Costing anaesthetic practice: reconciling perspectives and approaches

Summary

In a previously published article by Broadway and Jones, the anaesthesia-related cost of a hernia repair operation was estimated to be £74.40, of which 21% was accounted for by anaesthetic agents and adjunct drugs. This result contrasts with our estimate of the total procedure cost for an inpatient hernia repair operation of £1,037.39, of which anaesthetic agents and adjunct drugs comprised less than 1%. In order to explain this difference, in this paper we compare and contrast our methodology for and perspective on costing resource use in anaesthesia with those used by Broadway et al. We conclude that these two apparently divergent results, once reconciled in terms of cost coverage and perspectives taken, are broadly equivalent (a reconciled cost of £78.21 compared with the £74.40 of Broadway and Jones.), and that the cost of anaesthetic agents and adjunct drugs constitute a small proportion of total procedure costs.     

Healthcare resource utilization among patients with relapsed multiple myeloma in the UK,France, and Italy

Aims: To assess the real-world healthcare resource utilization (HRU) and costs associated with different treatment regimens used in the management of patients with relapsed multiple myeloma in the UK, France, and Italy.

Methods: Retrospective medical chart review of characteristics, time to progression, level of response, HRU during treatment, and adverse events (AEs). Data collection started on June 1, 2015 and was completed on July 15, 2015. In the 3 months before record abstraction, eligible patients had either disease progression after receiving one of their country’s most commonly prescribed regimens or had received the best supportive care and died. Costs were calculated based on HRU and country-specific diagnosis-related group and/or unit reference costs, amongst other standard resources.

Results: Physicians provided data for 1,282 patients (387 in the UK, 502 in France, 393 in Italy) who met the inclusion criteria. Mean [median] total healthcare costs associated with a single line of treatment were €51,717 [35,951] in the UK, €37,009 [32,538] for France, and €34,496 [42,342] for Italy, driven largely by anti-myeloma medications costs (contributing 95.0%, 90.0%, and 94.2% of total cost, respectively). During active treatment, the highest costs were associated with lenalidomide- and pomalidomide-based regimens. Mean cost per month was lowest for patients achieving a very good partial response or better. Unscheduled events (i.e. not considered part of routine management, whether or not related to multiple myeloma, such as unscheduled hospitalization, AEs, fractures) accounted for 1–9% of total costs and were highest for bendamustine.

Limitations: The use of retrospective data means that clinical practice (e.g. use of medical procedures, evaluation of treatment response) is not standardized across participating countries/centers, and some data (e.g. low-grade AEs) may be incomplete or differently adjudicated/reported. The centers involved may not be fully representative of national practice.

Conclusions: Drug costs are the main contributor to total HRU costs associated with multiple myeloma. The duration of active treatment may influence the average total costs, as well as response, associated with a single line of therapy. Improved treatment outcomes, and reductions in unscheduled events and concomitant medication use may, therefore, reduce the overall HRU and related costs of care in multiple myeloma.     

Sources and directions of technological accumulation in France: a statistical comparison with FR Germany and the UK

Technological activities are an important determinant of national economic performance. Data on R&D and on the national origins of patenting in the USA show that, compared to those of FR Germany and the UK, French technological activities have the following characteristics: (1) a relatively high rate of growth over the past 20 years in aggregate activity; (2) concentration of technological strength in sectors dominated by state procurement and related R&D funding, rather than in “core” technologies; (3) stronger performance in fast-growing technologies in defence, electrical products and fine chemicals, than in electronics and motor vehicles; (4) a relatively stable and speialized sectoral pattern of technological strengths and weaknesses; and (5) sectoral patterns of trading strengths and weaknesses that broadly reflect those in technology. These characteristics of France's technological activities cannot be explained by their greater or lesser concentration, which is very similar to that found in both FR Germany and the UK, both in aggregate and in specific sectors. As in the other two countries, a few large firms have a major influence on national technological activities, especially in R&D-intensive sectors and automobiles. These results are on the whole consistent with the recent assessment by INSEE and CEPII of France's competitive position in international markets. However, they do show a strong Franch “niche” in technologies linked to state markets, and they do suggest certain advantages in long-term stability, rather than rapaid change, in technological priorities.     

Use of opioid substitution therapies in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study

Aims: This study investigated the cost-effectiveness of buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) vs no opioid substitution therapy (OST) for the treatment of opioid use disorder, from the UK National Health Service (NHS)/personal social services (PSS) and societal perspectives over 1 year.

Methods: Cost-effectiveness of OST vs no OST was evaluated by first replicating and then expanding an existing UK health technology assessment model. The expanded model included the impact of OST on infection rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection.

Results: Versus no OST, incremental cost-effectiveness ratios (ICERs) for BMT and MMT were £13,923 and £14,206 per quality-adjusted life year (QALY), respectively, from a NHS/PSS perspective. When total costs (NHS/PSS and societal) are considered, there are substantial savings associated with adopting OST; these savings are in excess of £14,032 for BMT vs no OST and £17,174 for MMT vs no OST over 1 year. This is primarily driven by a reduction in victim costs. OST treatment also impacted other aspects of criminality and healthcare resource use.

Limitations: The model’s 1-year timeframe means long-term costs and benefits, and the influence of changes over time are not captured.

Conclusions: OST can be considered cost-effective vs no OST from the UK NHS/PSS perspective, with a cost per QALY well below the UK’s willingness-to-pay threshold. There were only small differences between BMT and MMT. The availability of two or more cost-effective options is beneficial to retaining patients in OST programs. From a societal perspective, OST is estimated to save over £14,032 and £17,174 per year for BMT and MMT vs no OST, respectively, due to savings in victim costs. Further work is required to fully quantify the clinical and health economic impacts of different OST formulations and their societal impact over the long-term.     

Country-Specific Characteristics of Patent Applications in France,Germany and the UK in the Biotechnology Sectors

Given that institutions are highly country-specific, the differences in the national systems of innovation in the different countries of Europe are likely to give rise to country-specific patterns in new technology investment. The objective of this paper is to identify such differences, in the biotechnology sectors, in France, Germany and the UK. The results, based on an analysis of patent applications, indicate that France is focused on the 'dominant' technology of genetic engineering and its public laboratories and collective patent applications play an important role. Germany is leading in the total number of patent applications but is focused on 'intermediate' and 'residual' technologies with a significant number of individual depositors. The UK is leading in the 'dominant' technology. Its public laboratories and firms are strongly involved in depositing patents with a marked strategy of international protection.     

Country-Specific Characteristics of Patent Applications in France, Germany and the UK in the Biotechnology Sectors

Given that institutions are highly country-specific, the differences in the national systems of innovation in the different countries of Europe are likely to give rise to country-specific patterns in new technology investment. The objective of this paper is to identify such differences, in the biotechnology sectors, in France, Germany and the UK. The results, based on an analysis of patent applications, indicate that France is focused on the 'dominant' technology of genetic engineering and its public laboratories and collective patent applications play an important role. Germany is leading in the total number of patent applications but is focused on 'intermediate' and 'residual' technologies with a significant number of individual depositors. The UK is leading in the 'dominant' technology. Its public laboratories and firms are strongly involved in depositing patents with a marked strategy of international protection.     

Cost-effectiveness of Viridal Duo compared to MUSE and Viagra in the treatment of erectile dysfunction in the UK - a preliminary model

Summary

This study estimated the cost-effectiveness of starting erectile dysfunction (ED) treatment with Viridal Duo relative to MUSE and Viagra over one year, from the perspective of the National Health Service. Decision analysis techniques were used to estimate the expected costs and consequences of managing ED, stratified by initial treatment. The model was based on estimates of clinical outcome and resource use obtained from published literature and a Delphi panel.

Viridal Duo is a registered trademark of Schwarz Pharma;

MUSE is a registered trademark of Astra Pharmaceuticals;

Viagra is a registered trademark of Pfizer Consumer Healthcare

Starting ED treatment with Viridal Duo instead of Viagra leads to an average 0.8 additional months during which a man can achieve successful erections (from 6.5 to 7.3 months) over one year, for an additional cost of £106 per patient (from £369 to £475). Starting ED treatment with Viagra instead of MUSE leads to an average 1.1 additional months during which a man can achieve successful erections (from 5.4 to 6.5 months) over one year and reduces the cost per patient by £85 (from £454 to £369).

Fifty-two percent of patients who start treatment with Viridal Duo continue successfully over one year. This compares to 38% and 18% of patients who start treatment with Viagra and MUSE respectively. Eighty-seven percent of the total success with Viridal Duo can be directly attributed to this treatment when used first-line. In contrast, 68% and 44% of the total success attributed to Viagra and MUSE respectively can be attributed to these treatments when chosen first-line. Moreover, an additional 44% and 27% of the expected total success with MUSE and Viagra is attributable to Viridal Duo.

Starting ED treatment with Viridal Duo rather than MUSE, when Viagra is either unavailable or contraindicated, increases the period during which a man can achieve successful erections by 1.8 months (from 5.5 to 7.3 months) for an additional cost of £14 per patient (from £460 to £474). Additionally, in patients who have previously failed Viagra, starting second-line treatment with Viridal Duo rather than MUSE leads to an average 1.6 additional months during which a man can achieve successful erections (from 4.0 to 5.6 months) over one year and reduces the cost per patient by £15 (from £493 to £478).

In conclusion, Viridal Duo is clinically more effective than Viagra and MUSE. Therefore, starting ED treatment with Viridal Duo instead of Viagra or MUSE increases the period during which a man can achieve successful erections, albeit for an additional cost. In patients who have previously failed first-line treatment with Viagra, starting second-line treatment with Viridal Duo instead of MUSE increases the period during which a man can achieve successful erections (by 40% at one year) and reduces healthcare costs (by £15 per patient).     

Resource use in patients hospitalized with complicated skin and soft tissue infections in Europe and analysis of vulnerable groups: the REACH study

Background:

Hospitalized patients with complicated skin and soft tissue infections (cSSTI) present a substantial economic burden, and resource use can vary according to the presence of comorbidities, choice of antibiotic agent, and the requirement for initial treatment modification. REACH (NCT01293435) was a retrospective, observational study aimed at collecting empirical data on current (year 2010–2011) management strategies of cSSTI in 10 European countries.

Methods:

Patients (n?=?1995) were aged ≥18 years, hospitalized with a cSSTI and receiving intravenous antibiotics. Data, collected via electronic Case Report Forms, detailed patient characteristics, medical history, disease characteristics, microbiological diagnosis, disease course and outcomes, treatments before and during hospitalization, and health resource consumption.

Results:

For the analysis population, mean length of hospital stay (including duration of hospitalizations for patients with recurrences) was 18.5 days (median 12.0). Increased length of hospital stay was found for patients with comorbidities vs those without (mean?=?19.9; [median?=?14.0] days vs 13.3 [median?=?8.0] days), for patients with methicillin-resistant Staphylococcus aureus compared with patients with methicillin-sensitive S. aureus (mean?=?27.7 [median?=?19.5] days vs 18.4 [median?=?13.0] days) and for patients requiring surgery (mean?=?24.4 [median?=?16.0] days vs 15.0 [median?=?11.0] days). Patients requiring modification of their initial antibiotic treatment had an associated increase in mean length of hospital stay of 10.9 days (median?=?6.5) and additional associated hospital resource use. A multivariate analysis confirmed the association of nosocomial infections, comorbidities, directed treatment, recurrent infections, diabetes, recent surgery, and older age (≥65 years), with longer hospital stay.

Conclusions:

This study provides real-life data on factors that are expected to impact length of hospital stay, to guide clinical decision-making to improve outcomes, and reduce resource use in patients with cSSTI.     

Direct treatment cost of atrial fibrillation in the elderly American population: a Medicare perspective

Abstract

Objective: Although atrial fibrillation (AF) is the most commonly sustained arrhythmia in adults, few studies have examined the direct treatment cost of AF.

Methods: A Medicare database of a 5% random national sample of all beneficiaries was used to identify patients diagnosed with AF in 2003 and to follow them for 1 year after diagnosis. These patients were matched on a 1:1 basis by age, gender and race. The incremental cost of treating AF was calculated with multivariate regression models adjusting for covariates.

Results: In total, 55,260 subjects developed new AF, of which 69% were ≥75 years old, 54% were female and 91% were White. The adjusted mean incremental treatment cost of AF was $14,199 (95% confidence interval $13,201–15,001; p<0.01). Some of this cost was attributable to the incidence of stroke and heart failure at the 1-year post-AF diagnosis. A significantly higher proportion of AF patients experienced stroke (23.1 vs. 13.3%; p<0.01) and heart failure (36.7 vs. 10.4%; p<0.01) compared with Medicare beneficiaries without AF.

Conclusions: Mean incremental direct treatment costs for Medicare beneficiaries with AF were higher than previously reported. Interventions that can reduce the incidence of AF and its complications may also reduce the national economic impact of AF.     

Resource utilisation,charges and mortality following hospital inpatient admission for congestive heart failure among the elderly in the US

Abstract

Objectives: This study examined resource utilisation, charges and mortality among congestive heart failure (CHF) patients over the course of the first year following initial hospital discharge for CHF in the US.

Methods: The Medicare Standard Analytic Files for the years 1998 through to 2001 were used for the analysis. The study sample included patients with an inpatient hospitalisation between the 1st January 1999 and the 31st December 2000 with a primary ICD-9 diagnosis code of CHF. Statistical analysis including univariate and multivariate regression analysis were conducted.

Results: Within 1 year following initial CHF discharge, 50% of patients had at least one all-cause readmission and 20% had at least one CHF-related readmission. The mean total charges among all patients was $36,230 (sd $55,086). Of the patients 20% incurred more than $55,000 in medical charges during the year after discharge; 10% incurred charges exceeding $90,000. More than one-half of the CHF patients visited the emergency department within 3 months of hospital discharge, and within 1 year almost one-third of the CHF patients (31.4%) died.

Conclusions: The charges, morbidity and mortality associated with CHF patients are significant. Reducing these risks through more effective disease management offers the potential for substantial cost savings.     

Economic analysis of the use of contrast media during percutaneous coronary interventions in France and Spain

Summary

The iso-osmolar contrast medium iodixanol (Visipaque?; GE Healthcare, UK) has been reported to reduce the risk of major adverse cardiac events and to have a higher success rate when used during percutaneous coronary intervention (PCI) compared with the ionic low-osmolar contrast medium ioxaglate (Hexabrix; Guerbet, France) for patients at risk of complications. This study assessed to what extent these clinical benefits translate into economic benefits for patients undergoing PCI in France and Spain using a decision tree model. Clinical data were derived from the COURT and VIP trials. Medical resource use data were obtained from panels of French and Spanish interventional cardiologists. Resource use was converted to costs using country-specific tariffs. The study results suggest that using iodixanol rather than ioxaglate confers an economic benefit in addition to the reported clinical benefit in high-risk patients undergoing PCI in both countries. For low-risk patients, iodixanol may be regarded as cost-effective when relating the extra cost to the small reported increase in angiographic success.     

A cost analysis of SIR-Spheres yttrium-90 resin microspheres versus tyrosine kinase inhibitors in the treatment of unresectable hepatocellular carcinoma in France,Italy, Spain and the UK

Abstract

Background and aims: A wide range of treatment options are available for hepatocellular carcinoma (HCC), including systemic treatment with tyrosine kinase inhibitors (TKIs) such as sorafenib and lenvatinib, immunotherapies, locoregional therapies such as selective internal radiation therapy (SIRT) and treatments with curative intent such as resection, radiofrequency ablation and liver transplantation. Given the substantial economic burden associated with HCC treatment, the aim of the present analysis was to establish the cost of using SIRT with SIR-Spheres yttrium-90 (Y-90) resin microspheres versus TKIs from healthcare payer perspectives in France, Italy, Spain and the United Kingdom (UK).

Methods: A cost model was developed to capture the costs of initial systemic treatment with sorafenib (95%) or lenvatinib (5%) versus SIRT in patients with HCC in Barcelona Clinic Liver Cancer (BCLC) stages B and C. A nested Markov model was utilized to model transitions between progression-free survival (PFS), progression and death, in addition to transitions between subsequent treatment lines. Cost and resource use data were identified from published sources in each of the four countries.

Results: Relative to TKIs, SIRT with SIR-Spheres Y-90 resin microspheres were found to be cost saving in all four country settings, with the additional costs of the microspheres and the SIRT procedure being more than offset by reductions in drug and drug administration costs, and treatment of adverse events. Across the four country settings, total cost savings with SIR-Spheres Y-90 resin microspheres fell within the range 5.4–24.9% and SIRT resulted in more patients ultimately receiving treatments with curative intent (4.6 vs. 1.4% of eligible patients).

Conclusion: SIR-Spheres Y-90 resin microspheres resulted in cost savings relative to TKIs in the treatment of unresectable HCC in all four country settings, while increasing the proportion of patients who become eligible for treatments with curative intent.     

Healthcare resource use and costs of privately insured patients who switch,discontinue, or persist on anti-muscarinic therapy for overactive bladder

Objectives:

To compare the healthcare costs of patients with overactive bladder (OAB) who switch vs persist on anti-muscarinic agents (AMs), describe resource use and costs among OAB patients who discontinue AMs, and assess factors associated with persisting vs switching or discontinuing.

Methods:

OAB patients initiating an AM between January 1, 2007 and March 31, 2012 were identified from a claims database of US privately insured beneficiaries (n?≈?16 million) and required to have no AM claims in the 12 months before AM initiation (baseline period). Patients were classified as persisters, switchers, or discontinuers, and assigned a study index date based on their AM use in the 6 months following initiation. Baseline characteristics, resource use, and costs were compared between persisters and the other groups. Resource use and costs in the 1 month before and 6 months after the study index date (for switchers, the date of index AM switching; for persisters, a randomly assigned date to reflect the distribution of the time from AM initiation to switching among switchers) were also compared between persisters and switchers in unadjusted and adjusted analyses. Factors associated with persisting vs switching or discontinuing were assessed.

Results:

After controlling for baseline characteristics and costs, persisters vs switchers had significantly lower all-cause and OAB-related costs in both the month before (all-cause $1222 vs $1759, OAB-related $142 vs $170) and 6 months after the study index date (all-cause $7017 vs $8806, OAB-related $642 vs $797). Factors associated with switching or discontinuing vs persisting included index AM, younger age, and history of UTI.

Conclusion:

A large proportion of OAB patients discontinue or switch AMs shortly after initiation, and switching is associated with higher costs.     

Kidney involvement in tuberous sclerosis complex: the impact on healthcare resource use and costs

Abstract

Objective:

Tuberous sclerosis complex (TSC) is associated with non-malignant kidney lesions—angiomyolipomata—that may be associated with chronic kidney disease (CKD). This study investigated the relationship between renal angiomyolipomata and CKD in TSC, including the impact on healthcare resource utilization (HCRU) and costs.     

Characteristics,comorbidities, and use of healthcare resources of patients with phenylketonuria: a population-based study

Abstract

Background: Phenylketonuria is a well-known disease, yet the characteristics of the affected population and their use of healthcare resources have not been comprehensively evaluated. Patient characteristics and use of resources are subjects of interest for most governments, especially for a disease included in newborn screening programs.

Objective: The aim of this study was to determine characteristics and use of healthcare resources of patients with phenylketonuria in the region of Catalonia.

Methods: Records of 289 patients admitted with phenylketonuria between 2007 and 2017 were extracted from the PADRIS database that includes admission data from primary care centers, hospitals (inpatient and outpatient care), extended care facilities, and mental health centers.

Results: The patient population was composed of 140 male patients and 149 female patients, and 102 patients were registered via newborn screening during the study period. Patients were admitted on average 2.19 times per year, mostly into primary care centers which concentrated the largest portion of direct medical expenses. Similar percentages of urgent and scheduled admissions were registered both in primary care and hospitals. Annual direct medical cost of treating patients with phenylketonuria was €667 per patient. Finally, 66.80% of the patients suffered from chronic conditions affecting two or more systems, likely to correspond to a wide variety of conditions.

Conclusions: Altogether, phenylketonuria patient demographics and direct medical costs in Catalonia have been revised. Patients diagnosed with phenylketonuria appeared 1.3-times more likely to suffer from chronic conditions in distinct organ systems, which is expected to have an effect on their use of healthcare resources. These results support the need to adapt and improve the healthcare system, taking multimorbidity into consideration in an effort to control the medical expenses derived.