Socio-economic evaluation of mental health as a basis for financing health care in Sweden

The objective of this paper is to examine hypotheses about the relationships between socio-economic factors, risk factors in working life, and the occurrence of mental illness, together with the degree of quality of life and consumption of health care, costs for health care, and costs for social insurance. This is a prospective and longitudinal study of 1,347 individuals of an active working age, 18–64 years, who have been on sick leave for more than 30 days. The group is characterized by the prevalence of risk factors in their work environment and welfare losses, such as multiple health problems, poor quality of life, inability to work, and dependency on society's support from health care and social insurance. The costs for health care were just over 2.8 million SEK, or 30 percent higher for those with psychological distress as compared to the group without. The payments from social insurance also increased by approximately 15 percent. The relatively greater weighting of health care costs and sickness cash benefits were motivating factors to study whether this group had an optimal amount and quality of health care, or if the resources available for health care should be distributed in another way that better satisfies the needs of the group.     

Inpatient and outpatient rehabilitation for patients with rheumatoid arthritis: a clinical and economic assessment

Summary

The aim of this study was to compare inpatient and outpatient rehabilitation for patients with active rheumatoid arthritis from clinical and cost perspectives.

A single-centre, randomised trial design was used. Data were recorded at baseline, post treatment and at 6 months follow-up. The primary outcome measure was the Arthritis Impact Measurement Scale 2. Several other disease activity, functional and quality of life measures were also assessed (erythrocyte sedimentation rate, C-reactive protein, visual analogue scale for pain, early morning stiffness, tender and swollen joint count, grip strength, timed ‘Up and Go’ test and Schedule for the Evaluation of the Individual Quality of Life—Direct Weighting). All direct and indirect costs were measured. A total of 47 subjects were randomised to the study.

No sustained significant differences were detected between the two groups for the primary or secondary measures at the end of treatment or at follow-up. Total inpatient costs (€81,590) were more than three times higher than total outpatient costs (€25,450).     

Time-driven activity-based cost analysis for outpatient anticoagulation therapy: direct costs in a primary care setting with optimal performance

Objectives: To determine how overall cost of anticoagulation therapy for warfarin compares with that of Novel Oral Anticoagulants (NOACs). Also, to demonstrate a scientific, comprehensive, and an analytical approach to estimate direct costs involved in monitoring and management of anticoagulation therapy for outpatients in an academic primary care clinic setting, post-initiation of therapy.

Methods: A population-based cross-sectional study was conducted in conjunction with observations of patient care processes between August 2014 and January 2015. The study was conducted in an academic primary care outpatient setting at Mayo Clinic’s warfarin anticoagulation clinic, Rochester, MN. The anticoagulation clinic serves patients 18?years of age or older in Warfarin therapy management, for any indication, after referral from the patient’s primary care provider. The study included anticoagulation clinic enrollment data on a population of 5,526 patients. Time-Driven Activity-Based Costing (TDABC) technique was applied. Detailed process flow maps which showed process steps for all the anticoagulation program components and care continuum phases were created. Staff roles associated with each of the process steps were identified and displayed on the maps. Process times and costs were captured and analyzed. The main outcome was direct cost of monitoring and management of anticoagulation therapy, post-initiation of therapy.

Results: The cost of warfarin management for patients who display unstable International Normalized Ratio (INR) is more than three times those who display stable INR over time. (Comparator to distinguish stability: Frequency of point-of-care visits needed by patients.) For complex anticoagulation patients, total cost of medication and monitoring for warfarin anticoagulation therapy is similar to that for NOACs.

Conclusion: Despite warfarin being significantly less expensive to purchase than NOACs, overall warfarin management incurs higher costs due to laboratory monitoring and provider time than NOACs. NOAC treatment, therefore, may not be more expensive than warfarin therapy management for complex anticoagulation patients.     

Association between provider specialty and healthcare costs and glycemic control for patients with diabetes

Aims: To analyze the association between provider, healthcare costs, and glycemic control for patients with diabetes mellitus (DM).

Materials and methods: This cross-sectional study identified adults with type 1 or 2?DM (T1D, T2D) in the Optum database. The main independent variable was provider (endocrinologist or primary care). Regression analysis compared total medical and pharmacy costs, adjusting for health status and other patient differences, by provider.

Results: For all patients, HbA1C improvement was greater, and medical costs significantly lower with an endocrinologist rather than a primary care provider. The largest HbA1C improvement (4%) occurred for insulin-dependent patients seen by endocrinologists. Significant medical savings with endocrinologist management occurred within the Medicare Advantage population in every sub-group of patients, with 14% lower costs ($4,767) for patients with T1D, 11% lower costs ($3,160) for patients with macro- and microvascular complications, and 10% lower costs ($2,237) for insulin-dependent patients. Within the commercial insurance population, medical costs were reduced by ≥9% in every sub-group of patients, with a 20% reduction ($8,450) for patients with micro- and macrovascular complications. Overall total costs (medical and pharmacy) were 8% ($1,541) higher for patients receiving endocrinologist rather than primary care, although endocrinologist care resulted in a 9% reduction (–$3,710) in costs for Medicare Advantage patients with T1D. Total medical costs (excluding pharmacy costs) may be a more accurate indicator of costs associated with patients in various stages of DM.

Limitations: There was insufficient data to develop risk-adjustment payments for pharmacy costs based on disease severity. The cross-sectional design identifies associations and not cause–effect relationships.

Conclusion: DM management by an endocrinologist was associated with greater HbA1C improvement and significantly lower medical costs. Total costs were higher with an endocrinologist, but for patients with T1D lower costs were seen, ranging from 2–9% regardless of insurance type.     

Economic evaluation of rehabilitation: The quality of life approach using EuroQol

By using resources in a health care alternative activity, the objective for improved health requires the valuation of competing health care programs to inform resource allocation and facilitate prioritization. A measure of health status is used as an outcome of rehabilitation. This paper uses the EuroQol/EQ-5 as an instrument to measure health-related quality of life. Health status is used to determine values that correspond to preferences of the general public. This analysis assumes the existence of a structural problem where the performance of the rehabilitation program and the prognosis behind the definition of need for rehabilitation are determined simultaneously.     

Exploring the variability of patient costs in disease management programs: a hierarchical modelling approach

Disease management programs include a wide variation of patients with different chronic diseases and different health care utilization. The aim of this article was to identify factors on patient-level and organizational-level that explain the variability in costs of patients with different chronic diseases enrolled in a DMP by employing a rigorous analytical model. A generalized linear mixed model (GLMM) was specified to perform a multi-level analysis of cross-sectional hierarchical data from 16 DMPs in the Netherlands. Multiple imputation, sub-group analysis per disease and analysis from both the health care and the societal perspectives were also performed. Our model showed that age, the presence of cardiovascular disease, multi-morbidity and payments on top of the payment for the usual care had positive relation with costs, while better quality of life was associated with lower health care costs. In the COPD sample, physical activity and employment were associated with health care costs. Our study showed that there is great variability in health care costs among patients included in DMPs and identified patient and organizational explanatory factors. The findings are relevant to the design of future DMPs and their payment schemes.     

Estimated cost savings associated with the use of valsartan in heart failure in a large US health plan

Summary

Results from a large, randomised clinical trial demonstrated reduced rates of hospitalisation and mortality, and reduced length of stay associated with valsartan added to the usual care of heart failure patients not currently receiving angiotensin-converting enzyme inhibitors (ACEIs). These results were used in a budget impact model for a large US health plan. Administrative claims data were used to estimate cost savings over 1 year. In the study health plan, 63,218 patients were identified with heart failure, with 55% not currently receiving ACEI or valsartan. Using health plan-specific cost data, care for the untreated heart failure patients with valsartan would reduce hospitalisation costs from $135 million to $43 million owing to averted heart failure-related hospitalisations and shortened length of stay for the remaining hospitalisations. Economic effects of other aspects of treatment with valsartan (e.g. outpatient or physician visits or adverse events) were not considered. Taking into account only hospitalisations and the costs of valsartan therapy, net savings in the study health plan would be expected to be $64 million.     

Therapy Cost 2000: a computer model for pharmacoeconomic analysis

Summary

Today more than ever, providing quality care to patients at the lowest cost is of primary concern to hospitals, clinics, managed care organisations, integrated health systems, and all other healthcare providers operating in a prospective payment environment. Healthcare decision makers must allocate resources based on the most cost-effective treatments without sacrificing quality of care. Therapy Cost 2000 is a user-friendly Windows-based software program that can assist decision makers in reaching the goal of cost-effective quality patient care. Potential uses of the software include: cost analysis for formulary recommendations and policy initiatives, quantification of the budgetary impact of new therapies, head-to-head cost-effectiveness analysis of treatment options, and forecasting of future resource expenditures through modelling of treatment costs and treatment patterns.     

Model to evaluate the cost-effectiveness of different antibiotics in the management of community-acquired pneumonia in Germany

Summary

This study investigated the primary cost-drivers and determinants of the cost-effectiveness of antibacterial treatment of community-acquired pneumonia (CAP) in Germany. It assessed the health care costs and consequences related to treatment initiated in the community using macrolides, fluoroquinolones, and cephalosporins. Patients were categorised according to disease severity. Decision analysis was used to consider the clinical and economic consequences of various treatment options from first-line treatment initiated by a primary care physician in the community to success or failure after third-line treatment in hospital.

The key cost drivers were the clinical success/failure rates of first-line treatment and, in moderate CAP, the cost per day of hospitalisation. Thus, antibiotics with the cheapest purchase price are not necessarily the most cost-effective treatment. This is because the extra costs associated with treatment failure, especially in more severely ill patients, can be much greater than the acquisition costs of the first-line antibiotic. Of the antibiotics considered, none was consistently found to be the most cost-effective across the full range of scenarios investigated. However, in moderate CAP the fluoroquinolones and cephalosporins were generally more cost-effective than the macrolides. Given the high cost associated with hospitalisation, and the low mortality rates in low-risk patients with mild and moderate CAP, successful outcomes and health care cost savings can be achieved if such patients receive appropriate antibiotics as first-line treatment in the community.     

Economic assessment of doripenem versus imipenem in the treatment of ventilator-associated pneumonia

Abstract

Background: Ventilator-associated pneumonia (VAP), the most common nosocomial infection in critically ill patients, is associated with significantly longer duration of mechanical ventilation, and increased mortality, hospital days, and health-care costs. A previously published prospective, randomized study established the noninferiority of intravenous (IV) doripenem versus IV imipenem/cilastatin (‘imipenem‘) for VAP. This study compares the economic outcomes of IV therapy with doripenem versus imipenem as first-line treatment for VAP.

Methods: A decision-analytic model of inpatient care and outcomes for VAP was used to estimate costs associated with VAP treatment. The model calculates total hospital costs, comprising costs of initial and concomitant therapy, and costs associated with mechanical ventilation, intensive care unit stays, and total days in hospital.

Results: Total treatment costs for doripenem were $10,630 lower than for imipenem ($71,259 vs. 81,889), driven primarily by differences in costs of mechanical ventilation ($45,224 for doripenem, $57,348 for imipenem). Probabilistic sensitivity analyses found doripenem consistently cost saving versus imipenem in 1,000 simulations. Study limitations include use of a simple model to represent a complex disease process and reliance on trial data that may not reflect real-world care and outcomes.

Conclusions: Doripenem is a cost saving first-line treatment for VAP versus imipenem while providing an equivalent rate of cure.     

Clinical and economic benefit of enzymatic debridement of pressure ulcers compared to autolytic debridement with a hydrogel dressing

Abstract

Objective:

The purpose of this study was to determine the cost-effectiveness of enzymatic debridement using collagenase relative to autolytic debridement with a hydrogel dressing for the treatment of pressure ulcers.

Methods:

A 3-stage Markov model was used to determine the expected costs and outcomes of wound care for collagenase and hydrogel dressings. Outcome data used in the analysis were taken from a randomized clinical trial that directly compared collagenase and hydrogel dressings. The primary outcome in the clinical trial was the proportion of patients achieving a closed epithelialized wound. Transition probabilities for the Markov states were estimated from the clinical trial. A 1-year time horizon was used to determine the expected number of closed wound days and the expected costs for the two alternative debridement therapies. Resource utilization was based on the wound care treatment regimen used in the clinical trial. Resource costs were derived from standard cost references and medical supply wholesalers. The economic perspective taken was that of the long-term care facility. No cost discounting was performed due to the short time horizon of the analysis. A deterministic sensitivity analysis was conducted to analyze economic uncertainty.

Results:

The number of expected wound days for the collagenase and hydrogel cohorts are estimated at 48 and 147, respectively. The expected direct cost per patient for pressure ulcer care was $2003 for collagenase and $5480 for hydrogel debridement. The number of closed wound days was 1.5-times higher for collagenase (317 vs 218 days) than with the hydrogel. The estimated cost/closed wound day was 4-times higher for the hydrogel ($25) vs collagenase ($6).

Conclusions:

In this Markov model based on a randomized trial of pressure ulcer care in a long-term care setting collagenase debridement was economically dominant over autolytic debridement, yielding better outcomes at a lower total cost. Since it was a single institution study with a small sample size, the results should be interpreted with caution. Specifically, the findings may not necessarily be generalized to other hydrogel dressings, healthcare settings, age groups, or to wounds of other etiologies.     

Treatment patterns and healthcare resource utilization and costs in heavy menstrual bleeding: a Japanese claims database analysis

Aims: Heavy menstrual bleeding (HMB) is a highly prevalent condition, characterized by excessive menstrual blood loss and cramping, that interferes with activities of daily life. The aim of this study was to investigate treatment patterns in HMB in Japan, and to assess healthcare resource utilization and costs among women newly-diagnosed with the condition.

Materials and methods: This study retrospectively analyzed health insurance data available in the Japan Medical Data Center (JMDC) database on women aged 18–49 years who were newly-diagnosed with primary or secondary HMB. Treatment patterns were analyzed, and healthcare utilization and costs were evaluated and compared to matched controls.

Results: The study included a total of 635 patients, 210 with primary HMB and 425 with secondary HMB. In the primary HMB cohort, 60.0% of patients received one or more pharmacological or surgical treatments, compared with 76.2% in the secondary HMB cohort. The most commonly prescribed medications in all patients were hemostatic agents (28.7%), traditional Chinese medicine (TCM) (12.1%), and low-dose estrogen progestins (LEPs) (10.1%). After adjustment for patient baseline characteristics, healthcare costs were 1.93-times higher in primary HMB cases (p?<?.0001) and 4.44-times higher in secondary HMB cases (p?<?.0001) vs healthy controls. Outpatient care was the main cost driver.

Limitations: The main limitations of this study are related to its retrospective nature, and the fact that only reimbursed medications were captured in the source database.

Conclusions: A substantial proportion of HMB patients did not receive the recommended treatments. Healthcare costs were considerably increased in the presence of an HMB diagnosis.     

Saving the public from the private? Incentives and outcomes in dual practice

We consider a monopoly physician offering free public treatment and, if allowed, a private treatment for which patients have to pay out of pocket. While patients differ in the propensity to benefit from private treatment it always yields better health outcomes than public treatment but is also more costly in terms of money and time. We study the physician's supply of private care and allocation of time costs across public and private patients and contrast these with the first‐best allocation. To increase the willingness‐to‐pay for private treatment the physician shifts time costs to public patients. While this turns out to be socially optimal, the resulting positive network effect leads to an over‐provision of private care if time costs are sufficiently high. A second‐best allocation arises when the health authority sets public reimbursement but has no control over private provision. Depending on the welfare weight the health authority attaches to physician profits, a ban of dual practice may improve on the second‐best allocation. Notably, a ban benefits not only public patients but also private patients with a moderate propensity to benefit from private care.     

Medical economic impact of tracheotomy patients on a hospital system

Abstract

Background:

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system.

Methods:

A retrospective review of the health system’s hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated.

Results:

There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ～18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed.

Conclusions:

There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.     

Cost-effectiveness of subdermal implantable buprenorphine versus sublingual buprenorphine to treat opioid use disorder

Aims: Subdermal implantable buprenorphine (BSI) was recently approved to treat opioid use disorder (OUD) in clinically-stable adults. In the pivotal clinical trial, BSI was associated with a higher proportion of completely-abstinent patients (85.7% vs 71.9%; p?=?.03) vs sublingual buprenorphine (SL-BPN). Elsewhere, relapse to illicit drug use is associated with diminished treatment outcomes and increased costs. This study evaluated the cost-effectiveness of BSI vs SL-BPN from a US societal perspective.

Methods: A Markov model simulated BSI and SL-BPN cohorts (clinically-stable adults) transiting through four mutually-exclusive health states for 12 months. Cohorts accumulated direct medical costs from drug acquisition/administration; treatment-diversion/abuse; newly-acquired hepatitis-C; emergency room, hospital, and rehabilitation services; and pediatric poisonings. Non-medical costs of criminality, lost wages/work-productivity, and out-of-pocket expenses were also included. Transition probabilities to a relapsed state were derived from the aforementioned trial. Other transition probabilities, costs, and health-state utilities were derived from observational studies and adjusted for trial characteristics. Outcomes included incremental cost per quality-adjusted-life-year (QALY) gained and incremental net-monetary-benefit (INMB). Uncertainty was assessed by univariate and probabilistic sensitivity analysis (PSA).

Results: BSI was associated with lower total costs (?$4,386), more QALYs (+0.031), and favorable INMB at all willingness-to-pay (WTP) thresholds considered. Higher drug acquisition costs for BSI (+$6,492) were outpaced, primarily by reductions in emergency room/hospital utilization (?$8,040) and criminality (?$1,212). BSI was cost-effective in 89% of PSA model replicates, and had a significantly higher NMB at $50,000/QALY ($20,783 vs $15,007; p?Conclusions: BSI was preferred over SL-BPN from a health-economic perspective for treatment of OUD in clinically-stable adults. These findings should be interpreted carefully, due to some relationships having been modeled from inputs derived from multiple sources, and would benefit from comparison with outcomes from studies that employ administrative claims data or a naturalistic comparative design.     

The cost of imperfect agency in health care: Evidence from rural Cameroun

Health is a pressing problem facing Africans today, yet health care systems in Africa are inadequate and under-funded. We show that pervasive imperfect agency means that they are also inefficient. Imperfect agency (due to unobservable medical effort) is a recognized market failure in health care, but its impact is difficult to measure. We take an indirect approach to estimation and infer the cost of unobservable effort from the behavior of utility-maximizing patients, specifically their willingness to incur measurable costs to avoid practitioners who shirk. We use a unique data set from rural Cameroun where patients choose between the government health system, church-operated (mission) health facilities and, importantly, traditional healers. Traditional healers provide health services on an outcome–contingent basis where patients pay only if they are cured. Both government and mission facilities, in contrast, are paid on a fee-for-service basis. Patients' choices of practitioners, combined with quantitative information about patients' illnesses, permit a structural estimation of the value of unobservable medical effort. The results allow investigation into the nature of agency, its costs, and the manner in which contracts reduce and patient behavior mitigates those costs. We estimate that in the absence of imperfect agency, utility from health care would increase by at least 160%. Even in the face of imperfect agency, the sophistication of patients in choosing between existing contracts for different illnesses increases utility by up to 20%.     

Economic evaluation of inhalers used in the treatment of asthma

Summary

Asthma is an important disease for New Zealand in terms of prevalence and costs, both direct and indirect. The objective of this study was to determine if there were any differences in primary care medical costs between treatment of asthma with four corticosteroid inhaler drug delivery systems (Autohaler? [AUTO], Diskhaler? [DISK], metered dose inhaler [MDI] and Turbuhaler? [TURB]) in a general practice setting.

The retrospective observational data-based research completed for this study involved a large population and recorded actual general practitioner prescribing practice. The perspective taken was that of the funder of health care. Data were obtained from the computerised clinical records of 28 New Zealand general practices. Cost data were on a per year per patient basis.

The largest single cost item identified in this study was that of corticosteroid inhalers which ranged from 41% of total primary care cost for MDI to 52% for the TURB group. Total drug acquisition cost (inclusive of dispensing costs and wholesale and retail markups) was highest for TURB at $490 and lowest for MDI at $265, a difference of 85%. There was less variation in general practitioner consultations for asthma with total costs ranging from $104 for AUTO to $127 for DISK. Total primary care costs were lowest for MDI at $392 per annum and highest for TURB at $608, a difference of 55%. If the MDI total primary care costs are used as the base for an index (MDI total primary care costs set at 100) then AUTO becomes 116, DISK 134 and TURB 155.

The model was robust with respect to conclusions relating to cost differences between the treatment groups. In all but one instance TURB remains the highest cost group.     

Changing health care, one phone call at a time

Demand management is an approach to providing health care benefits that is designed to help beneficiaries receive the appropriate level of care at the appropriate time. When this is accomplished, health care expenditures are reduced. This case study shows how a large union health plan implemented a demand management program that has been well received by its members and has been effective in helping to control plan costs.     

Second opinion programs: continued savings from nonconfirmed surgeries

A second opinion program for elective surgery was one of the first tools utilized by employers to "manage" health care costs. These authors argue that second opinion programs continue to demonstrate their usefulness as part of overall health care cost-management effort.