Hospital costs of pediatric intensive care.

OBJECTIVE: To characterize hospital costs of pediatric intensive care and to determine which demographic and disease characteristics are associated with cost. DESIGN: Prospective cohort study. SETTING: A 20-bed pediatric intensive care unit (PICU) in an urban university-affiliated teaching children's hospital. PATIENTS: All children (n = 1,376) admitted to the multidisciplinary PICU during the fiscal year 1994. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, diagnoses, organ failure, Pediatric Risk of Mortality score, length of stay (LOS), and outcome were recorded. All hospital charges were obtained. The actual hospital costs were calculated by two separate methods. First, we converted the itemized patient charges into costs, using corresponding cost-to-charge ratios for each charge. In addition, we examined all direct and indirect expenses for the PICU. Univariate and multivariate regression analyses were used to determine the correlates to cost. The study population was similar to that of other studies of pediatric intensive care. The PICU was 86% efficient. The total cost for PICU care was $16,983,323. Average cost per admission was $12,342 +/- $22,313, and average cost per patient day was $2,264 +/- $868. The cost because of the PICU location (room cost) was 52.1% of all costs, and cost of laboratory studies was 18.3%. Respiratory therapy, pharmacy services, and radiology each accounted for between 6% and 8%. Total cost was most closely related to LOS, but severity of illness (Pediatric Risk of Mortality), diagnosis, and organ failure were also significant. Severity of illness was the most important factor in determining the variation in daily costs. Increased severity of illness was associated with higher laboratory and diagnostic study costs. We found little difference in the PICU room cost when calculated by adding direct and indirect expenses, compared with that obtained by using the cost-to-charge ratio. CONCLUSIONS: The maintenance of the specialty location and its personnel is the most costly component of pediatric intensive care. The strongest correlate with total cost for pediatric intensive care is LOS, but if costs are normalized for LOS, severity of illness best explains cost variation among patients. These data may serve as the basis for additional studies of resource allocation and consumption in the future.     

Relationship between TISS and ICU cost

Objective: To determine whether the therapeutic intervention scoring system (TISS) reliably reflects the cost of the overall intensive care unit (ICU) population, subgroups of that population and individual ICU patients. Design: Prospective analysis of individual patient costs and comparison with TISS. Setting: Adult, 12 bedded general medical and surgical ICU in a university teaching hospital. Subjects: Two hundred fifty-seven consecutive patients including 52 coronary care (CCU), 99 cardiac surgery (CS) and 106 general ICU (GIC) cases admitted to the ICU during a 12-week period in 1994. A total of 916 TISS-scored patient days were analysed Main outcome measures: A variable cost (VC) that included consumables and service usage (nursing, physiotherapy, radiology and pathology staff costs) for individual patients was measured daily. Nursing costs were calculated in proportion to a daily nursing dependency score. A fixed cost (FC) was calculated for each patient to include medical, technical and clerical salary costs, capital equipment depreciation, equipment and central hospital costs. The correlation between cost and TISS was analysed using regression analysis. Results: For the whole group (n = 257) the average daily FC was ￡ 255 and daily VC was ￡ 541 (SEM 10); range ￡ 23–￡ 2,806. In the patient subgroups average daily cost (FC + VC) for CCU was ￡ 476 (SEM 17.5), for CS ￡ 766 (SEM 13.8) and for GIC ￡ 873 (SEM 13.6). In the group as a whole, a strong correlation was demonstrated between VC and the TISS for each patient day (r = 0.87, p < 0.001) and this improved further when the total TISS score was compared with the total VC of the entire patient episode (r = 0.93, p < 0.001). This correlation was maintained in CCU, CS and GIC patient cohorts with only a small median difference between actual and predicted cost (2.2 % for GIC patients). However, in the individual patient, the range of error was up to ± 65 % of the true variable cost. For the whole group the variable cost per TISS point was ￡ 25. Conclusion: These results demonstrate that TISS reliably measures overall ICU population costs as well as those of the subgroups CCU, CS and GIC. However, the relationship between TISS and cost is less reliable for the individual patient. Received: 4 August 1997 Accepted: 22 March 1998     

Economies of scale in British intensive care units and combined intensive care/high dependency units

Objective To estimate the relationship between size of intensive care unit and combined intensive care/high dependency units and average costs per patient day.Design Retrospective data analysis. Multiple regression of average costs on critical care unit size, controlling for teaching status, type of unit, occupancy rate and average length of stay.Setting Seventy-two United Kingdom adult intensive care and combined intensive care/high dependency units submitting expenditure data for the financial year 2000–2001 as part of the Critical Care National Cost Block Programme.Interventions None.Measurements and results The main outcome measures were total cost per patient day and the following components: staffing cost, consumables cost and clinical support services costs. Nursing Whole Time Equivalents per patient day were recorded. The unit size variable has a negative and statistically significant (p<0.05) coefficient in regressions for total, staffing and consumables cost. The predicted average cost for a seven-bed unit is about 96% of that predicted for a six-bed critical care unit.Conclusion Policy makers should consider the possibility of economies of scale in planning intensive care and combined intensive care/high dependency units.     

Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit.

OBJECTIVE: To determine the change in chest radiograph use if each chest radiograph requires a separate order and clinical indication. DESIGN: Prospective, nonrandomized, controlled design with an intervention. SETTING: The pediatric intensive care unit (PICU) at Primary Children's Medical Center, Salt Lake City, UT. PATIENTS: The study comprised 3,727 PICU patients treated between 1992 and 1996. INTERVENTIONS: A change in ordering practice: There will be no standing orders for routine daily morning chest radiographs. Each radiograph requires a written order and a clinical indication. MEASUREMENTS AND MAIN RESULTS: During a 29-month control phase when routine daily chest radiographs were obtained for all intubated patients, 1.026 chest radiographs per patient day were performed. After the intervention, the ratio dropped to 0.653 chest radiographs per patient day, a decrease of 36.4%. This resulted in a (projected) variable cost savings of $45,476. Data were also collected for quality assurance purposes. CONCLUSIONS: These results demonstrate the impact of an evaluation and subsequent change in radiology ordering practice in our PICU. The change resulted in decreased variability in ordering practice, fewer chest radiographs per patient, and an accompanying cost savings to our patients and payors.     

Direct and indirect costs of management of long‐term warfarin therapy in Canada

Summary. Background: Comparisons of overall costs and resource utilization associated with anticoagulation management are important as new alternatives to warfarin are introduced. The aim of the present study was to assess total costs of warfarin‐based anticoagulation in different health care models. Methods: Physician‐ or pharmacist‐managed hospital‐ or community‐based anticoagulation clinics in five Canadian provinces were asked to provide itemized information on costs for staff, laboratory, hardware and overheads associated with warfarin management. At each site, cohorts of patients were provided with diaries and participants prospectively entered all costs for warfarin medication and associated health professional contacts, travel to the laboratory, required assistance and time lost from work by patient or caregiver over 3 months. All costs were calculated for a 3‐month period. Results: Data from 429 patients at 15 sites were evaluated. The cost from the Ministry of Health perspective ranged from $108 to $199 per 3 months in the different settings, the patient costs were $40–$80 and the total societal costs ranged from $188–$244. Sensitivity analyses with typical blood test intervals, the most prescribed strength of warfarin and dispensing fee from another province increased these estimates to $230–$302. When reimbursement for unemployed caregivers was also entered the total cost was $308–$503 per 3 months. Conclusions: The total cost for warfarin‐based anticoagulation amounted to at least 10 times the lowest cost for the drug. The costs provided should be useful for comparisons with newer drugs without requirement for routine laboratory monitoring and dose adjustments.     

The cost of intensive care: A comparison on one unit between 1988 and 1991

Objective To assess the changes in cost of intensive care in one unit after a 3 year period and to evaluate the relative costs of an integrated high dependency unit.Design Combined retrospective and prospective audit of all expenditure incurred in an intensive care/high dependency unit over two periods: April 1988 – Feburary 1989 and January–July 1991.Setting Combined 13-bedded intensive care/high dependency unit of a central London teaching hospital.Results: The overall cost rose by 50%. Hidden costs such as infrastructure maintenance, capital assets, pathology and radiology services accounted for nearly a quarter of total expenditure. Pharmacy and supplies each accounted for some 10% of total expenditure whereas staff costs exceeded 50%. The cost of the intensive care section rose by 14% to £ 1149 per patient day as increased bed occupancy offset increases in nurse: patient ratios and expenditure on consumables. However, the cost of the high dependency unit section rose by 87% to £ 437.83. This was due to a lower bed occupancy (through increased patient turnover), improved staffing ratios, and increased utilisation of equipment and supplies.Conclusions Intensive care is an increasingly expensive speciality, the costs for which are rising over and above the rate of general inflation. Staff costs are by far the largest single item of expenditure. Large reductions in spending on drugs and consumables are unlikely to provide considerable savings on the total budget. Hidden costs account for a high proportion of the budget and should be taken into account when evaluating cost. The significantly lower cost of high dependency care should encourage studies into its cost-effectiveness.     

Cost analysis of secondary prophylaxis with oral clodronate versus pamidronate in metastatic breast cancer patients

Objective We compared the direct medical costs of secondary prophylaxis with bisphosphonates (BPs) in bone metastases (BMs) of breast cancer (BCa) from a payer perspective.Patients and methods This study adopted an incidence-based chart review of consecutive BCa patients with BMs who received prophylactic treatment with orally administered (PO) clodronate (CLODpo group), or intravenously administered (IV) pamidronate (PAM group) in 1997 at two large oncology centers in Toronto, Ontario. We evaluated the difference in costs of management of patients among the CLODpo and PAM groups using an intent-to-treat analysis from diagnosis of BMs to death, or last follow-up. The results are presented as observed mean and average lifetime (including terminal care) costs per patient.Results The observed mean costs in the PAM and CLODpo groups were $49,472 and $50,307 (2002 Canadian dollars), respectively. The difference in costs between the CLODpo (n=34) and PAM (n=18) groups was not significant (P=0.64), and remained robust after sensitivity analyses. The corresponding average lifetime costs were $65,677 in the CLODpo group and $61,254 in the PAM group. Inpatient and terminal care were the major cost drivers, comprising 45% and 25% of overall costs. Of all hospitalizations, 46% were associated with complications from BMs.Conclusions Our analysis, which was based on a convenience sample, failed to reveal a statistically significant difference in the observed mean costs between groups of patients who initiated treatment with PO clodronate versus IV pamidronate. The cost estimates from this study can be used for future corroborative economic analyses.     

Health Care Resource Utilization and Medical Costs of Spinal Cord Injury With Neuropathic Pain in a Commercially Insured Population in the United States

ObjectiveTo evaluate health care resource use, costs, and cost drivers among patients with neuropathic pain (NeP) after spinal cord injury (SCI) in a commercially insured population.DesignRetrospective longitudinal cohort study comparing SCI patients with and without NeP.SettingTruven Health MarketScan commercial claims database from 2005 through 2012.ParticipantsCommercially insured SCI patients with NeP (n=3524) propensity score matched to SCI patients without NeP (n=3524).InterventionsNot applicable.Main Outcomes MeasuresHealth care resource utilization and expenditures for the 12 months after NeP onset (index event; identified through International Classification of Diseases, 9th Revision, Clinical Modification diagnosis 338.0x or use of NeP-specific antiepileptic drugs or NeP-specific antidepressants) in patients with SCI compared with matched patients without NeP.ResultsUtilization over 12 months postindex among patients with SCI-associated NeP was higher than among SCI-only patients for inpatient admissions (27.4% vs 22.1%), emergency department visits (36.7% vs 26.4%), and office visits per patient (mean ± SD: 13.0±9.5 vs 9.5±8.3); all P values were <.001. All-cause expenditures showed adjusted incremental costs of $22,545 (95% confidence interval, $19,010–$26,168) per patient with SCI-associated NeP during the 12-month postindex period.ConclusionsPatients with evidence of NeP secondary to SCI have significantly higher health care utilization and total costs compared with SCI patients without evidence of NeP. Factors contributing to NeP in patients with SCI need to be clinically assessed to determine the optimal approach for treating these individuals.     

Using lean techniques to define the platelet (PLT) transfusion process and cost-effectiveness to evaluate PLT dose transfusion strategies

BACKGROUND: Platelet (PLT) doses of 1.1 × 10¹¹, 2.2 × 10¹¹, and 4.4 × 10¹¹/m² body surface area are equally effective in preventing bleeding. These different dose strategies involve different numbers of transfusions. We conducted a cost analysis of three separate PLT dose therapies. STUDY DESIGN AND METHODS: A process map of preparation and administration of a PLT transfusion identified 46 steps (23 steps in the blood bank and 23 steps on the care unit). Time studies were conducted for these 46 steps. Supply costs and personnel costs were estimated based on time studies. We conducted a cost analysis of three separate treatment regimes involving 16 transfusions per patient for the low‐dose, 12 transfusions for medium‐dose, and eight transfusions for high‐dose regimes. RESULTS: The time and the cost of the transfusion process for the blood bank were 32.41 minutes and $21.93 per unit, and for the patient care unit, 58.36 minutes and $57.71 per unit. The total cost for a course of PLT therapy per patient ranged from $4503.77 to $7014.59 for three different PLT doses. For a simulated bone marrow transplantation unit with 259 patients annually, there would be approximately a $700,000 difference among the clinically equivalent low‐, medium‐, and high‐dose treatment options. CONCLUSIONS: The overall cost of transfusion therapy is more influenced by the cost of the product than the cost of providing the transfusion. Depending on the cost adjustment by the supplier for different doses of PLTs, a low‐dose transfusion strategy can be less costly.     

Severe chemotherapy-induced diarrhea in patients with colorectal cancer: a cost of illness analysis

Background Diarrhea is common with many types of chemotherapy and can have a major impact on maintaining dose intensity and treatment effectiveness, and on overall health care resource consumption. In this study, a cost of illness analysis was conducted to estimate the overall economic impact of grade III/IV diarrhea in patients with colorectal cancer receiving adjuvant or palliative chemotherapy.Methods This was a retrospective cohort study of patients with colorectal cancer who had received fluoropyrimidines, irinotecan or oxaliplatin (or a combination of these) and had developed grade III or IV diarrhea. Data collection included patient demographics, disease-related information and healthcare resource utilization to manage the grade III/IV diarrhea event (n=96).Results Grade III/IV diarrhea developed after the first cycle of chemotherapy in 54.2% of patients and was responsible for a median dose reduction and delay of 20% and 7 days, respectively. Overall, 31 of 96 patients (32.3%) required a hospital admission for supportive care with an 8-day median length of stay (range 2 to 28 days). When the economic impact of the grade III/IV diarrhea was quantified, the mean cost was Can $2559 per patient (95%CI: $1665 to 3453). A logistic regression analysis identified grade IV diarrhea (OR 11.2; P<0.001) and severe diarrhea developing after the first chemotherapy cycle (OR 3.1; P=0.051) as being significantly associated with patient hospitalization.Conclusions Grade III/IV diarrhea is a debilitating and costly complication of chemotherapy in colorectal cancer. Effective interventions that prevent the development of severe diarrhea need to be identified to save health-care costs and reduce patient morbidity.Funding for this study was provided by an unrestricted research grant from Novartis Pharmaceuticals Canada Inc.     

Hyponatremia-Associated Healthcare Burden Among US Patients Hospitalized for Cirrhosis

Introduction

Hyponatremia is a frequent comorbid condition of patients hospitalized for cirrhosis and a predictor of disease severity and mortality. This study evaluated the healthcare burden of hyponatremia among patients hospitalized for cirrhosis in the real world.

Methods

Hyponatremic (HN) patients (>-18 years of age) with cirrhosis were identified using the Premier Hospital Database (January 1, 2007 to March 31, 2010) and matched to non-HN patients with cirrhosis using a combination of exact patient characteristics and propensity score matching. Univariate and multivariate statistics were utilized to compare hospital resource utilization, cost, and 30-day hospital re-admission among patient cohorts.

Results

The study population included 21,864 subjects (HN 10,932; non-HN 10,932). The hospital length of stay (LOS) (7.63 ± 7.4 vs. 5.89 ± 6.2 days; P < 0.001), hospital cost ($13,842 ± $20,702 vs. $11,140 ± $20,562; P < 0.001), intensive care unit (ICU) LOS (4.58 ± 4.7 vs. 3.59 ± 4.4 days; P < 0.001), and ICU cost ($7,038 ± $7,781 vs. $5,360 ± $7,557; P < 0.001) were greater for the HN cohort, as was the 30-day re-admission rate (all cause: 31.1% vs. 24.8%; P < 0.001; hyponatremia related: 25.1% vs. 11.0%; P < 0.001). Multivariate analysis showed that hyponatremia was associated with a 29.5% increase in hospital LOS, a 26.6% increase in overall hospital cost, a 23.2% increase in S. ICU LOS, and a 28.6% increase in ICU cost. Additionally, hyponatremia was associated with an increased risk of 30-day hospital re-admission (all cause: odds ratio [OR] 1.37; confidence interval [CI] 1.28-1.46; P < 0.001; hyponatremia related: OR 2.68; CI 2.48-2.90; P < 0.001).

Conclusion

Hyponatremia in patients with cirrhosis is a predictor of increased hospital resource use and 30-day hospital re-admission, and represents a potential target for intervention to reduce healthcare expenditures for patients hospitalized for cirrhosis.     

Cost Efficiency Analysis for Spasticity Management Based on Physician Botulinum Toxin Prescribing Habits

ObjectiveTo estimate differences in botulinum toxin type A (BoNT-A) treatment costs per patient for spasticity-injecting physicians, with a focus on physicians’ use of alternative BoNT-A agents other than onabotulinumtoxinA.DesignRetrospective cohort study.SettingNational Medicare data for fee-for-service beneficiaries in 2017.ParticipantsA total of 116 physicians, 6829 BoNT-A procedures, and 3051 patients were included in this analysis. Most physicians were physiatrists (84%) and used only onabotulinumtoxinA (82%).InterventionsType of BoNT-A selected by physicians was the independent variable of interest. Included physicians were separated into 2 groups: (1) onabotulinumtoxinA only injectors and (2) abobotulinumtoxinA and/or incobotulinumtoxinA injectors (may still use onabotulinumtoxinA).Main Outcome MeasureAverage cost per patient per year.ResultsThe total average BoNT-A cost per patient per year was significantly less for physicians who used abobotulinumtoxinA and/or incobotulinumtoxinA vs those who used only onabotulinumtoxinA ($3684 vs $4739; P=.01). Patients’ average annual out-of-pocket costs also reflected a similar difference ($855 vs $1082; P=.02) between the groups. Doses used and numbers of injections per patient per year were not significantly different between groups.ConclusionsThe present analysis demonstrated lower cost per patient for both the payer and patient when physicians used types of BoNT-A other than onabotulinumtoxinA for spasticity. Nevertheless, most physicians in this spasticity-focused study used exclusively onabotulinumtoxinA, the most expensive BoNT-A available. Reasons for this are complex and include history on the market and approved indications beyond those associated with spasticity. However, future research should continue to identify such issues with a goal of finding solutions to improve cost inefficiencies.     

Effective Antimicrobial Stewardship Strategies for Cost-effective Utilization of Telavancin for the Treatment of Patients With Hospital-acquired Bacterial Pneumonia Caused by Staphylococcus aureus

Purpose

Clinicians and stewardship programs are challenged with positioning of novel, higher priced antibiotic agents for the treatment of clinical infections. We developed a decision-analytic model to describe costs, including drug, total treatment costs, and health care outcomes, associated with telavancin (TLV) compared with vancomycin (VAN) for patients with Staphylococcus aureus (SA) hospital-acquired bacterial pneumonia (HABP).

Home visits by specially trained nurses after discharge from multi‐disciplinary pain care: A cost consequence analysis based on a randomised controlled trial

Objectives: To analyse the cost consequences of a nurse follow‐up intervention for chronic non‐malignant pain patients discharged from multidisciplinary pain treatment. Methods: The cost consequence analysis was based on a prospective, randomised controlled trial where 102 consecutive patients were randomised to either an intervention group (n=52) or a control group (n=50). During the 2‐year intervention period, nurses visited patients every 4th month (7 times in total). Changes in health status were measured by the 8 SF‐36 sub‐scales. Intervention costs were based on prospective registrations of nurses’ time use. Data on health care cost and resource use were collected retrospectively from administrative registers. Results: No statistically significant differences in health status were observed between the two groups after the 2‐year intervention period. The cost of the nurse intervention programme itself was 35,000€ (2004‐prices). The average cost per patient was estimated at 668€ per patient. During the observation period the average patient in the intervention group used other health care resources worth 4004€, while the average patient in the control group used 7464€. This difference (3460€, 46%) was not statistically significant. Conclusion: The nurse intervention did not significantly influence patients’ health status. Patients in the intervention group tended to use fewer health care resources than those in the control group and the cost of the intervention was more than balanced out by savings in other health care resources.     

Do we know the costs of what we prescribe?

Objective: To evaluate the level of cost awareness of drugs and devices among intensive care unit (ICU) doctors with variable levels of experience (senior intensivists, junior intensivists, residents). Design: Interview-questionnaire. Setting: ICU of the University of Rome “La Sapienza”. Participants: 60 ICU doctors (40 specialists in anaesthesia and intensive care, 20 residents). Measurements and results: The estimated prices of drugs and devices were compared with the correct prices; responses within a range ± 20 % of the true price were arbitrarily considered correct; all the subgroups of doctors made inaccurate estimates of the prices, showing an absence of any impact of professional experience of cost awareness. Conclusion: The doctors in the study showed a high level of inacurrate cost awareness of drugs and devices. Received: 3 December 1997 Accepted: 24 August 1998     

Tele-assistance in patients with amyotrophic lateral sclerosis: long term activity and costs

Purpose: To describe i) nurse’s utilisation and associated costs during 4-year tele-assistance in amyotrophic lateral sclerosis (ALS) ii) optimal time for initiating tele-assistance. Method: 73 ALS patients after hospital discharge were followed up on voice by phone calls conducted by a nurse through a clinical card which was tested for feasibility, efficacy and utility. Number of patients simultaneously assisted/month, calls/patient, fixed and variable costs were calculated. Results: Time between disease’s diagnosis and the beginning of tele-assistance was 720 ± 971 days. ALS patients’ percentage managed by nurses through tele-assistance increased over time by 628%. Tele-assistance integrated care (TAIC) followed up patients with a total of 5073 telephone calls. Steady state activity was reached at the 3rd year employing 5 ± 3 calls/pt/month (time/call 64 ± 44 min). Implementing the card was feasible, useful and effective by operator. Survival from diagnosis of ALS was 1224 ± 1150 days. Survival was related to tracheotomy. Conclusion: TAIC is a feasible tool to manage up to 25 ALS patients/month/nurse and costs about €105.00 per patient per month. Tele-assistance is proposed at 2/3 of time course of the disease.

Implications for Rehabilitation

• People with ALS have a complex time course of their disease necessitating important clinical decisions.

• Individually structured holistic and rehabilitative programmes are required.

• Tele-assistance has been demonstrated to be useful to follow-up providing autonomy of care, psychosocial monitoring, interventions and a source of information.

• Tele-assistance integrated care is a feasible tool to manage up to 25 ALS patients/month/nurse.

• Tele-assistance costs about €105.00 per patient per month.

• Tele-assistance is proposed at 2/3 of time course of the disease.

     

Treatment Persistence and Healthcare Costs Among Patients with Rheumatoid Arthritis Changing Biologics in the USA

Introduction

After a patient with rheumatoid arthritis (RA) fails tumor necrosis factor inhibitor (TNFi) treatment, clinical guidelines support either cycling to another TNFi or switching to a different mechanism of action (MOA), but payers often require TNFi cycling before they reimburse switching MOA. This study examined treatment persistence, cost, and cost per persistent patient among MOA switchers versus TNFi cyclers.

Methods

This study of Commercial and Medicare Advantage claims data from the Optum Research Database included patients with RA and at least one claim for a TNFi (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) between January 2012 and September 2015 who changed to another TNFi or a different MOA therapy (abatacept, tocilizumab, or tofacitinib) within 1 year. The index date was the date of the change in therapy. Treatment persistence was defined as no subsequent switch or 60-day gap in therapy for 1 year post-index. RA-related costs included plan-paid and patient-paid amounts for inpatient, outpatient, and pharmacy claims. Medication costs included index and post-index costs of TNFi and different MOA therapies.

Results

There were 581 (38.3%) MOA switchers and 935 (61.7%) TNFi cyclers. The treatment persistence rate was significantly higher for MOA switchers versus TNFi cyclers (47.7% versus 40.2%, P = 0.004). Mean 1-year healthcare costs were significantly lower among MOA switchers versus TNFi cyclers for total RA-related costs ($37,804 versus $42,116; P < 0.001) and medication costs ($29,001 versus $34,917; P < 0.001). When costs were divided by treatment persistence, costs per persistent patient were lower among MOA switchers versus TNFi cyclers: $25,436 lower total RA-related cost and $25,999 lower medication costs.

Conclusion

MOA switching is associated with higher treatment persistence and lower healthcare costs than TNFi cycling. Reimbursement policies that require patients to cycle TNFi before switching MOA may result in suboptimal outcomes for both patients and payers.

Funding

Sanofi and Regeneron Pharmaceuticals.

     

Cost‐effectiveness of hematopoietic stem cell mobilization strategies including plerixafor in multiple myeloma and lymphoma patients

Peripheral blood stem cells (PBSCs) are preferred source of hematopoietic stem cells for autologous transplantation. Mobilization of PBSCs using chemotherapy and/or granulocyte colony‐stimulating factor (G‐CSF) however fails in around 20%. Combining G‐CSF with plerixafor increases the mobilizations success. We compared cost‐effectiveness of following schemes: the use of plerixafor “on demand” (POD) during the first mobilization in all patients with inadequate response, the remobilization with plerixafor following failure of the first standard mobilization (SSP), and the standard (re)mobilization scheme without plerixafor (SSNP). Decision tree models populated with data from a first‐of‐a‐kind patient registry in six Czech centers (n = 93) were built to compare clinical benefits and direct costs from the payer's perspective. The success rates and costs for POD, SSP and SSNP mobilizations were; 94.9%, $7,197; 94.7%, $8,049; 84.7%, $5,991, respectively. The direct cost per successfully treated patient was $7,586, $8,501, and $7,077, respectively. The cost of re‐mobilization of a poor mobilizer was $5,808 with G‐CSF only and $16,755 if plerixafor was added. The total cost of plerixafor “on‐demand” in the sub‐cohort of poor mobilizers was $17,120. Generally, plerixafor improves the mobilization success by 10% and allows an additional patient to be successfully mobilized for incremental $11,803. Plerixafor is better and cheaper if used “on demand” than within a subsequent remobilization. J. Clin. Apheresis 28:395–403, 2013. © 2013 Wiley Periodicals, Inc.     

Sixty-four–slice Computed Tomography of the Coronary Arteries: Cost–Effectiveness Analysis of Patients Presenting to the Emergency Department with Low-risk Chest Pain

Objectives: The aim was to use a computer model to estimate the cost–effectiveness of 64‐slice multidetector computed tomography (MDCT) of the coronary arteries in the emergency department (ED) compared to an observation unit (OU) stay plus stress electrocardiogram (ECG) or stress echocardiography for the evaluation of low‐risk chest pain patients presenting to the ED. Methods: A decision analytic model was developed to compare health outcomes and costs that result from three different risk stratification strategies for low‐risk chest pain patients in the ED: stress ECG testing after OU care, stress echocardiography after OU care, and MDCT with no OU care. Three patient populations were modeled with the prevalence of symptomatic coronary artery disease (CAD) being very low risk, 2%; low risk, 6% (base case); and moderate risk, 10%. Outcomes were measured as quality‐adjusted life years (QALYs). Incremental cost–effectiveness ratios (ICERs), the ratio of change in costs of one test over another to the change in QALY, were calculated for comparisons between each strategy. Sensitivity analyses were conducted to test the robustness of the results to assumptions regarding the characteristics of the risk stratification strategies, costs, utility weights, and likelihood of events. Results: In the base case, the mean (±standard deviation [SD]) costs and QALYs for each risk stratification strategy were MDCT arm $2,684 (±$1,773 to $4,418) and 24.69 (±24.54 to 24.76) QALYs, stress echocardiography arm $3,265 (±$2,383 to $4,836) and 24.63 (±24.28 to 24.74) QALYs, and stress ECG arm $3,461 (±$2,533 to $4,996) and 24.59 (±24.21 to 24.75) QALYs. The MDCT dominated (less costly and more effective) both OU plus stress echocardiography and OU plus stress ECG. This resulted in an ICER where the MDCT arm dominated the stress echocardiography arm (95% confidence interval [CI] = dominant to $29,738) and where MDCT dominated the ECG arm (95% CI = dominant to $7,332). The MDCT risk stratification arm also dominated stress echocardiography and stress ECG in the 2 and 10% prevalence scenarios, which demonstrated the same ICER trends as the 6% prevalence CAD base case. The thresholds where the MDCT arm remained a cost‐saving strategy compared to the other risk stratification strategies were cost of MDCT, <$2,097; cost of OU care, >$1,092; prevalence of CAD, <70%; MDCT specificity, >65%; and a MDCT indeterminate rate, <30%. Conclusions: In this computer‐based model analysis, the MDCT risk stratification strategy is less costly and more effective than both OU‐based stress echocardiography and stress ECG risk stratification strategies in chest pain patients presenting to the ED with low to moderate prevalence of CAD. ACADEMIC EMERGENCY MEDICINE 2008; 15:1–10 © 2008 by the Society for Academic Emergency Medicine