Costs of asthma according to the degree of severity

An increase in asthma-related morbidity and mortality has been reported recently, resulting in a substantial increase in the economic impact of this condition. Little information is available relating to the costs of asthma depending on the degree of severity of the disease. Total, direct and indirect costs generated by asthma patients who sought medical care for asthma control over a one-year period in a northern area of Spain were determined. Data were obtained from the patients themselves and severity of illness was classified into mild, moderate and severe according to the International Consensus Report on Diagnosis and Treatment of Asthma, 1992. The average total annual asthma-derived cost was estimated at US$2,879 per patient, with averages of US$1,336 in mildly asthmatic patients, US$2,407 in moderate asthma and US$6,393 in severe asthma. At all levels of severity, indirect costs were twice as high as direct costs, and at the same degree of severity, direct costs due to medication and hospitalization were higher among females than males. A minority of severe asthmatics incurred some 41% of the total costs. The cost of asthma was surprisingly high and varied substantially depending on the degree of severity of the disease. Further knowledge of the costs of asthma across various levels of severity will contribute to a better characterization of optimal intervention strategies for asthma care.     

Differences in estimates of percent body fat using bioelectrical impedance

The effect of heliotherapy on psoriasis skin lesions and arthritis was studied in a trial comprising 4 weeks of therapy in the Canary Islands and a 6-month follow-up period. A total of 373 patients participated in the heliotherapy and 361 patients completed the follow-up period. The severity of skin lesions was evaluated using a psoriasis severity index (PSI), and that of the arthropathy by using an arthritis index (AI). During heliotherapy, the PSI decreased significantly from the initial median value of 4.5 to the final value of 0.2. A reduction in the PSI of at least 75% was achieved in 84% of the patients. Guttate psoriasis improved significantly better than plaque-type or erythrodermic psoriasis. There was no correlation between skin type and improvement. Initially, 129 patients had symptoms of arthritis. During heliotherapy, the AI decreased significantly from the initial median value of 6 to the final value of 2. The median time until starting another treatment after heliotherapy was 80 days, and the PSI had returned to its original value in 49% of the patients in 6 months. In patients with joint symptoms the AI returned to the pretreatment level within 6 months. A 4-week heliotherapy period effectively cleared psoriasis, alleviated joint symptoms, and reduced both morbidity and treatment requirement to a considerable extent in the ensuing 6-month period.     

Comparison of different hydrophobic anchors conjugated to poly(ethylene glycol): effects on the pharmacokinetics of liposomal vincristine

The cost-benefit ratio of tetravalent rhesus rotavirus vaccine (RRV-TV) in Finland for prevention of rotavirus gastroenteritis was assessed in a randomized, double-blind, placebo-controlled trial. Costs related to vaccination, side effects, and gastroenteritis were identified. Children received RRV-TV (n = 1,191) or placebo (n = 1,207) at 2, 3, and 5 months of age with other infant vaccinations. Prospective follow-up averaged 1.0 years per child. An intention-to-treat analysis was performed from the perspective of society. Nine cases of severe rotavirus gastroenteritis occurred in the RRV-TV group, versus 100 in the placebo group (P < .0001); mean cost per vaccinated child was 4 Finnish marks (FIM) in the RRV-TV group, versus 203 FIM in the placebo group. Side effects with related costs occurred after 11% and 7% of doses in the RRV-TV group and placebo group, respectively (P < .001); mean cost per child was 89 FIM vs. 75 FIM. The break-even cost (i.e., net benefit, excluding cost of vaccine) of RRV-TV in prevention of severe rotavirus gastroenteritis was 109 FIM (U.S. $19.60) per child.     

Financing HIV service provision in England: estimated impact of the cost of antiretroviral combination therapy

The objective of this study was to provide population-based estimates on the cost of HIV service provision in England and the use of dual or triple antiretroviral combination therapy. Contemporary cost estimates of treating HIV-infected individuals by clinical stage of HIV infection (indexed to 1995/96 prices) were linked to the number of diagnosed HIV-infected individuals using statutory medical services in England during 1996. Two cost measures were used: the first one was based on average hospital prices derived from a number of English HIV units. These results were compared with those estimated using standard unit costs obtained through specific costing studies performed at a national HIV referral centre. Overall annual expenditure on HIV service provision was estimated for different treatment scenarios as was expenditure by clinical stage of HIV infection. Using hospital prices, in 1996 the total annual cost estimate for HIV service provision amounted to pound sterling 131 m (range pound sterling 83 m to pound sterling 233 m), or pound sterling 150 m (95% CI pound sterling 126 m to pound sterling 173 m) using standard costs, if all patients with HIV disease were treated with AZT monotherapy. For all eligible patients to be treated with dual therapy, cost estimates amounted to pound sterling 161 m (range pound sterling 126 m to pound sterling 173 m) per year using hospital prices or pound sterling 180 m (95% CI pound sterling 156 m to pound sterling 203 m) when using standard cost estimates, while for triple therapy annual estimated expenditure amounted to pound sterling 204 m per year (range pound sterling 157 m to pound sterling 306 m) when using hospital prices or pound sterling 223 m (95% CI pound sterling 199 m to pound sterling 246 m) using standard costs. Increasingly costs will be more evenly distributed across the 3 stages of HIV infection, with a greater proportion of costs generated by HIV-infected individuals before the onset of AIDS. Using non-standardized hospital prices may systematically underestimate the real cost of service provision. Monitoring prospectively the use, cost and outcome of HIV service provision in a standardized format will provide information on the actual cost impact over the next 2-3 years of combination therapy compared with the scenario-based estimates produced in this paper.     

Cost-effectiveness of thrombolytic therapy for acute myocardial infarction

OBJECTIVE: To estimate the cost-effectiveness of thrombolytic therapy versus no thrombolytic therapy for patients following acute myocardial infarction, focusing on the impact of time to treatment on outcome. METHODS: A decision model was developed to assess the benefits, risks, and costs associated with thrombolytic therapy for treatment of acute myocardial infarction compared with standard nonthrombolytic therapy. The model used pooled data from a recent study of nine large randomized, controlled clinical trials and 12-month outcome data from a recently published meta-analysis of thrombolytic therapy trial data. Outcomes were expressed in terms of survival to hospital discharge and survival to 1 year after discharge. The risks of treatment that led to death, morbidity, or added costs were estimated. The model determined excess and marginal costs per death averted to hospital discharge and at 1 year. Results were also estimated in terms of cost per year of life saved. Sensitivity analyses included variations in time to treatment and drug cost. RESULTS: The marginal cost of thrombolytic therapy per death averted at 1 year was $222,344, or $14,438 per year of life saved. For patients treated within 6 hours of acute myocardial infarction, the marginal cost per death averted was $181,536 at 1 year, or $11,788 per year of life saved. CONCLUSIONS: Thrombolytic therapy is significantly more cost-effective than many other cardiovascular interventions and compares favorably with other forms of medical therapy. Results suggest that shortening the time to treatment has a critical impact on the cost-effectiveness of thrombolytic therapy.     

Total body heliotherapy

Sunlight has long been known to be beneficial for a variety of skin diseases. Patients with psoriasis and eczema frequently employ ambient heliotherapy to control their conditions. However, social norms do not permit a person to expose the entire body in public, thus placing severe restrictions on the utility of this modality for the treatment of generalized psoriasis, for example. Tan-Thru bathing suits, designed to attract those who wish to tan without an accentuated "tan line", are reported to absorb ultraviolet (UV) rays up to a maximum equivalent of a sun protection factor (SPF) 10 sunblock, thus offering approximately 89% protection while in use, according to their manufacturer. If so, this bathing suit may allow patients with UV-responsive skin dermatoses to achieve full body exposure in a socially acceptable manner. The objective of this study was to verify the SPF and to determine the actual transmittance to skin covered by a Tan-Thru bathing suit. Ten healthy adult subjects were recruited for this investigation. UVB minimal erythema dose (MED) was determined on unaffected gluteal or lower back skin, once with and once without the swimsuit on. Our results showed that the mean SPF afforded by the bathing suit was in fact 4.9 (range 4.5-5.6). In conclusion, theoretically, the Tan-Thru bathing suits could allow enough UVB penetration under ambient conditions to be beneficial for patients with UVB responsive conditions.     

Economic and policy implications of adopting paclitaxel as first-line therapy for advanced ovarian cancer: an Ontario perspective

PURPOSE: To determine the potential economic and policy implications that result from incorporating paclitaxel into first-line therapy for stage 3 and 4 ovarian cancer patients in the province of Ontario, Canada. METHODS: A cost-effectiveness analysis was conducted to compare cisplatin/cyclophosphamide (CC), a standard therapy, with cisplatin/paclitaxel (CT). Based on survival curves from a clinical trial, mean costs and survival were calculated. Sensitivity analyses were conducted based on altering the duration of paclitaxel infusion, discount rates, and efficacy of paclitaxel. RESULTS: The mean survival duration is prolonged from 2.06 years with the standard therapy to 2.44 years with the paclitaxel combination. The paclitaxel therapy is more expensive, with a mean cost of $17,469 (Canadian) per patient treated with CT compared with $5,228 per patient with CC. The incremental cost-effectiveness ratio is $32,213 per year gained. Sensitivity analyses show that the conclusions remain unchanged. The use of CT as first-line treatment for advanced ovarian cancer patients in Ontario requires an additional $9 million per year over and above the present costs to treat this patient population. CONCLUSION: Although paclitaxel-based therapy prolongs survival, it comes at an increased cost. It may not be possible to fund paclitaxel treatment using resources presently allocated to first-line chemotherapy for advanced ovarian cancer. The policy implications for absorbing the cost of paclitaxel in the context of a publicly funded health care system are discussed.     

One world, one hope: the cost of providing antiretroviral therapy to all nations

OBJECTIVE: To estimate the potential direct cost of making triple combination antiretroviral therapy widely available to HIV-positive adults and children living in countries throughout the world. METHODS: For each country, antiretroviral costs were obtained by multiplying the annual cost of triple antiretroviral therapy by the estimated number of HIV-positive persons accessing therapy. Per capita antiretroviral costs were computed by dividing the antiretroviral costs by the country's total population. The potential economic burden was calculated by dividing per capita antiretroviral costs by the gross national product (GNP) per capita. All values are expressed in 1997 US dollars. RESULTS: The potential cost of making triple combination antiretroviral therapy available to HIV-positive individuals throughout the world was estimated to be over US$ 65.8 billion. By far the greatest financial burden was on sub-Saharan Africa. The highest per capita drug cost in this region would be incurred in the subregions of Southern Africa (US$ 149) followed by East Africa (US$ 116), Middle Africa (US$ 44), and West Africa (US$ 42). In the Americas, subregional data indicated the highest per capita drug cost would be in the Latin Caribbean (US$ 22), followed by the Caribbean (US$ 17), Andean Area (US$ 7), the Southern Cone (US$ 6), North America (US$ 6), and Central American Isthmus (US$ 5). In Asia and Europe the percentage of the GNP necessary to finance drug therapy was less than 1% in most countries examined. CONCLUSION: Our results demonstrate that the cost of making combination antiretroviral therapy available worldwide would be exceedingly high, especially in countries with limited financial resources.     

Cost and outcome analysis of home parenteral and enteral nutrition

BACKGROUND: Previous estimates of the cost of home parenteral and enteral nutrition (HPEN) have excluded hospitalization costs or were conducted abroad and have limited applicability in the United States. Few studies have used validated measures to determine the effect of home nutrition support on quality of life. METHOD: A cost and clinical outcome analysis was performed by retrospective review of charts of patients receiving HPEN from 1991 to 1996. Questionnaires to determine the influence of therapy on lifestyle (n = 41) and a general health status questionnaire, the short form 36-item survey (n = 39), were mailed to patients. RESULTS: The annual cost per patient for parenteral solutions was $55,193 +/- 30,596 (mean +/- SD) based on Medicare charges and for enteral tube feedings was $9605 +/- 9327. The annual cost of hospitalization ranged from zero to $140,220 in the parenteral nutrition group and from zero to $39,204 in the enteral nutrition group. The annual number of hospitalizations per patient for patients receiving parenteral nutrition ranged from 0.52 to 1.10, compared with 0 to 0.50 in the enteral nutrition population. The health status of HPEN patients was significantly lower (p < .05) in five of the eight short-form 36 health domains compared with the general population. The areas of lifestyle most frequently affected were travel, sleep, exercise and leisure. CONCLUSIONS: The majority of the cost of therapy was associated with the direct provision of nutrition, although in some patients the hospitalization expenditure exceeded this cost. Home nutrition support had a significant negative impact on a patient's quality of life and lifestyle.     

Laparoscopic interventions in gastroesophageal reflux--a cost-benefit analysis

On the basis of a cost analysis of conservative and surgical therapy of gastroesophageal reflux disease in 70 patients health economic aspects are discussed. In a prospective documented series of reflux patients a retrolective analysis of medication cost and duration of conservative therapy is performed. In addition, the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization as well as costs for complications with necessary additional treatment and readmissions are assessed. For the conservative treatment of 70 reflux patients a total of more than DM < 700,000 had to be spent during preoperative 5 years. A major part of this sum was spent for patients who needed to increase the initial 20 mg dosage of Omeprazol within 5 years. A mean of approximately DM 2,000 per patient was spent for conservative treatment. Surgical treatment without complications was calculated with DM 5,425 per case. However, in 7 patients complications occurred causing prolonged or even rehospitalization with necessary further treatment summing up to about DM 486,000 for surgical therapy in 70 patients including complications. Cost relevant factors are therefore in conservative treatment patients who need increasing dosages, while, in surgical treatment, the cost relevant patients are those with complications and necessary additional treatment.     

Effects of drug solubility, drug loading, and polymer molecular weight on drug release from Polyox tablets

BACKGROUND: This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians. METHODS: A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed. RESULTS: In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510. CONCLUSIONS: Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.     

Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality

OBJECTIVE: To estimate the annual incidence, the mortality and the direct and indirect costs associated with occupational injuries and illnesses in the United States in 1992. DESIGN: Aggregation and analysis of national and large regional data sets collected by the Bureau of Labor Statistics, the National Council on Compensation Insurance, the National Center for Health Statistics, the Health Care Financing Administration, and other governmental bureaus and private firms. METHODS: To assess incidence of and mortality from occupational injuries and illnesses, we reviewed data from national surveys and applied an attributable risk proportion method. To assess costs, we used the human capital method that decomposes costs into direct categories such as medical and insurance administration expenses as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Some cost estimates were drawn from the literature while others were generated within this study. Total costs were calculated by multiplying average costs by the number of injuries and illnesses in each diagnostic category. RESULTS: Approximately 6500 job-related deaths from injury, 13.2 million nonfatal injuries, 60,300 deaths from disease, and 862,200 illnesses are estimated to occur annually in the civilian American workforce. The total direct ($65 billion) plus indirect ($106 billion) costs were estimated to be $171 billion. Injuries cost $145 billion and illnesses $26 billion. These estimates are likely to be low, because they ignore costs associated with pain and suffering as well as those of within-home care provided by family members, and because the numbers of occupational injuries and illnesses are likely to be undercounted. CONCLUSIONS: The costs of occupational injuries and illnesses are high, in sharp contrast to the limited public attention and societal resources devoted to their prevention and amelioration. Occupational injuries and illnesses are an insufficiently appreciated contributor to the total burden of health care costs in the United States.     

Cost-effectiveness of new treatments for overactive bladder: the example of tolterodine, a new muscarinic agent: a Markov model

Economic analyses of interventions for chronic diseases require evaluations over a long timeframe to illustrate the benefits and costs of treatments. Clinical trials are generally short and carried out in strictly controlled conditions. They are therefore of limited value for economic evaluation aimed at facilitating decisions about resource allocation. The objective of this study was to develop a simulation model that allows integration of data from different sources to calculate the incremental cost-effectiveness and cost-utility of new treatments for overactive bladder. The model compares tolterodine, a new treatment that aims at alleviating symptoms and improving patients' quality of life, to no treatment. Simulations for Sweden are presented as an example. The Markov model combines clinical, observational, and economic data. Markov states are defined based on severity of symptoms of overactive bladder (frequency of voids and leaks). Specific costs for drug treatment and use of sanitary protections as well as utilities are assigned for each state. The effectiveness of tolterodine is based on controlled clinical trials and open long-term extensions of these trials. Outcome is measured as quality-adjusted life years (QALYs) and as the number of months spent in a state with no or very limited symptoms. During the course of 1 year, patients treated with tolterodine spend more time in states with no or limited symptoms compared to those receiving no treatment. Tolterodine-treated patients having a better quality of life during the year. The mean utility of the treated cohort is 0.70, compared to 0.67 in the no-treatment cohort, which is equivalent to the entire cohort moving by one level to a state with less severe symptoms. Mean total costs per patient in the tolterodine arm are SEK8,595 (US $1,131; 1 US$ = 7.6 SEK) compared to SEK3,286 (US$432) in the no-treatment arm. The extra cost due to tolterodine is SEK380 (US$50) per month, which falls within the range of monthly amounts that patients were willing to pay out of pocket for a 25 or 50% improvement of their symptoms in a previous study. The cost for pads is reduced by 23%. The marginal cost per QALY gained with tolterodine is estimated at SEK213,000 (US$28,000). Based on this simulation model, it appears that treatment of overactive bladder with a well-tolerated pharmacological treatment such as tolterodine is cost-effective.     

Cost-effective appendectomy. Open or laparoscopic? A prospective randomized study

BACKGROUND: Laparoscopic hernia repair has often been criticized for its high costs. METHODS: To compare the costs of laparoscopic and open hernia repair, 40 patients were randomized for either transabdominal laparoscopic or Lichtenstein mesh repair (under local anesthesia) in a day-case surgery unit. RESULTS: Median operative times for the laparoscopic and open groups were 62 and 65 min, respectively. Postoperative pain was comparable for the two groups. The period before return to normal life was 14 days in the laparoscopic group and 21 days in the open group. The hospital costs were 2051 FIM ($1 US = 4.6 FIM) higher in the laparoscopic group, but the total costs for employed patients (including expenses due to lost work days) were lower. CONCLUSION: Although the Lichtenstein operation is cheaper for the hospital, the total costs for working patients are lower with the laparoscopic technique, when the cost of lost work days is factored into overall expense.     

Diagnosis of breast cancer by measuring nuclear disorder using planar graphs

The purpose of this study was to determine the incidence of non-traumatic lower extremity amputations (LEAs) in diabetic and non-diabetic subjects in Madrid, Spain, and their direct cost. All patients who underwent LEAs between the 1st of January 1994 and the 31st of December 1996, and who had lived in area 7 of the city (569,307 inhabitants) for at least the last 6 months, were identified through operating theatre records cross-checked with Vascular Surgery Department discharge records. In addition, the direct cost of LEAs per year was estimated, taking into account the length of the hospital stay, the period of rehabilitation in the outpatient clinic after discharge, and the use of artificial limbs and their maintenance. The incidence of LEAs was 1.6 (95% CI: 1.1-2.2) per 10(5) non-diabetic subjects and 46.1 (95% CI: 34.5-57.6) per 10(5) diabetic patients. Relative risk was 28. Total direct costs associated with LEAs per year were US$ 56,131 in the diabetic population and US$ 30,765 in the non-diabetic population. Thus, potential cost savings associated with excess amputations in the diabetic population was estimated at US$ 541,353 per year of US$ 94,736 per 10(5) inhabitants. It is concluded that the incidence of LEAs in both diabetic and non-diabetic populations in area 7 is the lowest reported in European countries. The potential cost savings per 10(5) inhabitants and per year is estimated at US$ 94,736.     

One-year economic evaluation of intensive vs conventional patient education and supervision for self-management of new asthmatic patients

The purpose was to compare the short-term cost-effectiveness of intensive vs conventional education and supervision for the self-management of mild asthmatic patients. Consecutive newly diagnosed asthmatic patients (n = 162) were randomized into an intervention group (IG) and a control group (CG) with 1 yr of treatment and follow-up. Intensive education was given to 77 patients at visits every third month in the outpatient clinic. Eighty CG patients received conventional education and advice at the baseline visit only. All patients received similar inhaled anti-inflammatory treatment. At baseline and at 12 months standard clinical lung functions and health-related quality of life (HRQOL) were measured, the latter by the disease-specific St George's Respiratory Questionnaire and the generic 15D. Furthermore, the use of extra health care services, medication and sickness days were recorded. The IG experienced a significant improvement in all clinical and HRQOL outcome variables. The same applied to the CG except spirometric values. The groups differed significantly only in terms of FEV1 (P < 0.05) in favour of the IG. There was a significant difference between the groups in extra costs. The mean cost was FIM 2351 per patient (294 Pounds sterling) in the CG and FIM 2757 per patient (345 Pounds) in the IG, of which the intervention cost was FIM 1978 per patient (247 Pounds). In 1 yr follow-up the intensive education programme did not prove to be cost effective but was dominated by the conventional one regardless of what effectiveness measure was used. Also, a purely monetary cost-benefit calculation showed that the intervention resulted in a negative net benefit (loss) of FIM 406 per patient (51 Pounds). A longer follow-up may be needed before definitive conclusions about the cost-effectiveness of this kind of intervention can be drawn.     

Cost effectiveness study of a year follow-up of selective serotonin reuptake inhibitor (SSRI) and augmentor combination compared with SSRI and placebo

We describe a method for evaluating the value of increased cost of pharmacological augmentation that, taken for 6 weeks, accelerates the action of an antidepressant. We test the hypothesis that, if onset of action is taken into account, any added direct costs of the augmenting agent are offset by longer term cost effectiveness. Data to illustrate the method were based on a double-blind randomized placebo controlled study, in which 80 patients originally took part. Patients received the selective serotonin reuptake inhibitor (SSRI) antidepressant paroxetine and an augmenting agent (pindolol) or placebo. After 6 weeks, patients were offered SSRI alone on an open label basis for up to 6 months. At that point they were discharged to their general practitioner or local psychiatric services and subsequently assessed by us at one year. We have used techniques of decision analysis, cost effectiveness and cost benefit and have included a sensitivity analysis. The direct costs over one year of SSRI and augmenting agent, if taking the acceleration effect into account, represented greater cost effectiveness than the SSRI antidepressant alone. The cost effectiveness analysis was positive in both cases. We conclude that the direct costs of treatment are higher than those of previous calculated with SSRIs; but the rate of onset must be taken into account. The application of the model appears valid and useful, and may be used as part of the evaluation of other augmentation regimes.     

Cost-effectiveness analysis of the eradication of Helicobacter pylori as treatment for duodenal ulcer

OBJECTIVE: To assess the cost-effectiveness of H. pylori eradication in patients with duodenal ulcer in Spain. METHODS: A decision model was used to compare the cost per cured patient and the cost per patient without recurrence in one year for four treatment strategies: 1) intermittent antisecretory therapy, 2) initial antisecretory therapy and H. pylori eradication if ulcer recurrence, 3) initial H. pylori eradication with antibiotics and antisecretory drugs, 4) antisecretory therapy followed by continuous maintenance therapy with ranitidine. Clinical variables were obtained from published studies made in Spain. RESULTS: Initial H. pylori eradication is the cheapest strategy (74,702-82,028 ptas per cured patient) and the most effective (83.3-85.2% patients without recurrence in one year). Intermittent antisecretory therapy is one of the most expensive (94,891-105,324 ptas per cured patient) and the less effective (12% patients without recurrence in one year). CONCLUSION: Initial eradication of H. pylori is the treatment of choice in patients with duodenal ulcer.     

Estimating the cost of lung cancer diagnosis and treatment in Canada: the POHEM model

Because lung cancer is a major health care problem in Canada, it would be useful to identify the direct health care costs of diagnosing and treating this disease and to create an analytic framework within which diagnostic and therapeutic options can be assessed. This paper describes a method of modelling the costs of care for lung cancer. The perspective of the costing model is that of the government as payer in a universal health care system. Clinical algorithms were developed to describe the management of non-small cell (NSCLC) and small cell (SCLC) lung cancer. Patients were allocated to the treatment algorithms in the model, based on a knowledge of the stage distribution of cases within provincial cancer registries and an estimate of the use of therapeutic modalities, according to lung cancer experts. A microsimulation model (POHEM) developed at Statistics Canada was used to integrate data on risk factors, disease onset and progression, health care resource utilization and direct medical care costs. The model incorporates survival data on patients, according to cell type and stage, based on published studies. Relapse and terminal care costs were assigned during the year of death, in order to determine the cost of continuing care and the cumulative cost of lung cancer management over time. Patients surviving five years were assumed to be cured. The model estimates that the total five year cost to provide care to the 15,624 cases of lung cancer diagnosed in Canada in 1988 was in excess of $328 million. Over 82% of this total was spent in the first year for diagnostic tests, therapy (surgery, chemotherapy, radiation therapy, or combinations of these), hospitalization and follow-up costs. The average five year cost per case was $21,000, and ranged from a high of $29,860 for limited disease SCLC, to a low of $16,500 for Stage IV NSCLC. The actual cost of providing care, including the management of complications, is unknown and our estimates should be regarded as an idealized estimate of the cost of lung cancer management. However, the POHEM model has a level of sophistication which, we believe, reasonably reflects the cost per case and total costs of treating lung cancer by stage and therapeutic modality in Canada.