Audit of trauma case load suitable for a day surgery trauma list and cost analysis

Background

Day surgery trauma lists are becoming an increasingly popular and widespread approach to address the inpatient trauma demand on NHS services. A ‘Rapid Access’ list initiative was set-up to book patients from an emergency pathway who require surgery and also fulfilled the standard day case patient criteria but for whom it was safe to wait for over 24 h before going to theatre.

Materials & Methods

We performed a prospective audit of the cases undertaken on the day surgery trauma list over a 12-month period and analysed the number of cases, spectrum of procedures, complications and the cost benefits.

Results

A total of 119 day surgery trauma cases were performed (42 lists; average of 3 cases per list; upper limb procedures accounted for 60%.). The overall cost benefit for day surgery was calculated as the difference between the tariff and the costs for day surgery and inpatient procedures. A cost benefit of £617 per case for day surgery over inpatient surgery was noted with a total saving of £67,450 for the performed procedures.

Discussion

We demonstrate day trauma surgery to be a safe and cost effective method of optimising the management of the appropriate trauma case workload. Further it reduces demand for inpatient beds, provides significant cost savings for the trust and improves patient satisfaction.     

Mortality and treatment cost estimates for 1075 consecutive patients treated by a regional adult burn service over a five year period: The Liverpool experience

Objective

To assess the clinical outcomes and treatment costs of a regional adult burn service in northwest England.

Methods

We retrospectively reviewed data on a five year cohort of 1075 patients treated by the Mersey Regional Burn Service between 2006 and 2010 to obtain age-stratified mortality estimates based on the lethal area 50 (LA50) measure. Treatment cost estimates were made for a one year cohort of 262 patients treated between April 2011 and April 2012.

Results

44 (4.1%) of the five year cohort died; 36 had suffered flame burns. Our LA50 was 71.08 for the 15–44 age group, 56.64 for the 45–64 age group, and 28.82 for the 65 and over age group. Mean treatment costs associated with patients allocated to different burn-specific healthcare resource groups ranged from £2527.77 to £31,870.95. Detailed cost estimates for three patients ranged from £12,553.23 to £66,029.33.

Conclusion

The LA50 estimates for the Mersey Regional Burn Service compare favourably with previous reports in the literature. Our treatment costs were substantially lower compared to those reported previously in the United Kingdom. This study demonstrates that high quality and cost effective care can be delivered by a service that treats relatively few major burns (>70% TBSA).     

The cost of inpatient burn management in Nepal

IntroductionThe management of burns is costly and complex with inpatient burns accounting for a high proportion of the costs associated with burn care. We conducted a study to estimate the cost of inpatient burn management in Nepal. Our objectives were to identify the resource and cost components of the inpatient burn care pathways and to estimate direct and overhead costs in two specialist burn units in tertiary hospitals in Nepal.MethodsWe conducted fieldwork at two tertiary hospitals to identify the cost of burns management in a specialist setting. Data were collected through semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) with burn experts; unit cost data was collected from hospital finance departments, laboratories and pharmacies. The study focused on acute inpatient burn cases admitted to specialist burn centres within a hospital-setting.ResultsExperts divided inpatient burn care pathways into three categories: superficial partial-thickness burns (SPT), mixed depth partial-thickness burns (MDPT) and full thickness burns (FT). These pathways were confirmed in the FGDs. A ‘typical’ burns patient was identified for each pathway. Total resource use and total direct costs along with overhead costs were estimated for acute inpatient burn patients. The average per patient pathway costs were estimated at NRs 102,194 (US$ 896.4), NRs 196,666 (US$ 1725), NRs 481,951 (US$ 4,227.6) for SPT, MDPT and FT patients respectively. The largest cost contributors were surgery, dressings and bed charges respectively.ConclusionThis study is a first step towards a comprehensive estimate of the costs of severe burns in Nepal.     

Implications of Attendance Patterns in Northern Ireland for Abdominal Aortic Aneurysm Screening

Introduction

Evidence supports the introduction of an abdominal aortic aneurysm (AAA) screening programme. The aims of this study were to estimate future disease patterns and to determine the effect of the proportion attending on the programme’s cost-effectiveness.

Patients and methods

The results of the local AAA screening programme were reviewed. Ultrasonic infrarenal aortic diameter of 30 mm was considered aneurysmal. Projected population numbers from the Department of Health and current disease prevalence were used to estimate future number of potential patients. The Multi-centre Aneurysm Screening Study (MASS) Markov model was used to calculate an incremental cost-effectiveness ratio (ICER) and 95% uncertainty intervals (UI), using a 30-year time horizon and 3.5% per annum discount, to determine the effect of attendance.

Results

Men were recruited from August 2004 to May 2010. 13316 were invited for a scan and 5931 (44.5%) attended. 321 AAA were diagnosed, giving a prevalence of 5.4%, while 27 large AAA (0.46%) were repaired. The annual incidence of AAA until 2021 will range from 441 to 526, with an incidence of 40–48 large AAA, with both showing a gradual increase with time. Using this attendance rate, the ICER was calculated at £2350 per life-year gained (95% UI: £1620–£4290), or £3020 per quality-adjusted life-year gained (95% UI: £2080–£5500).

Conclusions

The prevalence of disease in this local AAA screening was similar to other studies. The low attendance will result in many AAA being missed, but will not impact greatly on the long-term cost-effectiveness.     

Timing of operative intervention in the management of acutely fractured ankles and the cost implications

A study of the length of the time between the diagnosis of an ankle fracture and operative intervention and the length of subsequent hospital stay was undertaken. The delay in operative fixation beyond 24 h from injury was associated with a lengthening of stay. The cost implication of a longer stay was assessed. Eighty-seven patients with 87 fractures fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 34 unimalleolar, 35 bimalleolar and 18 trimalleolar fractures. Only 47 (54%) of the patients were operated on within 24 h of injury, even though 74 had presented by 6 h and a further five by 24 h. The mean inpatient stay was 9.6 days for this early operation group.The patients who had their operation delayed were in hospital for a mean of 14 days, a significant difference (P<0.0001) (using Wilcoxon's Signed Rank test). The cost per patient per day of an acute trauma bed is estimated at pound sterlings 225. This translates into an average cost of pound sterlings 990 more per patient whose operation is delayed.We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles as this would result in significant financial savings.     

Economic impact of laparoscopic versus open abdominal rectopexy

BACKGROUND: The introduction of new laparoscopic techniques has important cost implications. The aim of this study was to compare the cost effectiveness of laparoscopic rectopexy with that of open abdominal rectopexy for full-thickness rectal prolapse. METHODS: A cost effectiveness study was conducted alongside a randomized trial of laparoscopic versus open abdominal rectopexy. RESULTS: The efficacy trial demonstrated significant subjective and objective differences in favour of the laparoscopic technique. The mean operating time was 51 min longer for laparoscopic rectopexy than for the open procedure. Laparoscopic disposables incurred a mean cost of pound 291 per patient. The mean duration of hospital stay was significantly shorter for the laparoscopic group (P = 0.001). Laparoscopic rectopexy was associated with an overall mean cost saving of pound 357 (95 per cent confidence interval pound 164 to pound 592; P = 0.042) per patient. CONCLUSION: Laparoscopic rectopexy is associated with superior clinical outcomes and is cheaper than the open approach.     

Cost description of inpatient treatment for ankle fracture

Background

The study estimated the hospital costs associated with the surgical fixation of ankle fractures by either open reduction internal fixation (ORIF) or external fixation.

Method

A retrospective review of the clinical records of all 264 patients admitted with an ankle fracture requiring surgical stabilisation between 1 March 2007 and 29 February 2008. Patient records were examined for a minimum of 6 months after primary admission. A mean cost per patient was calculated based on patient-level hospital resource use. This included all procedures received during both their primary hospitalisation and subsequent re-admissions.

Results

Approximately equal numbers of males and females (mean age 46.2 years) were admitted, and males were significantly younger than females. The mean length of stay was 10.8 days (SD 9.1); however, ORIF (which was performed in the vast majority of cases, 94.7%) was associated with a much shorter mean length of stay compared with external fixation (10.4 days; SD 8.9 vs. 17.4 days; SD 10.2). The mean total hospital cost per patient including was £4730.28 (SD £2340.73) with a higher mean cost for those who received external fixation as the primary procedure (£9453.92; SD £3391.84) compared with ORIF (£4465.76; SD £1965.10). Patients with severe health problems had significantly higher costs than fit and healthy patients (£5982.65; SD £28 77.74 vs. £4375.00; SD £1957.65).

Conclusions

The results highlight the considerable hospital costs associated with the surgical fixation of an ankle fracture, thus providing valuable information for resource planners. Future research should broaden the perspective of the economic analysis to include rehabilitation costs and assess the cost-effectiveness of potential cost-saving strategies.     

Short-term cost effectiveness and long-term cost analysis comparing laparoscopic Nissen fundoplication with proton-pump inhibitor maintenance for gastro-oesophageal reflux disease

BACKGROUND: This study examined the short-term cost-effectiveness and long-term cost of laparoscopic Nissen fundoplication (LNF) versus maintenance proton-pump inhibitor (PPI) medication for severe gastro-oesophageal reflux disease (GORD) based on a randomized clinical trial. METHODS: Costs and outcomes for 12 months were obtained from the first 100 patients in the trial. Detailed costing was performed using resource use data from hospital records and general practitioners' notes. Short-term incremental cost-effectiveness ratios, calculated as the cost difference divided by the effectiveness difference between LNF and PPI therapy, were analysed using net benefit and bootstrap approaches. Long-term cost was examined using sensitivity analyses incorporating published data from other large series. RESULTS: The incremental cost of LNF compared with PPI therapy per additional patient returned to a physiologically normal acid score (less than 13.9) at 3 months was pound5515 (95 per cent confidence interval (c.i.) pound3655 to pound13 400) and the incremental cost per point improvement in combined Gastro-Intestinal and Psychological Well-being score at 12 months was pound293 (90 per cent c.i. pound149 to pound5250). On average, LNF cost pound2247 (95 per cent c.i. pound2020 to pound2473) more than PPI therapy in year 1 and broke even in year 8. Break-even was highly sensitive to hospital unit costs but less sensitive to PPI ingestion rate after LNF, LNF reoperation rate, PPI relapse rate, future PPI price, PPI dose escalation and discount rate. CONCLUSION: From a National Health Service perspective, LNF may be cost-saving after 8 years compared with maintenance PPI therapy for the treatment of GORD.     

Analysis of real-world length of stay data and costs associated with use of autologous skin cell suspension for the treatment of small burns in U.S. centers

BackgroundAutologous skin cell suspension (ASCS) is a treatment for acute thermal burn injuries associated with significantly lower donor skin requirements than conventional split-thickness skin grafts (STSG). Projections using the BEACON model suggest that among patients with small burns (total body surface area [TBSA]<20 %), use of ASCS± STSG leads to a shorter length of stay (LOS) in hospital and cost savings compared with use of STSG alone. This study evaluated whether data from real-world clinical practice corroborate these findings.Materials and methodsElectronic medical record data were collected from January 2019 through August 2020 from 500 healthcare facilities in the United States. Adult patients receiving inpatient treatment with ASCS± STSG for small burns were identified and matched to patients receiving STSG using baseline characteristics. LOS was assumed to cost $7554/day and to account for 70 % of overall costs. Mean LOS and costs were calculated for the ASCS± STSG and STSG cohorts.ResultsA total of 151 ASCS± STSG and 2243 STSG cases were identified; 63.0 % of patients were male and the average age was 44.2 years. Sixty-three matches were made between cohorts. LOS was 18.5 days with ASCS± STSG and 20.6 days with STSG (difference: 2.1 days [10.2 %]). This difference led to bed cost savings of $15,587.62 per ASCS± STSG patient. Overall cost savings with ASCS± STSG were $22,268.03 per patient.ConclusionsAnalysis of real-world data shows that treatment of small burn injuries with ASCS± STSG provides reduced LOS and substantial cost savings compared with STSG, supporting the validity of the BEACON model projections.     

What is the financial cost of treating periprosthetic hip fractures?

A total of 146 patients were identified from a prospective database of all hip fractures over a 10-year period at a United Kingdom teaching hospital. The financial costs were calculated and analysed and then compared with the money recovered through the tariff produced by Payment by Results.A total of 62% of the study group were female; mean age of 79 years; mean length of stay of 39 days. Fractures occurred around total hip replacement (THR) in 63 cases, revision THR in 27 cases and hemiarthroplasty in 56 cases. Fixation of the fracture was performed in 61 cases, revision arthroplasty in 62 cases and 23 were treated non-operatively.The mean cost of treatment was £23,469 per patient (range £615-£223,000; median £18,031). Ward costs were responsible for 80.3%, theatre costs 5.7%, implants 6.7% and investigations 7.3%. The difference in cost was statistically significant when further surgery was required (p = 0.01) and length of stay was greater than 30 days (p < 0.0001), and when compared with the money recovered by the Trust (mean £3702; p < 0.0001). These results reveal the significant economic impact of treating this group of patients at specialist centres.     

Estimation of the additional costs of chemotherapy for patients with advanced non-small cell lung cancer

BACKGROUND: A large multicentre randomised trial, the Big Lung Trial, which in part compared supportive care with or without cisplatin-based chemotherapy in patients with advanced non-small cell lung cancer, provided an opportunity to evaluate the impact on the UK National Health Service of the costs incurred with the use of chemotherapy. METHODS: This costing study was based on the retrospective collection of resource use data from hospital records. Case notes from 194 patients (98 chemotherapy + supportive care (C), 96 supportive care alone (NoC)) were inspected in eight centres recruiting the largest numbers of patients into the Big Lung Trial. Quantities were multiplied by fixed unit costs to calculate a total cost for each patient. The main outcome measure was the total cost incurred by the use of secondary care resources (including investigations, chemotherapy, radiotherapy, surgical procedures, inpatient days, outpatient attendances, and hospice inpatient care) in the two groups. RESULTS: Patients randomised to receive cisplatin-based chemotherapy had an average of 3.4 more inpatient bed days than the mean of 11.9 days for patients randomised to supportive care alone, and more outpatient attendances. NoC patients were more likely to have received palliative radiotherapy. The mean total cost for C patients was 5355 sterling pound compared with 3595 sterling pound for the NoC group, difference 760 sterling pound (95% CI 781 sterling pound to 2742 sterling pound ). When split, the cost in the C group associated with the administration of chemotherapy was 1233 sterling pound and non-chemotherapy costs were 4122 sterling pound . CONCLUSION: The additional cost of chemotherapy was not offset by a reduction in subsequent costs (as the non-chemotherapy costs were similar), so the survival benefit of about 10 weeks observed in the C group was achieved with the cost of chemotherapy administration.     

The cost of a hot drink scald

Approximately 6400 children per year are admitted to UK hospitals for treatment of burns [National Burn Care Review Committee Report (NBCRC). Standards and Strategy for Burn Care: a review of burn care in the British Isles. 2001.]. This paper investigates the financial costs involved in the management of uncomplicated, minor paediatric scalds. Three cases (2-4% TBSA scalds) were studied to quantify consumables used, services required during management and costs obtained from appropriate Purchasing Departments and Directorate Accountants. Management in all cases involved a general anaesthetic for cleaning of wounds, application of BioBrane (Bertek Pharmaceuticals) and dressings, observation on Children's Ward and discharge following wound review at 48 h. The calculated mean average cost per case was pound1850. In the period 01/12/2002-30/11/2003, 144 children were admitted to Frenchay hospital, Bristol, for treatment of a minor burn or scald (less than 10%TBSA). This caseload is therefore estimated to currently cost pound266,400 per year. These findings may facilitate improved planning for future resource allocation and could also contribute evidence towards the cost effectiveness of prevention strategies.     

Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme

BACKGROUND: Pulmonary rehabilitation programmes improve the health of patients disabled by lung disease but their cost effectiveness is unproved. We undertook a cost/utility analysis in conjunction with a randomised controlled clinical trial of pulmonary rehabilitation versus standard care. METHODS: Two hundred patients, mainly with chronic obstructive pulmonary disease, were randomly assigned to either an 18 visit, 6 week rehabilitation programme or standard medical management. The difference between the mean cost of 12 months of care for patients in the rehabilitation and control groups (incremental cost) and the difference between the two groups in quality adjusted life years (QALYs) gained (incremental utility) were determined. The ratio between incremental cost and utility (incremental cost/utility ratio) was calculated. RESULTS: Each rehabilitation programme for up to 20 patients cost pound 12,120. The mean incremental cost of adding rehabilitation to standard care was pound -152 (95% CI -881 to 577) per patient, p=NS. The incremental utility of adding rehabilitation was 0.030 (95% CI 0.002 to 0.058) QALYs per patient, p=0.03. The point estimate of the incremental cost/utility ratio was therefore negative. The bootstrapping technique was used to model the distribution of cost/utility estimates possible from the data. A high likelihood of generating QALYs at negative or relatively low cost was indicated. The probability of the cost per QALY generated being below pound 0 was 0.64. CONCLUSIONS: This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service.     

Quality and cost between transcervical and transurethral prostatectomy

Although transurethral resection of the benign prostate (TURP) is a popular technique, it is not without problems. The average postoperative morbidity could be up to 50%. Therefore the quality of life and the total cost have been evaluated in this study, since the incidence of re-TURP was reported to be as high as 25% in 8 years period. This was attributable to incomplete resection, in that only about 40% of the prostatic tissue being resected by this technique.In contrast, transcervical prostatectomy (TCP) performs a total enucleation of the gland. It seems to be cost effective, in that the postoperative urethral catheter is removed routinely on the second day and the patients are discharged home on the fourth day routinely. The total incidence of morbidity, by contrast, was less than 5% and that of mortality under 1%.The initial cost for the primary operation would not be much difference between the these two techniques, but the average cumulative cost per TURP would be expensive, if all the expenses incurred for the treatment of postoperative complications are added together. It would be between £2574.00 and £2434.00, for the primary operation. But the cumulative cost for TURP would be £4333.00 and for TCP £2580.00. The true cost for the operation of TURP could be as high as £10720, compared to £2434.00, being the operation charge for TCP, if all expenses have to be paid by the patient.Conclusion: Transcervical Prostatectomy compares favourably with TURP in every aspect, apart from the skin cut in the lower abdomen.     

Population-based study of the surgical workload and economic impact of bowel obstruction caused by postoperative adhesions

BACKGROUND: Intestinal obstruction is the most severe consequence of adhesion formation. This study examined the annual surgical workload and costs of intestinal obstruction caused by postoperative intra-abdominal adhesions. METHODS: The study was a retrospective case-note review of patients hospitalized for intestinal obstruction caused by postoperative adhesions in a well defined geographical area. The surgical workload and direct costs of inpatient care were analysed. RESULTS: There were 138 admissions for postoperative adhesion-related intestinal obstruction during the study with a total of 1118 inpatient days. The median hospital stay was 4 (range 1-58) days among patients who had non-operative treatment and 11 (range 2-34) days for those who had surgery. Surgery was necessary in 40 patients (29.0 per cent). The mean operating time (time from skin incision to last stitch) and the mean time spent in the operating theatre were 79 and 141 min respectively. The cumulative operating time for the surgical group was 52 h 20 min and the cumulative theatre time was 93 h 44 min. The annual direct hospital cost for postoperative adhesional intestinal obstruction was pound 181 653 in the district studied and the estimated cost for the whole of Finland was pound 2 077 796. CONCLUSION: This population-based study indicates that the workload and costs associated with bowel obstruction caused by postoperative adhesions are substantial.     

Randomized clinical trial of the effectiveness of emergency day surgery against standard inpatient treatment

BACKGROUND: The aim of this study was to assess the feasibility of treating patients with minor and intermediate general surgical emergency conditions as day cases. METHODS: Emergency referrals for minor and intermediate general surgical conditions were assessed by a surgeon. Those fitting day-case criteria and requiring operation under general anaesthesia were randomized to receive standard inpatient care or day surgery. Patients in the latter group were booked on to day-case lists or gaps on inpatient elective lists for surgery within 48 h. The process was coordinated by an experienced theatre sister. RESULTS: One hundred patients were randomized. There was a reduction in the number of nights spent in hospital in the day-case group (median 0 versus 2 nights; P < 0.001). The median time from diagnosis to treatment was 1 day in both groups, although there was a small but significant delay in the day-case group (P = 0.018). There was no significant difference in postoperative outcome or patient and general practitioner satisfaction. The day-case option had no increased impact on primary care services but was associated with a significant saving of about pound sterlings 150 per patient (P < 0.001).CONCLUSION: Certain general surgical emergencies may be managed as day cases with cost saving but without detriment to patient care.     

A model for analyzing the cost of the main clinical events after lung transplantation.

BACKGROUND: The aim of this project was to model clinically important events experienced by lung transplant patients (from the day after transplant to 5 years or death) and costs associated with these events, and to assess the economic impact of different immunosuppression therapies. METHODS: The population comprised 356 lung transplant patients (223 heart-lung, 102 single lung and 31 double lung) transplanted between April 1984 and December 1997. All patients received a cyclosporine-based triple-immunosuppression protocol. We designed a Markov model that included 3 time periods (0 to 6, 7 to 12, and 13 to 60 months), 5 clinical states (well, acute rejection, cytomegalovirus infection, non-cytomegalovirus infection and bronchiolitis obliterans syndrome), and death. For the well state, cost elements were immunosuppression, prophylaxis, and routine clinic visits. For all other states, cost elements were diagnosis, treatment, and bed days/visits. We excluded costs of the procedure. RESULTS: The monthly costs associated with the well state decreased over time, from pound sterlings 1,778 ($2,658) in the first 6 months to pound sterlings 503 ($752) in months 7 to 12 and pound sterlings 350 ($523) after the first 12 months. The cost per event of the acute states remained reasonably constant over the 3 periods: pound sterlings 1,850 ($2,766) for rejection, pound sterlings 3,380 ($5,053) for cytomegalovirus, and pound sterlings 2,790 ($4,171) for other infections. The average cost per patient, discounted at 6%, over 5 years was pound sterlings 35,429 ($52,966) (95% range, pound1,435 [$2,145] to pound67,079 [$100,283]). This estimate is most sensitive to changes in immunosuppression. Substituting tacrolimus for cyclosporine increased 5-year costs by 5%; substituting mycophenolate mofetil for azathioprine increased 5-year costs by 26%. CONCLUSIONS: This model is valuable in estimating the effect of new immunosuppression agents on the costs of follow-up care.     

Cost implications of sexual dysfunction: the female picture

This study examined the clinical workload, outcome and direct costs of managing women with sexual dysfunction in an NHS clinic in the UK. A retrospective analysis of a 3-month period showed that of 47 referrals to the clinic, 38 undertook treatment. The therapists' assessments suggested that over 80% of patients improved on treatment. The average cost per patient was pound 472 (compared to pound 335 per annum for erectile dysfunction, which included physician's and drug costs). The average cost by type of practitioner was pound 278 (psychologist), pound 322 (physician), pound 532 (physician and psychologist) and pound 597 (sex therapist). Patients required between 1 and 51 treatment sessions, which were mainly restricted to psychological therapy. Female sexual dysfunction (FSD) represents a significant economic burden to the NHS. Further research on the potential role and cost effectiveness of pharmacological agents for FSD is warranted.     

Burn care costing: the Welsh experience

It has been accepted for many years that the cost of care for the burn-injured patient is high. There is, however, little published data to show how "expensive" it is. At the Welsh Centre for burns we have undertaken a costing exercise in an attempt to define the true cost to the treatment of burns. Using our current cost base and activity, we established a cost per health related group (HRG) for burns and also prospectively calculated costs for three inpatients to determine whether HRG-based burn tariffs accurately represent these costs. The NHS is under increasing pressure to provide evidence to support budgetary requirements; we feel this paper offers a framework for burn care costing upon which calculations could be based.     

Cost-effectiveness of raloxifene in the UK: an economic evaluation based on the MORE study

Raloxifene treatment has been shown to reduce the risk of vertebral fractures and breast cancer in postmenopausal women. The long-term economic implications of treatment with raloxifene have not yet been investigated. The aim of this study was to assess the cost-effectiveness of treating postmenopausal women in the UK with raloxifene. A previously developed computer simulation model was used to estimate the cost-effectiveness of osteoporotic treatments with extra skeletal benefits. The model was populated with epidemiological data and cost data relevant for a UK female population. Data on the effect of treatment were taken from the Multiple Outcomes of Raloxifene (MORE) study, which recruited women with low bone mineral density or with a prior vertebral fracture. Cost-effectiveness was estimated using Quality Adjusted Life Years (QALYs) and life years gained as primary outcome measures. The cost per QALY gained of treating postmenopausal women without prior vertebral fractures was £18,000, £23,000, £18,000 and £21,000 at 50, 60, 70 and 80 years of age. Corresponding estimates for women with prior vertebral fractures were £10,000, £24,000, £18,000 and £20,000. In relation to threshold values that are recommended in the UK, the analysis suggests that raloxifene is cost-effective in the treatment of postmenopausal women at an increased risk of vertebral fractures.