocated using activity-based costing. To measure the effects of the intervention, 338 children were followed through household surveys at regular intervals from birth until the age of 18 months. The intervention had a clear positive impact both on the use of nutrition-related services and on children's growth outcomes. Children in the intervention areas made 17.6 visits to health facilities in the first 18 months of life, compared with 14.1 visits for children in the control areas (P < 0.001). This pattern holds true for all socioeconomic groups. The intervention prevented 11.1 cases of stunting per 100 children. In multivariate logistic regression analysis, children in the intervention were 0.33 times as likely to be stunted as the controls (P = 0.002). The marginal cost of the intervention - including external costs, training, health education materials and extra travel and equipment - is 6.12 US dollars per child reached and 55.16 US dollars per case of stunting prevented. The estimated marginal cost of the intervention per death averted is 1952 US dollars.     

Economic analysis of a school-based obesity prevention program

OBJECTIVE: To assess the cost-effectiveness and cost-benefit of Planet Health, a school-based intervention designed to reduce obesity in youth of middle-school age children. RESEARCH METHODS AND PROCEDURES: Standard cost-effectiveness analysis methods and a societal perspective were used in this study. Three categories of costs were measured: intervention costs, medical care costs associated with adulthood overweight, and costs of productivity loss associated with adulthood overweight. Health outcome was measured as cases of adulthood overweight prevented and quality-adjusted life years (QALYs) saved. Cost-effectiveness ratio was measured as the ratio of net intervention costs to the total number of QALYs saved, and net-benefit was measured as costs averted by the intervention minus program costs. RESULTS: Under base-case assumptions, at an intervention cost of $33,677 or $14 US dollars per student per year, the program would prevent an estimated 1.9% of the female students (5.8 of 310) from becoming overweight adults. As a result, an estimated 4.1 QALYs would be saved by the program, and society could expect to save an estimated $15,887 USD in medical care costs and $25,104 USD in loss of productivity costs. These findings translated to a cost of $4305 USD per QALY saved and a net saving of $7313 USD to society. Results remained cost-effective under all scenarios considered and remained cost-saving under most scenarios. DISCUSSION: The Planet Health program is cost-effective and cost-saving as implemented. School-based prevention programs of this type are likely to be cost-effective uses of public funds and warrant careful consideration by policy makers and program planners.     

Paying for pharmaceutical registration in developing countries

Fees charged by drug regulatory authorities (DRAs) may be used as a policy instrument to speed up regulatory approval, to encourage retention of quality staff and to stimulate introduction of generics versus new chemical entities. Often, the cost recovery function of these registration fees is not related to the true cost of the pharmaceutical regulatory process. In this paper, we scaled new drug registration fees of various DRAs to indices of economic development - the GNP per capita and the total government health expenditure per capita. Based on our analyses of 34 countries, most DRA registration fees for new drug applications for developing/non-OECD countries are less than the current GNP/capita of that country or are about US dollars 5000 for each US dollars 1000 spent per capita on healthcare. At present, each US dollars 1000 new drug registration fee for the developing/non-OECD countries analyzed corresponds to a total pharmaceutical market share of about US dollars 85 million. Our analyses further suggest little relationship between DRA registration fees and drug approval times in developing countries. The situation is complex, however, as policy tradeoffs are important to consider. Differential registration fees, presumably designed to encourage locally produced versus imported products, may violate international trade regulations. Moreover, certain DRA registration fees may provide perverse incentives for the pharmaceutical industry. Developing countries should require that DRA registration fees be based on accurate accounting of the cost of services provided. At present levels, these fees could be increased without disincentive to the pharmaceutical industry. For new drug registration fees, our analyses suggest that developing countries could charge between 1-5 times their GNP per capita or between US dollars 17000 and US dollars 80000 for each US dollars 1000 spent per capita on healthcare.     

Cost-effectiveness of social marketing of insecticide-treated nets for malaria control in the United Republic of Tanzania

OBJECTIVE: To assess the costs and consequences of a social marketing approach to malaria control in children by means of insecticide-treated nets in two rural districts of the United Republic of Tanzania, compared with no net use. METHODS: Project cost data were collected prospectively from accounting records. Community effectiveness was estimated on the basis of a nested case-control study and a cross-sectional cluster sample survey. FINDINGS: The social marketing approach to the distribution of insecticide-treated nets was estimated to cost 1560 US dollars per death averted and 57 US dollars per disability-adjusted life year averted. These figures fell to 1018 US dollars and 37 US dollars, respectively, when the costs and consequences of untreated nets were taken into account. CONCLUSION: The social marketing of insecticide-treated nets is an attractive intervention for preventing childhood deaths from malaria.     

Using the DATCAP and ASI to estimate the costs and benefits of residential addiction treatment in the State of Washington

Funding agencies and policy makers often criticize residential addiction treatment because the cost of residential services is typically higher than for outpatient services and it is unclear whether the outcomes are significantly better for most clients. To address these concerns, proponents of residential treatment require economic evidence to justify further investments in this modality over less intensive and less costly options. Recent studies have developed methods and empirical guidelines for using the drug abuse treatment cost analysis program (DATCAP) and the addiction severity index (ASI) in a comprehensive economic evaluation of addiction treatment. The present study applied these methods and guidelines to estimate the economic costs and benefits of residential addiction treatment at five programs in the State of Washington, USA that serve publicly funded clients. Program- and client-specific economic cost estimates were derived using data collected on-site with the DATCAP along with opportunity cost estimates associated with treatment attendance. Economic benefits were calculated from client self-reported information at treatment entry and at 6 months post discharge using the ASI. Outcome categories included inpatient services, employment, medical and psychiatric conditions, and criminal activity. Results indicate that average weekly economic cost of treatment services at the five programs ranged from 463 dollars to 703 dollars. Average (per client) economic cost of treatment was 4912 dollars (composed of 3650 dollars in program cost and 1262 dollars in client cost) for all subjects that completed both a baseline and follow-up questionnaire (N = 222; 82%). Average (per client) total economic benefit was 21,329 dollars, leading to estimates of 16,418 dollars for average net benefit and 4.34 for the benefit-cost ratio. Total and net economic benefits were significantly related to gender, race, religious preference, and baseline ASI composite scores for drug use and legal status. A detailed sensitivity analysis did not alter the qualitative findings. This study provides conclusive evidence that, for this sample of programs in Washington State, the economic benefits of residential addiction treatment significantly exceeded the economic costs. Although the results are not necessarily generalizable to private-paying clients or clients from other States in the US, the methods are based on widely used data collection instruments and well-accepted economic principles. Thus, extensions of this research to other clients, States, and modalities should be feasible and straightforward.     

The operation, quality and costs of a district hospital laboratory service in Malawi

Laboratory services are run down in many low-income countries, severely constraining their input to patient care and disease surveillance. There are few data about the quality and cost of individual components of the laboratory service in poorer countries, yet this information is essential if optimal use is to be made of scarce resources. Staff time, range of tests, workload, and safety procedures were monitored over 12 months (1997-98) in a typical district hospital laboratory in Malawi. Data were collected to calculate the total economic cost of these services. Of the 31203 tests performed, 84% were to support blood transfusion and diagnosis of malaria and tuberculosis (TB). Test quality was reasonable for malaria and TB microscopy and blood transfusion, but poor for haemoglobin estimation. The cost per test ranged from US dollars 0.35 for haemoglobin to US dollars 11.7 per unit of blood issued and the total annual cost of the laboratory service was US dollars 32618. Blood transfusion and microscopy for malaria and TB comprised the majority of tests. Ensuring that these tests are of the highest quality will therefore have the most impact in reducing wastage of laboratory resources. Inadequate quality of haemoglobin estimations is a particular problem. The findings of this study are likely to be relevant to other low-income countries with similar disease burdens.     

Modified therapeutic community for mentally ill chemical abusers: outcomes and costs.

Several studies have established that the personal and social consequences of substance abuse are extensive and costly. These consequences are frequently compounded by mental illness. Although interventions that target mentally ill chemical abusers (MICAs) present several challenges, the potential benefits of successful interventions are significant. This article presents outcomes and costs of a modified therapeutic community (TC) intervention for homeless MICAs. Outcomes at follow-up are compared with those for a control group of homeless MICAs receiving standard services in a "treatment-as-usual" (TAU) condition. Annual economic costs for the modified TC and the average weekly cost of treating a single client are estimated. Treatment and other health service costs at 12 months postbaseline are compared for modified TC and TAU clients. The results of this study indicate that, suitably modified, the TC approach is an effective treatment alternative for homeless MICAs, with the potential to be highly cost-effective relative to standard services.     

The cost-effectiveness of permethrin impregnated bednets in preventing child mortality in Kassena-Nankana district of Northern Ghana

Permethrin impregnated bednets are now being widely promoted as an effective means of protecting African children against malaria, but there is little evidence of their cost-effectiveness. The impact on child mortality of introducing permethrin impregnated bednets was evaluated in a rural district of northern Ghana in a controlled trial. The cost-effectiveness of the intervention is reported in this paper. The total cost of the intervention over the 2 years of follow-up was US $148,245. Cost per impregnated bednet per year and per person protected per year was US $2.4 and 1.2, respectively. Approximately 16,800 child years were protected and 74 child deaths averted at an estimated cost of US $8.8 per child year protected and US $2003 per death averted. In this rural community, where life expectancy at the mean age of death of trial children was 57.5 years, the estimated cost per discounted healthy life-year gained was US $73.5. Sensitivity analysis suggested that this cost-effectiveness ratio might be reduced substantially by feasible changes in programme implementation. This study supports the argument that the cost-effectiveness of bednet impregnation is sufficiently attractive to make it part of a package of high priority interventions for children. Issues of how to finance the provision of nets and insecticide, and especially the relative contribution of governments, households and donors, need urgently to be addressed.     

Economic evaluation of an HIV prevention intervention for seropositive injection drug users.

OBJECTIVE: To assess the cost-effectiveness of Intervention for HIV-Seropositive injection drug users--Research and Evaluation (INSPIRE), designed to reduce risky sexual and needle-sharing behaviors in research sites in four US cities (2001-2003). METHODS: We collected data on program and participant costs. We used a mathematical model to estimate the number of sex partners of injection drug users expected to become infected with human immunodeficiency virus (HIV) (with and without intervention), cost of treatment for sex partners who became infected, and the effect of infection on partners' quality-adjusted life expectancy. We determined the minimum effect that INSPIRE must have on condom use among participants for the intervention to be cost-saving (intervention cost less than savings from averted HIV infections) or cost-effective (net cost per quality-adjusted life year saved less than $50,000). RESULTS: The intervention cost was $870 per participant. It would be cost-saving if it led to 53 percent reduction in the proportion of participants who had any unprotected sex in 1 year and cost-effective with 17 percent reduction. If behavior change lasted 3 months, the cost-effectiveness threshold was 66 percent; if 3 years, the threshold was 6 percent. CONCLUSIONS: Although cost-saving thresholds may not be achievable by the intervention, we anticipate that cost-effectiveness thresholds will be attained.     

Cost-effectiveness of a community-level HIV risk reduction intervention.

OBJECTIVES: The authors evaluated the cost-effectiveness of a community-level HIV prevention intervention that used peer leaders to endorse risk reduction among gay men. METHODS: A mathematical model of HIV transmission was used to translate reported changes in sexual behavior into an estimate of the number of HIV infections averted. RESULTS: The intervention cost $17,150, or about $65,000 per infection averted, and was therefore cost-saving, even under very conservative modeling assumptions. CONCLUSIONS: For this intervention, the cost of HIV prevention was more than offset by savings in averted future medical care costs. Community-level interventions to prevent HIV transmission that use existing social networks can be highly cost-effective.     

Cost effectiveness of a latrine revision programme in Kabul, Afghanistan

INTRODUCTION: We assessed a household latrine revision intervention implemented in Kabul, Afghanistan for evidence of a reduction in diarrhoeal disease. METHODS: A case-control design involving 1238 cases and 625 controls was used. Logistic regression modelling was performed both for children < 5 years and < or = 11 years, and the parameter estimates were later used with results from a stratified cluster sample survey. This survey used a verbal autopsy methodology to enable an estimation of the number of deaths averted over a 1-year period. A cost-effectiveness analysis using direct and indirect costs for the intervention was then conducted and the results compared with primary health care interventions identified from a Medline search. FINDINGS: Conditional logistic regression showed that patients were less likely than controls to live in households with revised latrines (odds ratio (OR) 0.57, 95% confidence interval (CI) = 0.42-0.77 for children < 5 years, and OR 0.53, 95% = CI 0.41-0.67 for children < or = 11 years). The results from the survey of cause-specific mortality by verbal autopsy enabled estimation of the number of deaths averted over a 1-year period due to the intervention; these estimations were 235 (95% CI = 109-360) for children < 5 years and 285 (95% CI = 180-397) for children < or = 11 years. Estimates of cost effectiveness ranged from approximately US dollars 1800 to US dollars 4100 per death averted depending on age and payer perspective. CONCLUSION: These estimates are conservative because only 1 year of effectiveness is considered, yet they compare favourably with a review of other paediatric interventions. These results are important because funding for sanitation interventions is often limited by the belief that the interventions are not cost-effective.     

Cost of work-related injuries in insured workplaces in Lebanon

OBJECTIVE: To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics. METHODS: A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims. FINDINGS: The median cost per injury was US dollars 83 (mean, US dollars 198; range, US dollars 0-16,401). The overall cost for all 3748 injuries was US dollars 742,100 (76% of this was medical costs). Extrapolated to all injuries within insured workplaces, the overall cost was US dollars 4.5 million a year; this increased to US dollars 10 million-13 million when human value cost (pain and suffering) was accounted for. Fatal injuries (three, 0.1%) and those that caused permanent disabilities (nine, 0.2%) accounted for 10.4% of the overall costs and hospitalized injuries (245, 6.5%) for 45%. Cost per injury was highest among older workers and for injuries that involved falls and vehicle incidents. Medical, but not compensation, costs were higher among female workers. CONCLUSION: The computed costs of work injuries--a fraction of the real burden of occupational injuries in Lebanon--represent a considerable economic loss. This calls for a national policy to prevent work injuries, with a focus on preventing the most serious injuries. Options for intervention and research are discussed.     

Health care costs of persons with diabetes prior to and following hospitalization in Argentina]

OBJECTIVE: To analyze and compare the ambulatory care expenditures for persons with diabetes during prehospitalization and posthospitalization periods with those of diabetics who were not hospitalized for diabetes-related illnesses during the same period. METHODS: We determined the hospitalization and ambulatory care expenses incurred by an Argentine health insurer for the hospitalization of diabetic clients during the study period, and compared these expenses to the expenses of insured diabetics who were not hospitalized during that period. RESULTS: We identified 2,760 persons with diabetes (2.4% of the total number of persons covered by the insurance company). Of those, 1,683 (59%) were on medication for diabetes and its associated cardiovascular risk factors. Diabetes was associated with either one (41%) or two (24%) cardiovascular risk factors. Of those 1 683 persons, 102 (6%) were hospitalized for diabetes-related reasons during the study period. The frequency of hospitalization increased significantly in cases where diabetes was associated with arterial hypertension and dyslipidemia. Cardiovascular illness was the cause of 43.1% of the hospitalizations, with a significantly higher per capita cost than any of the other causes identified (mean +/- standard error of the mean: US 1,673 dollars +/- US 296.8 dollars; P < 0.05). The total annual per capita cost for health care for the diabetics who had been hospitalized was greater than for those who had not (US 2,907.8 dollars +/- US 262.5 dollars compared to US 473.4 dollars +/- US 9.8 dollars, respectively; P < 0.01). While the total posthospitalization ambulatory care expenditures were 12% higher than the prehospitalization costs (US 903.6 dollars +/- US 108.6 dollars vs. US 797.6 dollars +/- US 14.9 dollars), the difference was not significant. CONCLUSION: Ambulatory care expenditures increase significantly in the prehospitalization and posthospitalization periods. The results suggest that intensive treatment of hyperglycemia and its associated cardiovascular risk factors may prevent hospitalization and is a more cost-effective option than hospitalization and posthospitalization ambulatory care.     

Technical skills for weight loss: preliminary data from a randomized trial

BACKGROUND: Optimal behavioral interventions for sustainable weight loss are uncertain. We therefore conducted a study among overweight/obese women comparing conventional dietary counseling of individuals (counseling-based intervention) to a novel, group-based skill-building intervention. METHODS: Eighty subjects were randomly assigned to either the counseling-based or to the skill-building intervention. Outcomes included weight loss, dietitian hours per group and per unit weight loss, and dollars spent per group and per unit weight lost. RESULTS: Weight loss at 6 months (follow-up rate 61.3%) in the counseling-based group was 8.8 lb (P = 0.0001), and in the skill-building group was 3.8 lb (P = 0.01). A total of 160 dietitian hours were required for the counseling-based group, and 131 for the skilled-building group. The counseling-based group cost an average of $21 per pound lost, while the skill-building cost an average of $48 per pound lost (P = 0.16). CONCLUSIONS: At 6 months, individualized office-based counseling produced more weight loss than a skill-building approach and cost less than half as much per pound of weight loss. Longer-term follow-up is required to determine if, as hypothesized, the skill-building intervention produces more sustainable weight loss.     

Time to give nutrition interventions a higher profile: cost-effectiveness of 10 nutrition interventions

The aim of this study was to evaluate the economic performance of 10 nutrition interventions. The interventions included Mediterranean Diet, Intensive Lifestyle Change (nutrition and physical activity) to Prevent Diabetes, Reduced Fat Diet for persons with IGT, Nutritional Counselling in GP (GP, general practice/primary care), Nurse Counselling in GP, Oxcheck Nurse Health Checks in GP, Gutbusters Workplace (for men), Talking Computer, Multi Media 2 fruit 5 veg Campaign and the FFFF (Fighting Fit, Fighting Fat) Media Campaign. Markov models were constructed in order to estimate economic performance expressed as cost per QALY (quality adjusted life year) gained. Data from original clinical trial reports were used to populate the models, supplemented by the wider literature where required. Performance of the Mediterranean Diet and Intensive Lifestyle Change to Prevent Diabetes interventions could be estimated with most certainty and both were highly cost-effective interventions, at AU $1020 (US $760, 410 pounds) and AU $1880 (US $1410, 750 pounds) per QALY gained, respectively. The media campaign interventions appear highly cost-effective at AU $46 (US $34, 18 pounds) for '2 fruit 5 veg' and AU $5600 (US $4200, 2200 pounds) per QALY gained for FFFF, but are associated with considerable uncertainty, and may be dominated under certain assumptions. Several interventions were cost-saving under plausible sets of assumptions, whereas a small number were potentially dominated. All interventions subject to economic evaluation appeared cost-effective relative to societal norms. Nutrition interventions can constitute a highly efficient component of a strategy to reduce the growing disease burden linked to over/poor nutrition. There is an urgent need for high-quality trial data from which economic performance of nutrition interventions can be modelled.