A cost-benefit analysis of colposcopy for cervical squamous intraepithelial lesions found on Papanicolaou smear

BACKGROUND: We performed a cost-benefit analysis of a protocol for studying patients with squamous intraepithelial lesions (SIL) on Papanicolaou smears to determine whether it compared favorably with resources spent on other health programs for screening and treatment. METHODS: During a 3-year period, 424 patients with dysplastic Papanicolaou smears were examined, studied by biopsy, and treated. We calculated costs based on a model protocol and derived a cost per year of life saved for preventing death from invasive cervical carcinoma. A sensitivity analysis was performed on selected assumptions of the analysis. RESULTS: The marginal, or incremental, cost of colposcopic evaluation and treatment of Papanicolaou smears with low-grade SIL, high-grade SIL (moderate), and high-grade SIL (severe), depending on assumptions, ranged from $406 to $5746, $160 to $2263, and $85 to $1197 per year of life saved, respectively. Depending on the assumption of the rate of Papanicolaou smears with SIL in the screened population being 1.8%, 5.1%, or 11.5%, the estimated total cost of screening and treating the referral base was $1.3 million, $538,126, and $307,037, respectively. This results in the average cost per year of life saved to screen and treat low-grade SIL, high-grade SIL (moderate), and high-grade SIL (severe) to be $1105 to $68,909, $375 to $21,673, and $177 to $8831, respectively. CONCLUSIONS: Both marginal cost and average screening costs of evaluating and treating abnormal Papanicolaou smears by the protocol described in this article compare favorably with costs per year of life saved for other health care screening and treatment strategies for many assumptions. The marginal cost to perform colposcopy on patients with a Papanicolaou smear with low-grade SIL is so low that it is relatively a very effective strategy.     

Coenzyme A independent acylation of phosphatidylethanolamine in isolated bovine rod cell outer segments

RATIONALE AND OBJECTIVES: The purpose of this prospective randomized study was to compare the long-term instructional effectiveness of a computer-based radiology multimedia textbook (MMTB) with that of a traditional lecture. METHODS: Volunteer faculty/fellows and residents were randomly assigned to either a computer-based MMTB group or to a lecture group. The course content for each instructional group was the same. Pretests, posttests, and 1-year long-term retention tests were administered to both groups. The same 10 questions were on all tests. The resulting data were analyzed using analysis of variance procedures available on the Statistical Analysis System. RESULTS: A comparison of the long-term instructional effectiveness of an MMTB versus a lecture showed that the MMTB computer instructional method was at least comparable in spite of the initial short-term appearance of lecture superiority. CONCLUSION: These results suggest a promising future for MMTB and other forms of computer-based education in radiologic instruction for medical students and radiologists.     

Economic implications of hepatic arterial infusion chemotherapy in treatment of nonresectable colorectal liver metastases. Meta-Analysis Group in Cancer

BACKGROUND: Approximately 20% of patients with colorectal cancer die of metastases confined to the liver. A meta-analysis recently performed by our group confirmed that in these patients hepatic arterial infusion of 5-fluoro-2'-deoxyuridine, compared with intravenous chemotherapy with fluoropyrimidines or supportive care (including symptom palliation when necessary), improved tumor response. PURPOSE: Because of the high cost of hepatic arterial infusion, we undertook a cost-effectiveness analysis that related the cost of such therapy to its medical efficacy. METHODS: The patient population was drawn from the seven randomized clinical trials included in the meta-analysis and included individual data on 654 patients. Of these seven trials, five compared hepatic arterial infusion and intravenous chemotherapy and two compared hepatic arterial infusion and a control group in which some patients could be left untreated. Patients assigned to receive hepatic arterial infusion made up the hepatic arterial infusion group; the other patients constituted the control group. The measures of efficacy were survival and tumor response. Health-care costs (in 1995 U.S. dollars) were computed over the duration of patient follow-up and were derived from actual costs in two centers, one at Henri Mondor Hospital (Paris, France) and the other at Stanford University Medical Center (Palo Alto, CA). The total cost of treatment included the initial procedure, chemotherapy cycles, and main complications. RESULTS: The mean gain in life expectancy in the hepatic arterial infusion group compared with the control group was 3.2 months (standard error = 1.0 month). For patients treated by hepatic arterial infusion in Paris, the hepatic arterial infusion pump, initial hospitalization, and the entire process (including follow-up and complications) cost, on average, $8400, $15172, and $29562, respectively; in Palo Alto, these costs were $4700, $13784, and $25 208, respectively. For patients in the control groups in Paris and Palo Alto, the total treatment costs were, on average, $9926 and $5928. The additional costs of hepatic arterial infusion over control treatment were $19636 in Paris and $19280 in Palo Alto. The cost-effectiveness (i.e., the additional cost divided by the additional benefit) with respect to survival of the patients in the hepatic arterial infusion group compared with the patients in the control group was $73635 per life-year in Paris and $72300 per life-year in Palo Alto. CONCLUSIONS AND IMPLICATIONS: The cost-effectiveness of localized chemotherapy for colorectal liver metastases is within the range of accepted treatments for serious medical conditions, although it might be considered borderline by policy-makers in some countries. Prospective clinical trials should be conducted to more definitively answer this question.     

Comparison of costs for infusion versus bolus chemotherapy administration--Part two. Use of charges versus reimbursement for cost basis

BACKGROUND: The costs of infusion versus bolus administration of chemotherapy has been a point of controversy as has been the method of quantitating the cost. The present study analyzes the reimbursement for chemotherapy administration by infusion compared with bolus delivery based on reimbursement and relates this to cost based on projected charges and actual charges in a private practice setting. METHODS: Actual reimbursement records were retrieved for selected patients receiving infusion or bolus administration of specific chemotherapy regimens for three tumors: colon carcinoma, breast carcinoma, and lymphoma. All services were included except for radiology and hospitalization. Medicare reimbursement represented 90% of the treatment cycles analyzed. RESULTS: Actual reimbursement per month for each infusion regimen was as follows: colon carcinoma, $528 (5-fluorouracil [5-FU]); breast carcinoma, $621 (doxorubicin and cyclophosphamide [AC]) and $685 (cyclophosphamide, methotrexate, and fluorouracil [CMF]); and lymphoma, $603 (cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP]). Actual reimbursement per month for a bolus regimen was colon carcinoma, $393 (5-FU + leucovorin); breast carcinoma, $991 (AC) or $453 (CMF); and lymphoma, $749 (CHOP). Actual reimbursement represents 21-36% of actual charges. Projected charges based on the model system are generally less than the actual charges. CONCLUSIONS: The cost of chemotherapy as defined by reimbursement are substantially less than actual charges and are also less than projected costs based on charges. Data comparing bolus versus infusion reimbursement costs for colon carcinoma, breast carcinoma, and lymphoma indicate that differences between reimbursement for bolus and infusion administration are not substantial.     

Teaching hospital costs: implications for academic missions in a competitive market

CONTEXT: As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions. OBJECTIVE: To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME). DESIGN: Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds). SETTING AND PARTICIPANTS: A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals. MAJOR OUTCOME MEASURES: Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case. RESULTS: In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity. CONCLUSIONS: The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.     

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.     

Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke

BACKGROUND: Most analyses of the economic benefits of smoking cessation consider long-term effects, which are often not of interest to public and private policy makers. These analyses fail to account for the time course of the short-run cost savings from the rapid decline in risk of acute myocardial infarction (AMI) and stroke. METHODS AND RESULTS: We estimate the time course of the fall in risk of AMI and stroke after smoking cessation and simulate the impact of a 1% absolute reduction in smoking prevalence on the number of and short-term direct medical costs associated with the prevented AMIs and strokes. In the first year, there would be 924+/-679 (mean+/-SD) fewer hospitalizations for AMI and 538+/-508 for stroke, resulting in an immediate savings of $44+/-26 million. A 7-year program that reduced smoking prevalence by 1% per year would result in a total of 63,840+/-15,521 fewer hospitalizations for AMI and 34,261+/-9133 fewer for stroke, resulting in a total savings of $3.20+/-0.59 billion in costs, and would prevent approximately 13,100 deaths resulting from AMI that occur before people reach the hospital. Creating a new nonsmoker reduces anticipated medical costs associated with AMI and stroke by $47 in the first year and by $853 during the next 7 years (discounting 2.5% per year). CONCLUSIONS: Although primary prevention of smoking among teenagers is important, reducing adult smoking pays more immediate dividends, both in terms of health improvements and cost savings.     

Costs and benefits of respiratory syncytial virus immunoglobulin to prevent hospitalization for lower respiratory tract illness in very low birth weight infants

BACKGROUND: Respiratory syncytial virus immunoglobulin intravenous (RSV-IGIV) has been shown to reduce the risk of lower respiratory illness (LRI) hospitalization in preterm infants and infants with bronchopulmonary dysplasia (BPD). The purpose of this analysis was to estimate the economic costs and benefits of prophylaxis with RSV-IGIV in these groups. METHODS: The analysis was performed from a payer's perspective and therefore included only costs and cost savings that would be realized by an insurer. Estimates of the direct costs of prophylaxis and the risk and cost of LRI hospitalization were based on data about preterm very low birth weight infants cared for at our medical center. Estimates of the reduction in risk of LRI hospitalization associated with RSV-IGIV were based on data from a randomized trial (the PREVENT Study). RESULTS: The range of cost for a five-dose course of RSV-IGIV was estimated to be $3280 to $8800 for infants weighing 1.2 to 10.0 kg at the time of the initial dose. Risks of LRI hospitalization were estimated to be 12, 17 and 28%, respectively, for preterm infants without BPD, with mild BPD and with moderate to severe BPD. Estimates of duration and per diem cost of LRI hospitalizations were, respectively, 5 days and $971. The estimated net cost of prophylaxis per infant ranged between $5415 for a 6-kg infant without BPD to $1689 for an infant with BPD and age < or =3 months. CONCLUSIONS: The cost of RSV-IGIV typically exceeds the cost of hospitalizations prevented by several thousand dollars. Cost minus benefit is lower for infants with BPD and infants 3 months of age or younger.     

The costs of healthcare worker respiratory protection and fit-testing programs

OBJECTIVE: We studied hospital costs associated with healthcare worker (HCW) respiratory protection and respirator fit-testing programs recommended by the Centers for Disease Control and Prevention (CDC) and mandated by the Occupational Safety and Health Administration to decrease nosocomial or occupational Mycobacterium tuberculosis (TB). DESIGN: The number and cost of high-efficiency particulate air (HEPA)-filter and dust-mist (DM) respirators for 1989 to 1994 were obtained from study hospital purchasing departments, and the costs of HCW fit-testing and education programs for 1994 were estimated from information provided by infection control practitioners. Costs of N-class respirator programs were estimated for study hospitals using retrospective cost analysis and an observational study. SETtING: Four urban hospitals with, and one rural community hospital without, documented nosocomial or occupational transmission of multidrug-resistant TB. RESULTS: During the study period, four of five hospitals introduced HEPA and DM respirators and respirator education and fit-testing programs. Median costs in 1994 were $83,900 (range, $2,000-$223,000) for respirators and $17,187 (range, $8,736-$26,175) for respiratory fit-testing programs. The projected median annual cost of N95 respirators was $62,023 (range, $270-$422,526). CONCLUSIONS: Compliance with CDC TB guidelines may require a substantial investment. However, outlays for respirators and education and fit-testing programs are more reasonable than would be suggested by analyses that estimated the costs of preventing one case of nosocomial TB.     

The complications of trauma and their associated costs in a level I trauma center

OBJECTIVES: To estimate the expected costs for acute trauma care, to quantify the costs associated with the development of complications in injury victims, and to determine the deficit incurred by patients in whom complications develop. DESIGN: A retrospective, cohort design. SETTING: A referral trauma center. PATIENTS: A total of 12,088 patients admitted to a single regional trauma center during a period of 5 years. INTERVENTIONS: This is an observational study, and no interventions specific to this study are included in the design. MAIN OUTCOME MEASURES: (1) The expected costs for injury victims based on readily available clinical data. (2) The costs associated with the most important complications of trauma. (3) The effect of complications on inadequate reimbursement for trauma care. RESULTS: The expected costs were estimated using a linear model incorporating demographic variables and measures of injury severity. The expected costs averaged $14,567, and the observed costs averaged $15,032. Six complications were important predictors of cost. These included adult respiratory distress syndrome, acute kidney failure, sepsis, pneumonia, decubitus ulceration, and wound infections. For 1201 individuals with these complications, the predicted costs averaged $23,266 and the observed costs averaged $47,457. The mean excess costs for a single complication ranged from $6669 to $18,052. Multiple complications led to greater increases in excess cost, averaging $110,007 for the 62 patients with 3 or more complications. Costs exceeded reimbursement to a much greater degree in those in whom any of the 6 complications developed. CONCLUSION: Expected hospital costs can be estimated using admission clinical data. Each of 6 complications was associated with enormous increases in costs, indicating their importance as a cause of avoidable expenditures in injury victims and identifying situations in which reimbursement may not be adequate.     

The cost-effectiveness of routine postoperative radiotherapy after sector resection and axillary dissection for breast cancer stage I. Results from a randomized trial

BACKGROUND: Cost-effectiveness of routine postoperative radiotherapy after breast-conserving surgery has not been prospectively evaluated earlier. In times of rationing of medical resources, valid assessments of cost-effectiveness are important for rational allocation of resources. PURPOSE: Cost and cost-effectiveness of routine postoperative radiotherapy was calculated in a prospective randomized trial comparing sector resection plus axillary dissection with (XRT group) or without (non-XRT group) postoperative radiotherapy in breast cancer stage I. Three hundred eighty-one patients were included. After a median follow-up of five years 43 local recurrences, six of them in the XRT-group occurred (P < 0.0001). No difference in regional and distant recurrence (P = 0.23) or survival (P = 0.44) was observed. PATIENTS AND METHODS: Direct medical costs as well as indirect costs in terms of production lost during the treatment period and travel expenses were estimated from data in the medical records and the national insurance registry of each patient. Average costs of different treatment activities and measures were estimated for the XRT-group and the non-XRT group respectively. From these estimates differences in costs and effectiveness between the groups were calculated and marginal cost-effectiveness ratios were estimated. For the construction of QALYs each life-year was quality-adjusted by a utility value depending on which health state the patient was considered to perceive. RESULTS: Taking into account the cost of primary treatment, the cost of follow-up, the cost of treatment of a local recurrence, travel expenses and indirect costs (production lost) excluding costs for treatment of regional and distant recurrence the cost per avoided local recurrence at five years was SEK 337,727 ($44,438, Pounds 27,018). Adjustment for quality of life showed a cost for every gained QALY to be SEK approximately 1.6 million, ($210,526, Pounds 128,000), range SEK 0.2-3.9 million ($26,315-513,158, Pounds 16,000-312,000). CONCLUSION: The cost of routine postoperative radiotherapy after sector resection and axillary dissection in breast cancer stage I per avoided local recurrence and gained QALY is high. The cost per gained QALY show great variation depending on utility value, which in this study was derived from external observers and not from the patients themselves. These results stress the importance of identifying risk factors for local recurrence, better understanding of impact on quality of life of a local recurrence and adding cost evaluations to clinical trials in early breast cancer.     

Predicting soft tissue changes in mandibular advancement surgery: a comparison of two video imaging systems

BACKGROUND: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented. OBJECTIVE: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention. DESIGN: Cost-effectiveness analysis using published data from clinical trials. SETTING: General population of asymptomatic 65-year-old men. INTERVENTION: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done. MEASUREMENTS: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios. RESULTS: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found). CONCLUSIONS: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.     

Pharmacoeconomics of intravenous antibiotic use in serious infection

A pharmacoeconomic study of 15 antibiotics available in Barbados was performed. The antibiotics studied were amoxycillin/clavulanate, ampicillin, ampicillin/sulbactam, cefazolin, cefotaxime, ceftazidime, ceftriaxone, clindamycin, cloxacillin, cotrimoxazole, gentamicin, imipenem, metronidazole, piperacillin, piperacillin/tazobactam, and vancomycin. The costs of use of these compounds were calculated for a five-day course using a formula comprising eight categories: antibiotic purchase cost, maintenance of intravenous access, drug delivery cost, drug monitoring cost, dose readjustment, general monitoring cost, 'sharps' disposal cost and adverse effects. The costs of adverse effects were not included in this study due to lack of accurate data. The total cost of antibiotic use (in U.S. dollars) ranged from $42.52 to $463.73 per five-day course. Generic compounds were less expensive ($45.52 - $98.23) than brand-name compounds ($106.18 - $106.18 - $463.73). Antibiotic purchase costs accounted for proportions of total costs ranging from 7 to 93%. Non-drug costs represented a much greater proportion of total costs of generic compounds. For most compounds the non-drug costs were related to the frequency of dosing, but for gentamicin the non-drug costs were relatively higher because of the need for monitoring of serum gentamicin levels. Efficacy and freedom from side-effects will remain the most important determinants in the choice of antibiotic therapy. However, pharmacoeconomic analyses can provide prescribers with the information required to make cost-effective choices for treatment of their patients.     

Pursuing clinical and operational improvement in an academic medical center

BACKGROUND: An academic medical center in an increasingly competitive market, the University of California-Davis Medical Center in Sacramento started working with a consulting firm in 1995 to reduce overall operational costs and costs for the clinical processes involved in treating patients with specific conditions. ESTABLISHING THE TEAMS: Twelve operational efficiency (OE) teams and five clinical teams were commissioned, with a combined total of nearly one-half of the target cost reduction. The second wave of six clinical teams was simultaneously initiated in late spring 1996. THE IMPROVEMENT METHOD: The quality improvement process for clinical improvement teams included the review and inquiry method, which enables many pilot experiments to be conducted in parallel by work groups and coordinated by the main task team. RESULTS AND CASE STUDIES: Within six weeks of launching, the 12 OE teams achieved their goals and identified savings opportunities of more than $27 million. One OE team, medical records, had set a goal of $514,000 in cost reduction for a three-year period and achieved the first-year goal of $190,000. For a clinical team on interventional cardiology, the clinical benchmark data revealed that the cost per case of providing cardiac catheterization was greater than for all three benchmark groups. These patients, including 270 patients per year, showed a possible savings through process improvement of nearly $1.4 million. From January 1996 through March 1997, the rate of occurrence of complications decreased from 5.5% to 3%. EPILOGUE: Physicians gradually accepted more responsibility and accountability for controlling and reducing costs, while maintaining their traditional role as advocates for improved patient care.     

Safety and cost-effectiveness of solvent-detergent-treated plasma. In search of a zero-risk blood supply

OBJECTIVE: To determine the public health and economic implications of solvent-detergent-treated frozen plasma (SD FP). While this processing technique nearly eliminates the risk of transmitting lipid-enveloped viruses (hepatitis B and C and human immunodeficiency virus), it has associated costs and, because it requires pooling many plasma units, may increase risks of nonenveloped virus transmission. DESIGN: A previously published Markov decision analysis model was modified to assess transfusion-related outcomes in hypothetical cohorts of plasma recipients. In-hospital mortality and other characteristics were determined in 61 patients receiving plasma transfusions at a medium-sized tertiary care center to provide data for the model. Other parameters were obtained from the medical literature. MAIN OUTCOME MEASURES: Expected SD FP costs, benefits, and cost-effectiveness, assessed as cost per quality-adjusted life-year saved. RESULTS: Compared with untreated plasma, a unit of SD FP produces a net benefit of 35 minutes in quality-adjusted life expectancy at a cost of about $19. Extrapolated to the 2.2 million plasma units transfused annually in the United States, SD FP would save 147 quality-adjusted life-years at a cost of $42.5 million. The marginal cost-effectiveness, $289,300 per quality-adjusted life-year saved in the baseline analysis, was most sensitive to estimates of SD treatment cost and the clinical setting of plasma use. In sensitivity analysis, the net benefit of SD FP was negated by the existence of even a minute risk of nonenveloped virus infection. CONCLUSIONS: From a public health perspective, the relatively high costs and small benefits of reducing enveloped virus infection risks with SD FP (and the additional risks of noneveloped virus transmission) do not appear to justify widespread implementation of this new technology.     

Research without billing data. Econometric estimation of patient-specific costs

OBJECTIVES: This article describes a method for computing the cost of care provided to individual patients in health care systems that do not routinely generate billing data, but gather information on patient utilization and total facility costs. METHODS: Aggregate data on cost and utilization were used to estimate how costs vary with characteristics of patients and facilities of the US Department of Veterans Affairs. A set of cost functions was estimated, taking advantage of the department-level organization of the data. Casemix measures were used to determine the costs of acute hospital and long-term care. RESULTS: Hospitalization for medical conditions cost an average of $5,642 per US Health Care Financing Administration diagnosis-related group weight; surgical hospitalizations cost $11,836. Nursing home care cost $197.33 per day, intermediate care cost $280.66 per day, psychiatric care cost $307.33 per day, and domiciliary care cost $111.84 per day. Outpatient visits cost an average of $90.36. These estimates include the cost of physician services. CONCLUSIONS: The econometric method presented here accounts for variation in resource use caused by casemix that is not reflected in length of stay and for the effects of medical education, research, facility size, and wage rates. Data on non-Veteran's Affairs hospital stays suggest that the method accounts for 40% of the variation in acute hospital care costs and is superior to cost estimates based on length of stay or diagnosis-related group weight alone.     

Reengineering a radiology department in an academic institution

OBJECTIVE: A 1-year program was undertaken in conjunction with an outside consultant to cut nonphysician labor expenses by 15%, cut nonlabor expenses by 10%, and improve all service parameters in an academic radiology department. MATERIALS AND METHODS: A steering committee decided on five major goal teams: improve report turnaround time and improve patient throughput, increase the efficiency of performance and improve the quality of radiologic examinations, decrease the cost of each examination, improve charge capture, and improve the perception of the department. The goal teams met at least every 2 weeks, made presentations to the steering committee at midyear, and were then disbanded. The steering committee implemented changes in the second half of the year and continues to meet every 2 weeks. Data were obtained from the radiology information system, financial statements, and surveys. RESULTS: In the first year, report turnaround time decreased from 157 hr to 83 hr (and to 46 hr at 2 years), the efficiency of performing examinations (according to our criteria) improved from 64% to 80%, the quality of examinations improved, labor costs were reduced by 5% (and by 11% at 2 years), nonlabor costs were reduced by 14% (and by 31% at 2 years), cost per examination was reduced by 10% (and by 16% at 2 years), increased charge capture resulted in an annual increase in professional fees of at least $110,000, and the perception of the department by referring clinicians improved. CONCLUSION: It is possible to simultaneously cut expenses and improve service. To gauge progress, objective parameters that can be measured easily are necessary.     

Stereotaxy reduces cost of brain tumor resection

BACKGROUND: Health care professionals are under increasing pressure to contain the cost of health care. Simultaneously, medical technology continues to advance. Medical institutions must therefore consider the costs and benefits before using a new technology. Using a direct costing system, we determined the cost efficacy of stereotaxy applied to the resection of brain mass lesions. METHODS: Twenty-nine patients underwent a stereotactically guided craniotomy and brain tumor resection. Fifteen of them underwent general and fourteen received local anesthesia. Twelve other patients, comprising a historical reference group, underwent a standard craniotomy and brain tumor resection under general anesthesia. costs were determined for every hospital charge item in all patients. Cost efficiency was then compared between the two groups. RESULTS: Patients treated stereotactically incurred additional costs in frame placement and neuroimaging. These costs were offset by savings in operating room time, patient acuity, length of stay, respiratory care, and medications. Savings were greatest for patients who had local anesthesia. Overall, patients treated by stereotactic craniotomy had a total hospitalization cost of $8,495.19, whereas those treated with standard craniotomy incurred a cost of $11,365.23 (p < 0.001). CONCLUSION: Stereotaxy is cost effective for the surgical treatment of brain tumors. Accurate estimates of cost can justify the use of medical technology. Directly measured cost data is a useful index for any cost containment program.     

Decision to use complementary medicine: fact oriented or irrational?

PROBLEM AND OBJECTIVE: Complementary medicine is being used to varying extent in all industrial countries. There are incomplete data concerning efficacy, safety and costs of such treatment, while little is known about special features and motivation of those persons who choose complementary medicine. The aim of the study was to ascertain, among patients who use complementary medicine and those who prefer traditional medicine, any differences with regard to sociodemographic, disease-related and psychological characteristics and their life-style. PATIENTS AND METHODS: A total of 419 patients were studied by a standardised interview and questionnaire (168 items) and divided into two groups (group 1: those using conventional treatment [n - 197; 91 women, 106 men; average age 43.2 +/- 16.9 years]; group 2: those preferring complementary medicine [n = 222; 159 women, 63 men; average age 43.2 +/- 15.0 years]). They were recruited from specialist internal medical or generalist medical practice with or without offer of complementary medicine (additional term: natural healing methods). Statistical analysis was with Student's-t-test and the chi(2)-test [correction of gamma-test]. RESULTS: Those patients who chose to be treated by complementary medicine clearly differed from the others with respect to sociodemographic, disease-related and psychological characteristics, as well as life-style. The patient-doctor relationship also differed between the two groups. On average those of group 2 had a higher educational level (higher education: 10.3% in group 1; 15.9 in group 2) and lower risk factors (68.9% nonsmokers in group 1, 77.8% in group 2; alcohol abstinence: 33.2 vs 46.4%). Patients in both groups preferred conventional medicine for serious diseases (cardiac infarct; tumour; AIDS). CONCLUSIONS: In general, those patients who choose complementary medicine have a healthier life-style. As the number of these patients is on the increase. Since as yet the efficacy, risks and costs of complementary medicine have been inadequately investigated, research in this area should be intensified.