Table 4 - uploaded by Suzanne Austin Boren
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-Application of Costing Protocol to Car- diac Rehabilitation Soon After Acute Myocardial Infarction*
Source publication
In the present era of cost containment, physicians need reliable data about specific interventions. The objectives of this study were to assist practitioners in interpretation of economic analyses and estimation of their own costs of implementing recommended interventions.
MEDLINE search from 1966 through 1995 using the text words cost or expense a...
Contexts in source publication
Context 1
... categories in Table 3 are not mutually exclusive. The way these measures are expressed con- stitute the link between Table 2 and Table 3. Table 4 exemplifies the practical use of the costing protocol used in this study and shows how practitioners can place results of a study into the structured costing protocol and identify available and ignored costs. Data were abstracted from a trial report on cardiac rehabilita- tion soon after myocardial infarction. ...
Context 2
... of available clinical studies should be taken as a warning by practitioners and administrators who routinely make in- ferences and draw conclusions based on incomplete information. The costing pro- tocol, described in the "Methods" sec- tion and illustrated in Table 4, shows the practical steps needed to collect direct cost data for economic analyses and to make pragmatic decisions regarding in- troduction of clinical interventions into patient care. ...
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Citations
... 25 Level I centers generally have greater resources readily available to mobilize an immediate response for those patients presenting in extremis from hemorrhagic shock 14 as well as access to multiple subspecialties and adjunctive therapies. 26,27 Placement of an ICP monitor may be a proxy for the increased resource availability seen at Level I centers and this increase in resources allows for more aggressive care after TBI. ...
Previous investigations suggest outcome differences at Level I and Level II trauma centers. We examined use of intracranial pressure (ICP) monitors at Level I and Level II trauma centers after traumatic brain injury (TBI) and its effect on mortality. The 2007 to 2008 National Trauma Databank was reviewed for patients with an indication for ICP monitoring based on Brain Trauma Foundation (BTF) guidelines. Demographic and clinical outcomes at Level I and Level II centers were compared by regression modeling. Overall, 15,921 patients met inclusion criteria; 11,017 were admitted to a Level I and 4,904 to a Level II trauma center. Patients with TBI admitted to a Level II trauma center had a lower rate of Injury Severity Score greater than 16 (80 vs 82%, P < 0.01) and lower frequency of head Abbreviated Injury Score greater than 3 (80 vs 82%, P < 0.01). After regression modeling, patients with TBI admitted to a Level II trauma center were 31 per cent less likely to receive an ICP monitor (adjusted odds ratio [AOR], 0.69; P < 0.01) and had a significantly higher mortality (AOR, 1.12; P < 0.01). Admission to a Level II trauma center after severe TBI is associated with a decreased use of ICP monitoring in patients who meet BTF criteria as well as an increased mortality. These differences should be validated prospectively to narrow these discrepancies in care and outcomes between Level I and Level II centers.
... Intervention Cost Calculation-The costs of delivering the PAQS intervention were estimated based on the recommendations of Balas et al. 18 , accounting for direct expenditures (e.g., staff wages, materials), and for start-up costs and elements of overhead. Training costs included 40 training hours for the asthma education nurse multiplied by a) the hourly wage of professional trainers ($48 + fringe), and b) the hourly wage of the asthma education nurses ($25 + fringe). ...
Caregivers who smoke and have children with asthma are an important group for intervention. Home-based interventions successfully reduce asthma morbidity, yet are costly. This study evaluated the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program, a combined asthma education and smoking cessation intervention.
Participants included caregivers (n = 224) that smoked, had a child with asthma, and were enrolled in a Medicaid managed care plan. Participants received nurse-delivered asthma education and smoking counseling in three home visits. Program implementation costs were estimated, and healthcare expenses were obtained from insurance claims data 12 months pre- and 12 months post intervention. ROI was calculated for all participants, children <6 years, children 6-18 years, and children with moderate/severe persistent asthma.
Total program implementation cost was $34,481. After intervention, there was increased mean annual refills of beta-agonist (0.51 pre, 1.64 post; P < 0.001), and controller medications (0.65 pre, 2.44 post; P < 0.001). Reductions were found in mean annual emergency department visits (0.33 pre, 0.14 post; P < 0.001), hospitalizations (0.23 pre, 0.08 post; P < 0.001), and outpatient visits (2.33 pre, 1.45 post, P < 0.001). The program had negative ROI (-21.8%) for the entire sample. The ROI was positive (+106.9) for children <6 years, negative (-150.3) for children 6-18, and negligible for moderate/severe persistent asthma (+6.9%).
PAQS was associated with increased medication use and decreased healthcare utilization. While the overall ROI for PAQS was negative, PAQS had a positive ROI for caregivers of young children with asthma. Pediatr Pulmonol. 2012. 47:950-955. © 2012 Wiley Periodicals, Inc.
... Balas et al. (Balas AE et al., 1998) (Adams ME et al., 1992) analyzed 121 out of 50,000 randomized controlled trials that were published from 1966 to 1988. After assessing those 121 articles, they calculated a mean quality of research score of .32 (scale 0 -1) and a mean completeness of assessment score of .52 (scale 0 -1) further demonstrating a lack of quality in medical economic reporting. ...
Purpose and Study Design: Retrospective cohort cost-minimization analysis (payer perspective) with decision analysis model to access cost-effectiveness of a treatment-based algorithm (TBC) for low back pain (LBP) compared to a "usual" care strategy in the outpatient setting.Methods: charge data was examined on 750 subjects with LBP from 42 regional clinics over 1 year period. Subjects were determined to be on or off protocol for the classification algorithms based on provider responses to minimum required initial exam and history intake data and subsequent interventions provided. Primary outcome measures were total net direct health care and physical therapy costs, along with total member and physical therapy member burden costs. In addition, protocol status was examined as a predictor variable for the following: top quartile of total direct health care and physical therapy expenditures, as well as total direct health care and physical therapy member burden. A 4% / yearly discounting rate was applied.Results: Baseline characteristics of the combined sample demonstrated a significant proportion of Medical Assistance patients were given non-adherent care. In addition, a significant but not clinical difference was found in fear-avoidance behavioral questionnaire physical activity (FABQ_PA) scores. Incremental cost-savings were demonstrated in all primary outcome measures for the combined sample. The specific exercise and flexion off-protocol subgroups demonstrated member burden savings but this was explained exclusively after adjustment by having Medical Assistance as an insurance type. Off-protocol status accounted for significant variation in explaining differences in the statistically different outcomes, as well as demonstrating predictive ability for attaining the top quartile of total direct health care expenditures. The decision analysis model demonstrated the dominance of classification approach to usual care across a variety of associated variable ranges and distributions.Conclusions: This evidence supports the TBC as a cost-effective alternative for LBP treatment compared to usual physical therapy care. It appears beneficial for a payer to adopt strategies to improve compliance with the TBC. Further recommendations are suggested to either validate or cross-validate these findings and to improve outcomes reporting. The TBC should also be compared as a cost-effective alternative to treating LBP against primary-care (non-rehabilitative) and chiropractic.
... As a result, these economic studies may not inform policy. Several economic studies reported that costs are the major source of variation in differing conclusions for cost-effectiveness of health interventions (56)(57)(58)(59). A recent workshop at the Institute of Medicine concluded that poor quality of information on resource costs of screening procedures is a major source of the inconsistency in results among several models of cost-effectiveness of colorectal cancer screening (60). ...
The reported estimates of the economic costs associated with prostate cancer screening, diagnostic testing, and clinical staging are substantial. However, the resource costs (i.e., factors such as physician's time, laboratory tests, patient's time away from work) included in these estimates are unknown. We examined the resource costs for prostate cancer screening, diagnostic tests, and staging; examined how these costs differ in the United States from costs in other industrialized countries; and estimated the cost per man screened for prostate cancer, per man given a diagnostic test, and per man given a clinically staged diagnosis of this disease.
We searched the electronic databases MEDLINE, EMBASE, and CINAHL for articles and reports on prostate cancer published from January 1980 through December 2003. Studies were selected according to the following criteria: the article was published in English; the full text was available for review; the study reported the resource or input cost data used to estimate the cost of prostate cancer testing, diagnosing, or clinical staging; and the study was conducted in an established market economy. We used descriptive statistics, weighted mean, and Monte Carlo simulation methods to pool and analyze the abstracted data.
Of 262 studies examined, 28 met our selection criteria (15 from the United States and 13 from other industrialized countries). For studies conducted in the United States, the pooled baseline resource cost was 31.77 for screening with digital rectal examination (DRE). For studies conducted in other industrialized countries, the pooled baseline resource cost was 33.54 for DRE. For diagnostic and staging methods, the variation in the resource costs between the United States and other industrialized countries was mixed.
Because national health resources are limited, a decision about whether to invest in early detection of prostate cancer requires an understanding of the factors included in estimates of the economic cost of this disease. This study may benefit health policy makers charged with allocating resources for prostate cancer.
... There are a number of options to enhance external validity; of these, additional modeling and observational data based on real-world disease management are the most promising (10). There have also been concerns about the analysis and interpretation of cost data from published trials (11)(12)(13). Potentially misleading conclusions about the relative costs of different or new therapies have often been reported in the absence of supporting statistical evidence. ...
Studies describing the economic impact of chronic obstructive pulmonary disease (COPD) are used for several purposes. There can, however, be limitations as costs based on results of a clinical trial are likely to be significantly different from real world practice. Sometimes, it may be more useful to capture the costs of the important components accurately rather than the often unachievable aim of capturing every cost however small. Burden of illness studies can help identify clinical targets or patterns of care-for example, hospitalization-that are major health care cost drivers. In the United Kingdom, burden of COPD studies suggest an annual cost of 781 pounds sterlings- 1,154 pounds sterlings per patient. Cost analyses can be divided into four types: cost minimization, cost-effectiveness, cost benefit, and cost utility. Utilities such as quality-adjusted life year (QALY) measure the effectiveness of different therapies, and can be obtained in various ways and in different populations, potentially leading to significant differences in the results. Payers often apply cost per QALY thresholds when assessing whether a new therapy should be used or not. In the United Kingdom, it is accepted that there is a sigmoid relationship between the cost per QALY and the likelihood of a therapy being recommended, with a lower inflection between 5,000 pounds sterlings and 15,000 sterlings, below which rejection is unlikely and an upper inflection between 25,000 pounds sterlings and 35,000, above which acceptance is unlikely, but not impossible. On this basis, pulmonary rehabilitation and inhaled steroids are unlikely to be rejected but lung volume reduction surgery may be.
... 4,5 Other studies have examined clinical outcomes, but have either completely omitted financial data or used only aggregate cost analyses when reporting results. 6,7 In today's revenue-constrained environment, cost containment and cost minimization are essential, and failure to link clinical outcomes with corresponding managerial cost decisions could compromise quality of care and, at the very least, makes it difficult for clinicians to choose the most economical and effective therapeutic option. ...
To examine whether cost management strategies are used in a revenue-constrained environment without compromising clinical effectiveness.
Cross-sectional analysis of monthly cost and acuity-adjusted hospitalization data.
This research included longitudinal regression analyses involving 10 years of data, 1990 through 1999, from each of 6 dialysis centers. Two sets of regression models were used: one set examined cost interactions and cost trends (P < or = .001); the second set examined clinical outcomes (P < or = .001). Four cost management strategies were examined: (1) selective reductions in targeted cost categories, (2) cost reductions through improved efficiencies, (3) cost avoidance by shifting responsibilities to external parties, and (4) uniform reductions across all cost categories.
Managers appeared to have limited opportunity to selectively or uniformly reduce costs because of cost "stickiness" and minimal resource substitutability. Improvements in operational efficiencies and cost shifting to external parties occurred. Over time, however, realized efficiencies increased at a decreasing rate, whereas cost shifting actually declined. Contrary to prior hospital studies, these results indicate significant economies of scale. No statistical correlation was found to indicate that the physician/clinic management teams' use of cost reduction strategies affected acuity-adjusted hospitalizations of dialysis patients.
Strategic models that include both financial and outcomes data can enable healthcare managers to predict both positive and negative results of cost management proposals. These models can help identify aspects of an organization's cost structure that affect sustainable cost savings: cost stickiness, cost substitutability, institutional experience, realized operational improvements, and economies of scale.
... Multiple published studies have criticized the rigor, relevance, objectivity, methods, and reports produced within the health economic research do- main456789101112 . Consequently, health economic research findings are not used as extensively as they could be and rational decision processes about the efficient use of healthcare resources may not be fully informed. ...
... [17][18][19] This report provides no data on the costs of healthcare, training and work-effort of the primary care education nurses, and medications, or on other indirect measures of cost that should be assessed in any complete financial evaluation of a clinical program. 76 However, since the impact of improved glycemic control on diabetic complications can be assessed only after several years, 77 an accurate assessment of any cost savings for our population cannot be performed adequately for the time period of this study. The most tangible expense for this type of program is the cost for education nurses; concerns over this expense can, however, be mitigated by considering the important role of these nurses in advocating the use of clinical guidelines, consolidating data collection, and conducting important disease management and patient education activities. ...
To describe outcomes associated with a health maintenance organization (HMO)-sponsored disease management program for diabetes.
Descriptive study that compared outcomes of patients with diabetes before and after entry into a disease management program.
The study was conducted in a mixed-model HMO with 275,000 members. The disease management program included a Steering Committee, clinical guidelines, primary care site-based diabetes education, coverage of glucose meters and strips, simplified outcomes reporting, and support of clinical leadership. Data were obtained for 5332 continuously enrolled patients who voluntarily entered the disease management program; 3291 patients (61.7%) received 3 months or more of follow-up, and 663 (12.4%) received 1 year or more of follow-up. The primary outcomes were change from baseline of mean hemoglobin A1c (HbA1c) and medication use after 3 months and 1 year of follow-up.
The mean baseline HbA1c for all program participants was 8.51% (standard deviation [SD] = 1.86%). At 3 months of follow-up, the mean HbA1c value for 2794 of 3291 participants (84.0%) had decreased to 7.41% (SD = 1.33%; P = .0001). At 1 year of follow-up, the HbA1c value, available for 605 of 663 patients (91.3%), had decreased from a mean baseline value of 8.76% (SD = 1.87%) to 7.41% (SD = 1.24%; P = .0001). Among 663 patients with 1 year of follow-up, insulin use increased from 30.0% to 31.6%, and sulfonylurea use decreased from 40.7% to 33.8%. Troglitazone and metformin use increased from 7.7% and 23.8%, respectively, to 16.4% and 28.8%, respectively.
Our data suggest that a multifaceted disease management program for diabetes can result in significant short-term improvements in glycemic control in the managed care setting. While the improvement in the HbA1c was accompanied by an increase in the use of insulin, troglitazone, and metformin, we suggest the influence of disease management on glycemic control among our participants was significant and should be considered in future studies in this area.
... Even if it is somehow known that an economic study is methodologically sound, inadequate reporting still presents a problem in that it hinders the ability of individuals to judge the applicability of a study's results and methods to their own (different) set of circumstances/conditions. 236 Mason and Drummond 201,235 comment on the results of a critical appraisal of 147 economic evaluations contained on a register of costeffectiveness studies held by the Department of Health in England. While the focus of the appraisal was not reporting standards, some reference is made to reporting. ...
