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Lifetime and Treatment-Phase Costs Associated With Colorectal Cancer: Evidence from SEER-Medicare Data

  • Boston Health Economics, Inc.

Abstract and Figures

This study provides detailed estimates of lifetime and phase-specific colorectal cancer (CRC) treatment costs. This retrospective cohort study included patients aged 66 years and older, newly diagnosed with CRC in a Surveillance Epidemiology and End Results (SEER) registry (1996-2002), matched 1:1 (by age, sex, and geographic region) to patients without cancer from a 5% sample of Medicare beneficiaries. The Kaplan-Meier sample average estimator was used to estimate observed 10-year costs, which then were extrapolated to 25 years. A secondary analysis computed costs on a per-survival-year basis to adjust for differences in mortality by stage and age. Costs were expressed in 2006 US$, with future costs discounted 3% per year. Our sample included 56,838 CRC patients (41,256 colon cancer [CC] patients and 15,582 rectal cancer [RC] patients; mean +/- SD age, 77.7 +/- 7.1 y; 55% women; and 86% white). Lifetime excess costs were $29,500 for CC and $26,500 for RC patients. Per survival year, stage IV CRC patients incurred $31,000 in excess costs compared with $3000 for stage 0 patients. CRC patients incurred excess costs of $33,500 in the initial phase, $4500/y in the continuing phase, and $14,500 in the terminal phase. RC patients had lower costs than CC patients in the initial phase, but higher costs in both the continuing and terminal phases. Excess costs associated with CRC are striking and vary considerably by treatment phase, cancer subsite, and stage at diagnosis. Interventions aimed at earlier diagnosis and prevention have the potential to reduce cancer-related health care costs.
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Lifetime and Treatment-Phase Costs Associated With Colorectal Cancer:
Evidence from SEER-Medicare Data
*Boston Health Economics, Inc., Waltham, Massachusetts;
GE Healthcare, Waukesha, Wisconsin; and
Harvard Medical School, Boston, Massachusetts
Background & Aims: This study provides detailed esti-
mates of lifetime and phase-specific colorectal cancer (CRC)
treatment costs. Methods: This retrospective cohort study
included patients aged 66 years and older, newly diagnosed
with CRC in a Surveillance Epidemiology and End Results
(SEER) registry (1996–2002), matched 1:1 (by age, sex, and
geographic region) to patients without cancer from a 5% sam-
ple of Medicare beneficiaries. The Kaplan–Meier sample av-
erage estimator was used to estimate observed 10-year costs,
which then were extrapolated to 25 years. A secondary analysis
computed costs on a per-survival-year basis to adjust for dif-
ferences in mortality by stage and age. Costs were expressed in
2006 US$, with future costs discounted 3% per year. Results:
Our sample included 56,838 CRC patients (41,256 colon can-
cer [CC] patients and 15,582 rectal cancer [RC] patients;
mean SD age, 77.7 7.1 y; 55% women; and 86% white).
Lifetime excess costs were $29,500 for CC and $26,500 for RC
patients. Per survival year, stage IV CRC patients incurred
$31,000 in excess costs compared with $3000 for stage 0 pa-
tients. CRC patients incurred excess costs of $33,500 in the
initial phase, $4500/y in the continuing phase, and $14,500 in
the terminal phase. RC patients had lower costs than CC
patients in the initial phase, but higher costs in both the
continuing and terminal phases. Conclusions: Excess costs
associated with CRC are striking and vary considerably by treat-
ment phase, cancer subsite, and stage at diagnosis. Interventions
aimed at earlier diagnosis and prevention have the potential to
reduce cancer-related health care costs.
Currently available estimates of the cost of colorectal cancer
(CRC) vary widely and are outdated. This study extends
previous research by estimating lifetime and phase-specific CRC-
related costs by cancer subsite, age, and stage at diagnosis using
the most current data available. Representative CRC cost data are
needed because they are used to evaluate technologies aimed at
early detection and prevention.1Further, age-specific CRC cost
data are important because the aggressiveness of treatment and
screening guidelines are age-dependent. Finally, understanding
costs by stage at diagnosis is important from a public health
perspective because it affects economic evaluations of new colo-
rectal screening technologies.2,3 The goal of screening is to
affect a positive shift in stage at detection from late to early
stage. The economic benefit of this stage shift is measured in
the incremental cost reduction in detecting CRC earlier.
Data Sources
This study used 3 data sources: (1) the linked Surveil-
lance Epidemiology and End Results (SEER)–Medicare database
(a collaborative effort of the National Cancer Institute, the
SEER registries, and the Centers for Medicare and Medicaid
Services); (2) the SEER*Stat database, containing clinical and
survival data from the SEER registries; and (3) survival data for
the general population from US life-tables.
SEER is a US cancer surveillance system consisting of pop-
ulation-based tumor registries designed to track incidence and
survival. The registries routinely collect information from mul-
tiple reporting sources about newly diagnosed cancer patients
in geographically defined areas representing approximately 25%
of the US population.4Complete details of the linkage of the
SEER and Medicare data have been described elsewhere.5
Patient Selection
Colorectal cancer cohort. All patients aged 66 years
and older with a new diagnosis of malignant adenocarcinoma of
the colon or rectum (ie, presence of a SEER cancer site recode value
between 15 and 27 and one of the following International Classi-
fication of Diseases for Oncology, 3rd Edition (ICD-O-3) histology
codes: 8140, 8210-11, 8220-21, 8260-63, 8470, 8480-81, and 8490)
reported to a SEER registry between January 1, 1996, and Decem-
ber 31, 2002, were identified for possible inclusion in the CRC
cohort. The index date for each patient was defined as the date of
CRC diagnosis. Patients were required to have a full 12 months of
data available pre-index.
To ensure complete expenditure information for our sample,
patients were excluded if at any time in the period 12 months
before, or anytime after the index date, they were enrolled in a
Medicare HMO, not eligible for both Medicare Part A and B
benefits, or eligible for benefits under the end-stage renal dis-
ease program. We also excluded patients who had claims in the
12-month pre-index period indicating any other cancer, were
diagnosed with CRC at the time of death or autopsy, or could
not be matched to an appropriate comparator.
Comparison cohort. Comparison cohort patients
were selected from Medicare enrollment files using a 5% random
sample of Medicare beneficiaries residing in SEER areas who did
not have cancer. One comparison patient of identical age, sex, and
census region was matched randomly to each CRC patient and
assigned the same index date (so that both patients were followed
up over the same time period). As with CRC patients, comparators
were not eligible for inclusion if they were enrolled in an HMO or
were not eligible for Medicare Part A and B benefits at any point
from 12 months before index through follow-up evaluation. These
Abbreviations used in this paper: CC, colon cancer; CRC, colorectal
cancer; RC, rectal cancer.
©2009 by the AGA Institute
patients were not required to have used services to be selected for
inclusion, and they were allowed to develop cancers other than
CRC after their index date. Patients in both cohorts were followed
up from their index date until death or the end of the Medicare
claims data (December 31, 2005).
Statistical Analyses
Baseline demographic and clinical characteristics of
both study cohorts were evaluated, including Deyo–Charlson
comorbidity scores.6Health care costs included all Medicare
payments, private insurer payments, and patient copayments
and deductibles for covered services. Covered services included
inpatient hospital and skilled nursing facility stays, outpatient
hospital services, physician and laboratory services, home
health, and hospice care. Prescription drugs (including chemo-
therapy) administered in hospitals were included in inpatient
expenditures. Outpatient chemotherapy costs were included in
outpatient expenditures; oral prescription drugs administered
on an outpatient basis were excluded because they were not
covered by Medicare at the time of the study.
Excess costs attributable to CRC were defined as the difference
in costs between CRC and matched comparison patients. We used
this definition to minimize bias caused by coding inconsistencies
and omissions associated with relying on a sum of expenditures
for medical events with a cancer diagnosis code.7For example,
treatment for the side effects of cancer therapy should be included
in the cost of cancer treatment but may not be coded with a cancer
diagnosis. In addition, patients may be treated for cancer-related
conditions and other conditions in the same medical encounter, in
which case it is impossible to determine from the claims the cost
of the cancer-related portion of the encounter.
Estimation of lifetime costs. Patients in our SEER–
Medicare analysis were accrued between 1996 and 2002 and
were followed up through 2005 (the end of the SEER–Medicare
database), for a maximum of 10 years of follow-up evaluation,
a time horizon unlikely to be adequate for evaluating lifetime
costs among patients diagnosed with less-advanced cancer or
for comparison patients. Thus, modeling techniques for the
analysis of censored cost data were used to estimate lifetime
health care costs attributable to CRC.8–11
Costs for years 1 through 10 were estimated directly from
observable SEER–Medicare data for CRC patients and controls
using the nonparametric Kaplan–Meier Sample Average estima-
tor.12 The Kaplan–Meier Sample Average computes costs by sum-
ming expected costs incurred per time interval, calculated as the
product of the probability of surviving to that time interval, and
the sample average cost among survivors to the start of that
The Kaplan–Meier Sample Average estimator is calculated by
using the following formula:
Where tis the post–index-date month, Ptis the survival proba-
bility, and Ctis the mean actual costs in period tamong
beneficiaries surviving to month t. The Kaplan–Meier Sample
Average estimator minimizes the bias associated with censored
data by dividing the time period into short intervals. This
calculation provides a nonparametric estimate of the average
costs for patients with variable lengths of follow-up evaluation.
Costs for years 11 through 25 were extrapolated for both
cohorts using the assumption that cohort-specific average an-
nual medical care costs were constant for years beyond the
available data until the year before the final year of life (ie,
continuing costs). These continuing-phase costs were estimated
from the subset of patients in each cohort who lived at least 3
years as the average annual cost for years between year 1 and the
final year of life, exclusive. In addition, we assumed that medical
care costs in the final year of life (ie, terminal costs) for patients
who lived beyond the 10-year study period were the same,
regardless of time from diagnosis; terminal costs were thus
estimated as the average final-year cost among cases in the
relevant cohort who died at least 2 years after the index date.
We used the following formula to estimate costs in years 11
to 25:
Here, Py
ˆis the probability of surviving to year y. For CRC
patients, this survival probability was estimated for years 11 to
16 using SEER*Stat data and for years 17 to 25 by fitting SEER
data from 1988 to 2004 to a Weibull model. US life tables from
the National Center for Health Statistics13 provided survival
probabilities for controls. Cy
ˆis the expected cost in year y,
computed as a weighted average of the annual cost for cases
dying in year y(ie, terminal cost) and those surviving through
year y(ie, continuing cost). Total lifetime costs in each
cohort are calculated by summing cohort-specific estimates
of C1and C2.
Lifetime excess costs among CRC patients were reported
overall and per year of survival, by stage, age at diagnosis, and
cancer subsite, in 2006 US dollars, with future costs discounted
at 3% per year. Estimates of lifetime costs per survival year were
calculated by dividing the estimate of expected lifetime costs for
each age- and stage-specific group by the expected years of
survival for that group.
Phase-specific cost estimates for the entire colo-
rectal cancer population. Our lifetime cost estimation re-
quired estimates of continuing and terminal costs for CRC
patients who survived at least 10 years. For completeness, we
also estimated phase-specific costs for the entire CRC popula-
tion (ie, short-term and long-term survivors). These costs were
estimated as follows: (1) terminal costs were assigned first and
were calculated as the average cost in the final year of life, with
all costs considered terminal for patients living fewer than 13
months after diagnosis; (2) initial costs were calculated as the
average costs in the initial (up to 1 year) period after diagnosis
and before the last year of life and were calculated among those
who lived at least 13 months after diagnosis; and (3) continuing
costs included the period between the first and last year of life
for patients with at least 25 months of survival, and were
reported on a per-year basis.
Patient Characteristics
We identified 56,838 CRC patients (41,256 colon cancer
[CC], 15,582 rectal cancer [RC]) who met our selection criteria.
Demographic and clinical characteristics for CC patients, RC pa-
February 2009 CRC COSTS 199
tients, the combined CRC cohort, and the comparison cohort are
presented in Table 1. The mean SD age was 77.7 7.1 years;
about 55% of patients in both cohorts were women and 86% were
Lifetime Cost Estimates
Total lifetime cancer-related costs were $28,500, with
an inverted U-shaped pattern by stage and a U-shaped pat-
tern by age (Table 2). Excess costs for RC patients were
somewhat higher than costs for CC patients for stages I to III
and substantially lower for stage 0. CC costs were $42,000 for
stage 0, $45,000 for stage I, $43,000 for stage II, and $41,000 for
stage III.
Among RC patients, excess costs for stages I to III were
approximately 50% greater than for stage 0 ($47,000 for stage I,
$49,000 for stage 2, and $46,500 for stage III vs $30,000 for
Table 1. Baseline and Demographic Characteristics of Patients With CRC and Matched Comparison Patients
Variable CC patients RC patients Combined CRC cohort Comparison cohort
N 41,256 15,582 56,838 56,838
Age, ya
Mean (SD) 77.9 (7.1) 77.1 (7.1) 77.7 (7.1) 77.7 (7.1)
Median 77.0 76.0 77.0 77.0
Interquartile range 72–83 71–82 72–83 72–83
Femalea57.0% 50.5% 55.2% 55.2%
White 85.6% 86.3% 85.8% 86.2%
African American 8.2% 6.6% 7.7% 6.7%
Hispanic 1.2% 1.4% 1.3% 2.1%
Other 5.0% 5.7% 5.2% 5.0%
Geographic regiona
Northeast 21.9% 22.4% 22.0% 22.0%
Midwest 24.0% 23.3% 23.8% 23.8%
West 40.1% 40.8% 40.3% 40.3%
South 14.0% 13.5% 13.9% 13.9%
Location of residence
Metropolitan county 82.6% 81.8% 82.4% 82.6%
Nonmetropolitan county 17.4% 18.2% 17.6% 17.3%
Missing 0.0% 0.0% 0.0% 0.1%
Year of CRC diagnosis
1996 10.0% 10.3% 10.1% b
1997 10.3% 10.6% 10.4% b
1998 10.2% 10.5% 10.3% b
1999 9.9% 10.0% 9.9% b
2000 19.8% 20.4% 20.0% b
2001 19.7% 19.4% 19.6% b
2002 20.0% 18.7% 19.6% b
Stage at diagnosis
Stage 0 6.7% 8.1% 7.1% b
Stage I 22.2% 27.6% 23.7% b
Stage II 30.5% 20.7% 27.8% b
Stage III 22.0% 18.2% 21.0% b
Stage IV 14.5% 16.5% 15.1% b
Unknown 4.1% 8.9% 5.4% b
Charlson scorec
Mean (SD) 1.9 (1.8) 1.7 (1.8) 1.8 (1.8) 1.7 (1.9)
Median 1.0 1.0 1.0 1.0
Interquartile range 0–3 0–3 0–3 0–3
Selected Charlson comorbidities (%)
Chronic pulmonary/respiratory disease 33.2% 32.1% 32.9% 28.8%
Congestive heart failure 32.7% 28.4% 31.5% 28.3%
Diabetes without complications 27.9% 24.9% 27.1% 24.3%
Cerebrovascular disease 21.6% 19.0% 20.9% 24.2%
Myocardial infarction 15.3% 14.5% 15.1% 14.3%
Peptic ulcer 9.4% 7.4% 8.9% 6.8%
Other major conditionsd33.3% 29.2% 32.2% 33.9%
Data from SEER–Medicare database, 1996 –2005.
aVariables used in matching cohorts.
bCharacteristics do not apply.
cModified Charlson comorbidity index6excluding cancer-related comorbidities.
dOther major conditions include rheumatologic disease, mild liver disease, diabetes with complications, major liver disease peripheral vascular
disease, dementia, renal disease, hemiplegia or paraplegia, and acquired immune deficiency syndrome.
stage 0). Excess costs among stage IV patients were negative,
reflecting patients’ shorter life expectancy and the incorpora-
tion of future medical costs of comparison patients who outlive
CRC patients.
On a per-survival-year basis, excess CRC costs were approx-
imately 9 times greater for patients diagnosed at stage IV versus
stage 0 (Figure 1). Excess CC costs per survival year were
approximately 3 times greater for stage IV than for stage III.
Excess RC costs per survival year were approximately 2 times
greater for stage IV than for stage II. Compared with costs for
CC, costs for RC were similar for stages 0 and I, somewhat
higher for stages II to III, and substantially lower for stage IV.
Across all stages, excess costs per year of survival were highest
among the oldest patients.
Table 3 reports lifetime cancer-related health care costs per
year of survival for combinations of age and stage at diagnosis.
Within stage, costs increase monotonically with age up to stage
III, but the difference is more pronounced in early stage disease.
Within age, costs increase monotonically with stage, with the
increase most pronounced in younger patients.
For the combined CRC cohort, costs for the 85group were
approximately 50% and 30% higher than costs for the 66 to 74
Table 2. Excess Cancer-Related Lifetime Health Care Costs
(2006 US$) by Cancer Subsite, Stage, and Age at
CC patients RC patients
CRC cohort
All stages $29,420 $26,544 $28,626
Stage 0 $42,127 $29,983 $38,155
Stage I $45,094 $46,703 $45,435
Stage II $42,847 $49,020 $44,311
Stage III $41,050 $46,614 $42,437
Stage IV $7428 $18,770 $10,864
Unknown/unstaged $25 $510 $474
All ages $29,420 $26,544 $28,626
Age 66–74 $36,226 $36,790 $36,401
Age 75–84 $22,815 $16,726 $21,167
Age 85$27,309 $12,960 $23,799
NOTE. Survival probabilities beyond year 10 were estimated with
SEER*Stat data (stage-specific survival data projected beyond year
16 with Weibull models). Future costs were discounted at 3% per year
Data from SEER-Medicare database, 1996-2005.
Figure 1. Excess lifetime cancer-related health care costs (2006 US$)
per year of survival, by cancer subsite, and stage at diagnosis.
Table 3. Excess Lifetime Cancer-Related Health Care Costs (2006 US$) per Year of Survival and by Age and Stage at Diagnosis
All ages Age 66–74 Age 75–84 Age 85
Stage at
diagnosis CC patients RC patients
Combined CRC
cohort CC patients RC patients
Combined CRC
cohort CC patients RC patients
Combined CRC
cohort CC patients RC patients
Combined CRC
All stages $8909 $8759 $8853 $8521 $9195 $8713 $9397 $9923 $9516 $12,917 $11,602 $12,639
Stage 0 $3348 $2975 $3210 $2629 $2641 $2551 $4267 $4674 $4308 $9350 $5038 $8027
Stage I $4197 $4363 $4238 $3744 $4554 $3954 $4875 $5206 $4988 $6667 $5848 $6419
Stage II $6337 $8401 $6723 $5849 $8412 $6498 $6283 $9136 $6804 $9333 $11,359 $9586
Stage III $10,192 $11,517 $10,516 $10,232 $12,578 $10,867 $10,428 $12,225 $10,926 $13,082 $14,178 $13,221
Stage IV $33,033 $25,455 $30,794 $36,117 $28,790 $34,622 $30,913 $25,335 $29,861 $28,224 $19,992 $25,888
$7670 $4804 $6225 $7954 $7004 $7650 $7255 $4750 $6431 $12,941 $4239 $9250
NOTE. Survival probabilities beyond year 10 were estimated with SEER*Stat data (stage-specific survival data projected beyond year 16 with Weibull models). Future costs were discounted at
3% per year.
Data from SEER–Medicare database, 1996 –2005.
February 2009 CRC COSTS 201
and 75 to 84 age groups, respectively. For the CC cohort, costs
for the 85age group were approximately 50% and 40% higher
than costs for the 66 to 74 and 75 to 84 age groups, respectively.
For the RC cohort, costs for the 85age group were approxi-
mately 20% and 10% higher than costs for the 66 to 74 and 75
to 84 age groups, respectively.
Across age groups, RC patients had less variation in costs
than CC patients. Compared with CC patients, RC patients had
higher costs for the 66 to 74 and 75 to 84 age groups and lower
costs for the 85age group.
Phase-Specific Cost Estimates for the Entire
Colorectal Cancer Population
Examining both short- and long-term survivors, CRC-
related initial phase costs were approximately $33,000, excess
continuing phase costs were about $4500 per year, and excess
terminal costs were more than $14,000 (Table 4). Initial-phase
costs were slightly higher for CC patients, whereas continuing-
phase costs were roughly one-third higher for RC versus CC and
terminal costs were higher for RC patients by a small margin.
Phase-specific costs were much higher for stages III and IV
compared with stages 0 to II for all phases. However, little can
be inferred from the difference in stage IV because these pa-
tients are treated continually for active disease. In all phases,
costs were highest for the 66 to 74 age group and lowest for the
85age group. The biggest difference in costs by age occurred
in the continuing phase, in which the 66 to 74 age group had
costs approximately two-thirds higher than that of the 75 to 84
age group.
This study evaluated lifetime and phase-specific excess
costs among elderly patients with CRC in the United States. We
found that lifetime CRC-related costs are substantial and vary
by cancer subsite, stage at diagnosis, age at diagnosis, and
treatment phase. Excess lifetime costs show an inverted U-
shaped pattern by stage at diagnosis, and a U-shaped pattern by
age at diagnosis for both CC and RC. Costs for RC patients are
lower than costs for CC patients in stage 0, higher in stages I to
III, and lower in stage IV. On a per-survival-year basis, costs are
substantially higher for both RC and CC patients diagnosed in
stage IV versus any other stage. RC patients had lower costs
than CC patients in the initial phase, but higher costs than CC
patients in both the continuing and terminal phases.
Our findings regarding excess costs associated with CRC are
broadly consistent with 2 previous studies. Etzioni et al9ana-
lyzed excess lifetime costs of care for CRC patients using data
from SEER–Medicare (1986–1994) using a methodology simi-
lar to ours (ie, subtracting total lifetime costs for a noncancer
control group from lifetime costs for CRC patients). Brown et
al11 used 5 years of SEER–Medicare data (1990–1994) to esti-
mate phase-specific (initial, continuing, and terminal) costs and
to project total lifetime costs associated with CRC, not account-
ing for future medical costs that would have been incurred in
the absence of cancer. Because their study did not account for
future medical costs, our estimates of excess costs are somewhat
lower. Total costs in our study for both cancer patients and
comparison patients are higher for all stages and cancer sub-
sites, which we would expect given our use of data that includes
more recent advances in CRC treatment (eg, irinotecan) and the
inflation in the cost of health care services that has occurred
during the decade between data sources.
One previous study found much higher estimates of CRC-
related direct medical costs.14 This study used an administrative
claims database, which included patients insured by private or
Medicare supplemental health plans. The investigators found
that Medicare beneficiaries had considerably lower monthly
expenditures than patients with commercial insurance, likely
explaining our difference in findings. An additional study
found that 41% to 55% of patients who were diagnosed with
CRC more than 5 years ago were still receiving treatment, well
past the time when CRC patients are traditionally thought of as
Table 4. Initial, Continuing, and Terminal Cancer-Related Health Care Costs (2006 US$) by Cancer Subsite, Stage, and Age
InitialaContinuing (per year)bTerminalc
CC RC All patients CC RC All patients CC RC All patients
All patients $33,520 $32,683 $33,294 $3927 $5254 $4280 $14,410 $14,878 $14,538
Stage 0 $18,052 $13,954 $16,762 $2374 $1744 $2175 $7103 $7161 $7121
Stage I $27,783 $25,659 $27,099 $2347 $3341 $2665 $7774 $9641 $8371
Stage II $35,055 $40,217 $36,092 $2750 $5126 $3216 $11,731 $16,741 $12,755
Stage III $41,222 $43,518 $41,796 $5768 $7142 $6109 $18,417 $20,255 $18,854
Stage IV $42,401 $39,436 $41,562 $19,987 $22,039 $20,582 $27,898 $20,625 $25,714
Unknown $27,841 $28,500 $28,132 $3737 $6179 $4788 $12,785 $12,147 $12,496
Age, y
66–74 $33,980 $35,002 $34,282 $5334 $6828 $5775 $16,788 $16,491 $16,699
75–84 $33,401 $31,741 $32,967 $3277 $4166 $3503 $13,457 $14,273 $13,675
85$32,966 $27,982 $31,869 $2261 $3534 $2502 $12,273 $12,571 $12,346
Data from SEER–Medicare database, 1996 –2005.
aInitial costs were defined as average costs in the initial (up to 1 year) period after diagnosis and before the last year of life and were calculated
among only those who lived at least 13 months after diagnosis.
bContinuing costs were defined as average annual costs in years beyond the initial year and before the last year of life and were calculated among
only those patients who lived at least 25 months after diagnosis.
cTerminal costs were defined as average costs in the final year of life (all costs are considered terminal for patients living 13 months after
cured.15 This reinforces our findings that continuing costs are
nearly $3500 higher for CRC patients than for the comparison
One recently published study of the phase-specific costs of
cancer care using SEER–Medicare data from 1999 to 2003
found similar costs for the initial year of life ($32,101 for male
CRC patients vs our estimate of $33,500 for all CRC patients).16
However, because of the methods used in matching terminal-
phase cancer patients to continuing-phase controls, their esti-
mates of terminal-phase costs were much higher than ours
($39,544 vs $14,500). Our continuing-phase cost estimate
($4500) was slightly higher than theirs ($2444 for men), possi-
bly because of a different approach to annualizing the data.
Our results are consistent with previous studies17–19 showing
that the costs of the last year of life are lower for older patients
than for younger patients, reflecting the fact that older patients
receive less aggressive treatment. This fact is important to
remember when calculating cost-effectiveness ratios, especially
for preventive care. When considering that terminal costs de-
crease with age, costs per quality-adjusted life years for preven-
tive interventions may be lowered by a substantial amount for
some patient groups.17
Our study contributes to the existing literature on costs
associated with CRC by evaluating the latest data, thus reflect-
ing some of the recent changes in treatment patterns for CRC,
such as the introduction of irinotecan and more use of multi-
modality therapy. This study reports colorectal cancer costs per
survival year.
The substantially higher costs for later-stage cancers may
indicate that these cancers receive more drastic or expensive
treatments. If this is the case, it may be important to focus on
earlier detection of CRC as a way to reduce medical expendi-
tures. In addition, per-survival-year costs are lower for younger
patients than for older patients. However, phase-specific costs
are higher for younger patients, perhaps reflecting more aggres-
sive treatments used in younger patients.
Although lifetime costs for RC are slightly lower than costs
for CC patients for all stages combined, costs vary considerably
by stage at diagnosis. For the later-stage cancers, RC patients
have substantially higher costs than CC patients. Our results
suggest that any discussion involving CRC patients would be
improved by focusing on RC and CC patients separately.
Our findings will be useful in shaping policy discussions
regarding CRC treatment, costs, and insurance coverage. In
addition, our findings regarding stage- and phase-specific costs
for the entire CC and RC populations can be used in economic
models such as cost-effectiveness models evaluating the poten-
tial impact of new technologies to detect and treat CRC.
This study is subject to certain limitations that are common
to all studies that rely on retrospective claims data, such as
potential coding errors and incomplete data.20 Our use of the
SEER–Medicare database, which includes complete claims only
for Medicare-eligible patients aged 65 years and older, intro-
duces additional limitations.10,21 Although the elderly comprise
the majority of patients with CRC, this sample is not represen-
tative of all US patients, particularly those with other forms of
health insurance (eg, managed care, private pay). Despite its
limitations, SEER–Medicare data have been used in numerous
published studies of colon cancer, as well as cancers of the
breast, prostate, and lung, among others.22
Only services covered by Medicare were included in this
analysis, and at the time of this study, coverage for most oral
prescription medications was not included. Because claims are
available only through 2005, the most recent changes in CRC
treatment patterns were not captured in the data. Until re-
cently, a combination of fluorouracil and leucovorin was the
standard of care for CRC; numerous other drugs have been
approved for use in CRC patients since 2004, including oxali-
platin, bevacizumab, cetuximab, and panitumumab.23 These
new cytotoxic and biologic agents used in cancer treatment are
among the most expensive technologies in medical care, and the
costs of these agents are substantially greater than costs for
older drugs. The impact of more expensive drugs on the cost of
CRC remains to be seen. If treatment is getting more expensive,
our estimates of CRC-related costs may be lower than the
current costs associated with the disease.
In conclusion, this study showed that excess costs associated
with CRC are striking and vary considerably by treatment
phase, cancer subsite, and stage at diagnosis. Within each treat-
ment phase and on a per-survival-year basis, costs increase
substantially for later-stage diagnoses. Interventions aimed at
prevention and earlier detection of CRC have the potential to
yield sizable economic benefits.
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Address requests for reprints to: Joseph Menzin, PhD, Boston Health
Economics, Inc., 20 Fox Road, Waltham, Massachusetts 02451.
e-mail:; fax: (781) 290-0029.
The authors disclose the following: This study was sponsored by a
grant from GE Healthcare, Waukesha, WI. D.W.L. is an employee of GE
Healthcare; K.L., L.M.L., J.R.K., and J.M. received research funding
from GE Healthcare; and C.C.E. is a consultant for Boston Health
Portions of this study were presented in preliminary form at the 13th
Annual Meeting of the International Society for Pharmacoeconomics
and Outcomes Research, May 5, 2008, Toronto, Ontario, Canada; and
the 44th Annual Meeting of the American Society of Clinical Oncology,
June 3, 2008, Chicago, IL.
The authors gratefully acknowledge Rick deFriesse, MEd, for assis-
tance with SAS programming, and David J. Vanness, PhD, for helpful
comments on earlier versions of this work.
... This could reflect the acute nature of sepsis, which is treated episodically, requiring intensive and expensive treatments when it occurs (likely within the inpatient setting where healthcare costs are high). Similar tapering trends in cost in the months following the initial diagnosis period have also been observed in previous studies similar that observed in the current study which may reflect the end of the intensive treatment and follow-up period [29,43,51]. It could also be due to a multitude of other factors; for instance, episodes of sepsis can lead to changes in the management of these patients including reduced intensity of treatments, cessation of therapy and/or prevention strategies for further episodes [52,53]. ...
... It is acknowledged that health care costs can vary across jurisdictions, particularly among those with differently funded health systems; for instance, cancer care costs often higher in the US compared to universal, publicly funded health systems in Canada and New Zealand [12,29,30,42,43,51]. However, given the similarity in disease patterns and cancer care strategies across the developed world, these results may be generalisable and can be valuable to other similar settings that currently lack a clear view of the economic burden of sepsis in cancer patients. ...
... Although we have attempted to match for age, sex, cancer type and year of cancer diagnosis, our analysis was limited by the lack of complete information on these potential confounders to allow for adequate matching. It is possible that patients with sepsis had a late cancer stage at diagnosis, were on more aggressive treatments and/or had existing comorbidities which may predispose sepsis cases to incur higher costs [51,58]. This could result in an over-estimation of the excess cost of sepsis. ...
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Background Cancer patients are at significant risk of developing sepsis due to underlying malignancy and necessary treatments. Little is known about the economic burden of sepsis in this high-risk population. We estimate the short- and long-term healthcare costs of care of cancer patients with and without sepsis using individual-level linked-administrative data. Methods We conducted a population-based matched cohort study of cancer patients aged ≥18, diagnosed between 2010 and 2017. Cases were identified if diagnosed with sepsis during the study period, and were matched 1:1 by age, sex, cancer type and other variables to controls without sepsis. Mean costs (2018 Canadian dollars) for patients with and without sepsis up to 5 years were estimated adjusted using survival probabilities at partitioned intervals. We estimated excess cost associated with sepsis presented as a cost difference between the two cohorts. Haematological and solid cancers were analysed separately. Results 77,483 cancer patients with sepsis were identified and matched. 64.3% of the cohort were aged ≥65, 46.3% female and 17.8% with haematological malignancies. Among solid tumour patients, the excess cost of care among patients who developed sepsis was $29,081 (95%CI, $28,404-$29,757) in the first year, rising to $60,714 (95%CI, $59,729-$61,698) over 5 years. This was higher for haematology patients; $46,154 (95%CI, $45,505-$46,804) in year 1, increasing to $75,931 (95%CI, $74,895-$76,968). Conclusions Sepsis imposes substantial economic burden and can result in a doubling of cancer care costs, particularly during the first year of cancer diagnosis. These estimates are helpful in improving our understanding of burden of sepsis along the cancer pathway and to deploy targeted strategies to alleviate this burden.
... Several previous studies have presented phase-specific cancer costs. [5,6,[12][13][14][15][16][17] Most studies, however, present lifetime costs for single cancers while few have examined multiple cancers in the same setting (examples of studies covering multiple cancers are Yabroff et al, [5] de Oliveira et al, [6] and Blakely et al [16] ). The Nordic countries all have excellent registries capturing virtually all individuals residing in those countries. ...
... In the scenario with an annual increase in incidence of 3% (compared with 2.4% from NORDCAN) (scenario B) the yearly average cost totaled EUR 2139 (+230 million EUR), while a 30% increase in monthly unit costs (scenario C1) implied a total cost of EUR 2485 (+575 million EUR). Finally, when scenario A and C1 were combined, the total costs was estimated at EUR 2651 (+740 million EUR), Several studies have estimated cancer-specific costs by using a "phase of care" approach," [5,6,[12][13][14][15][16][17] making it a standard method to estimate costs over time. [6] Consistent with similar studies, we found that cancer-related costs followed a U-shaped curve, with most costs occurring in the initial and terminal phases. ...
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Valid estimates of cancer treatment costs are import for priority setting, but few studies have examined costs of multiple cancers in the same setting.We performed a retrospective population-based registry study to evaluate phase-specific (initial, continuing, and terminal phase) direct medical costs and lifetime costs for 13 cancers and all cancers combined in Norway. Mean monthly cancer attributable costs were estimated using nationwide activity data from all Norwegian hospitals. Mean lifetime costs were estimated by combining phase-specific monthly costs and survival times from the national cancer registry. Scenarios for future costs were developed from the lifetime costs and the expected number of new cancer cases toward 2034 estimated by NORDCAN.For all cancers combined, mean discounted per patient direct medical costs were Euros (EUR) 21,808 in the initial 12 months, EUR 4347 in the subsequent continuing phase, and EUR 12,085 in the terminal phase (last 12 months). Lifetime costs were higher for cancers with a 5-year relative survival between 50% and 70% (myeloma: EUR 89,686, mouth/pharynx: EUR 66,619, and non-Hodgkin lymphoma: EUR 65,528). The scenario analyses indicate that future cancer costs are highly dependent on future cancer incidence, changes in death risk, and cancer-specific unit costs.Gender- and cancer-specific estimates of treatment costs are important for assessing equity of care and to better understand resource consumption associated with different cancers.Cancers with an intermediate prognosis (50%-70% 5-year relative survival) are associated with higher direct medical costs than those with relatively good or poor prognosis.
... The medical costs in this study were analyzed using the Kaplan-Meier Sample Average method. 13,14 The follow-up period after index data was divided into 1 month, and the average monthly cost incurred by survivors of each month was multiplied by the monthly survival probability determined using the Kaplan-Meier method, and then the cost was summed across a year and presented as an annual cost for each year. 13 ...
... ,14 The costs in this study included all-cause health care ...
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Aim Subsequent cancers (SCs) after melanoma diagnosis further increases the risks of mortality and medical costs. This population-based analysis aimed to evaluate risk factors for SC, mortality, and medical costs of melanoma patients with SC. Methods A retrospective cohort analysis was conducted using a nationwide claims database during 2002-2017 in South Korea. SC was defined as having other types of cancer diagnoses other than subsequent melanoma during-up to 5 years after melanoma diagnosis. Melanoma patients were divided into patients with and without SC, and the overall and subgroup survival rates, the risk of developing SC, and the total medical costs were analyzed using a Kaplan–Meier method and regressions. Results A total of 3740 melanoma patients were included in the analysis (mean age, 62.3 ± 15.4 y; 47.2% men), and 2273 patients (1157 within 2 months, 756 after 2 months of melanoma diagnosis) had SC. Higher Charlson comorbidity index score and male sex significantly increased the risk of developing SC. Five-year survival rate and cumulative medical costs were 62.3% (95% confidence interval [CI], 60.8-63.9) and $21,413, respectively, in all patients. Patients with SC diagnosed after 2 months showed the lowest survival rate of 47.8% (95% CI, 44.3-51.4) and the highest costs of $27,081, showing a mortality hazard ratio of 1.65 (range, 1.46-1.86) and a cost ratio of 1.189 (range, 1.112-1.271) compared with those without SC. Conclusion This study presented survival outcomes and medical costs in melanoma patients and confirmed that SC after the first diagnosis of melanoma significantly increased disease burden in terms of mortality and medical costs.
... Compared to older patients, younger patients with similar disease stages are exposed to a more aggressive treatment regime, which drives up costs [27]. This is supported by other studies as well [28,29]. Our study, on the other hand, found no statistically significant association of age with the cost of rectal cancer treatment. ...
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Objective To compare in-hospital complication rates and treatment costs between rectal cancer patients receiving permanent and temporary stomas. Summary background data Surgical complications and costs associated with permanent stoma formation are still poorly understood. While choosing between the two stoma options is usually based on clinical and technical factors, disparities exist. Methods Patients with rectal cancer, stoma formation, complications, and cost of care were identified from the Florida Agency for Health Care Administration Discharge Database. Rectal cancer patients who underwent elective surgery and received a permanent or temporary stoma were identified using ICD-10 codes. Patients who underwent colostomy with resection were included in the “Permanent stoma” group, and those who underwent “resection with ileostomy” were included in the “temporary stoma” group. Multivariable models compared patients receiving temporary vs. permanent stomas. Results Regression models revealed no difference in the odds of having a complication between patients who obtained permanent versus temporary stoma (OR 0.96, 95% CI: 0.70–1.32). Further, after adjusting for the number of surgeries, demographic variables, socioeconomic and regional factors, comorbidities, and type of surgery, there was a significant difference between permanent and temporary stomas for rectal cancer (ß − 0.05, p = 0.03) in the log cost of creating a permanent stoma. Conclusion Our findings suggest there are no differences associated with complications, and reduced cost for permanent compared to temporary stomas. Increased costs are also associated with receiving minimally invasive surgery. As a result, disparities associated with receipt of MIS could ultimately influence the type of stoma received.
... This difference may be attributed to the innovative biological therapies that were introduced and established as standard of care after the studies' publication. However, United States cost for mCRC accounted at $41,562 and this higher cost is due to higher unit costs than in Europe as well as a clinical practice with greater use of resources [31]. ...
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Objectives Colorectal cancer (CRC) is the second leading cause of cancer in Europe, with 1.931.590 people newly diagnosed in 2020. The purpose of this study is the investigation of treatment options and healthcare resource metastatic CRC (mCRC) in Greece. Methods This study is based on the information collected in November 2020 by an expert panel comprising of 6 medical oncologists from major public and private centers around Greece. A 3-round survey was undertaken, according to Delphi method. The treatment phases studied were: pre-progression; disease progression and terminal care. Pharmaceutical costs and resource utilization data were considered from the perspective of the Greek National Services Organization (EOPYY). RESULTS: Experts agreed that the anticipated prevalence of RAS mutation in mCRC is 47% (30% RAS/BRAF WT Left, 17% RAS/BRAF WT Right); 8% BRAF while, MSI-H/dMMR are found in 5% of mCRC tumors. Based on mutational status, 74.8% of patients receive biological targeted therapies in combination with fluoropyrimidine/based combination chemotherapy, as 1st line treatment, and 25.2% combination chemotherapy alone. At 2nd line, 58.6% of patients receive biological targeted therapies in combination with chemotherapy, 25.4% immunotherapy, 11% combination chemotherapy and 5% biological targeted therapies. At 3rd line 56% of patients receive combination chemotherapy, 28% biological targeted therapies, 10% biological targeted therapies in combination with chemotherapy and 6% immunotherapy. The weighted annual cost (pharmaceuticals and resource use cost) in 1st line per mCRC patient was calculated at €28,407, in 2nd line €33,568, in 3rd line €25,550. The annual cost beyond 3rd line per patient regardless mutation was €19,501 per mCRC patient. Conclusions mCRC is a societal challenge for healthcare systems as the treatment is more prolonged but expand patients’ survival. Thus, reimbursement decisions should be based not just on the cost of the treatment, but on the magnitude of the benefit of its treatment on patients’ survival and quality of life.
... We followed previously described methods [16][17][18][19][20] to estimate the costs of cancer care by phases-the initial, continuing and terminal phase. The initial phase comprises the first 12 months postdiagnosis, whereas the terminal phase consists of the last 12 months before death. ...
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Hospital certification has become an important measure to improve cancer care quality, with the potential effect of prolonging patient survival and reducing medical spending. However, yet to be explored is the cost-effectiveness of cancer care provided in certified hospitals, considering significant additional costs incurred from certification requirements. We performed a cost-effectiveness analysis (CEA) using two colon cancer populations (N=1,909) treated in different levels of certified hospitals (CHs) versus non-certified hospitals (NCHs) from a healthcare system's perspective. We matched patient-level data of incident colon cancer cases, diagnosed between 2008 and 2013 from a large statutory health insurance in Saxony, Germany, to calculate net treatment costs by phase (initial, continuing and terminal phase). The costs were supplemented with extra costs from 31 additional services required for certification. Effectiveness measure was total survival time in life-years. Outcome of interest was incremental costs per additional life-year. The annualized net colon cancer treatment costs by phase showed a U shape with high costs in the initial (mean €26,855; 95% CI €25,058 - €28,652) and the terminal phases (mean €30,096; 95% CI €26,199 - €33,993). The base-case CEA results and all sensitivity analyses consistently demonstrated longer survival and lower costs for the colon cancer cohort treated in CHs versus NCHs. To conclude, we used administrative data to derive the first cost-effectiveness evidence supporting that colon cancer care delivered in the certified cancer centers in Germany improves survival outcomes and saves costs from a healthcare system's perspective. Generalization of the study results should be exercised with caution.
... This breakout by age and sex is consistent with other meta-analyses and large published registries [11,32]. The published papers utilized in the model were derived from PubMed searches as found in the Additional file 4: Appendix S4 and; variables identified/used [33,34]. Costs for private payer colonoscopies were derived from several sources and included a range of private payer reimbursement rates relative to Medicare of 163-248% [35][36][37][38]. ...
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Background The objective of this Markov model lifetime cost-effectiveness analysis was to evaluate a new medical device technology which minimizes redo colonoscopies on the outcomes of cost, quality of life, and aversion of colorectal cancers (CRC). Methods A new technology (PureVu® System) which cleans inadequately prepped colons was evaluated using TreeAge 2019 software in patients who presented with inadequate prep in outpatient settings in the US. PureVu was compared to the standard of care (SOC). Peer reviewed literature was used to identify the CRC incidence cancers based on missing polyps. Costs for procedures were derived from 2019 Medicare and from estimated private payer reimbursements. Base case costs, sensitivity analysis and incremental cost effectiveness (ICE) were evaluated. The cost of PureVu was $750. Results Assuming a national average compliance rate of 60% for colonoscopy, the use of PureVu saved the healthcare system $833–$992/patient depending upon the insurer when compared to SOC. QALYs were also improved with PureVu mainly due to a lower incidence of CRCs. In sensitivity analysis, SOC becomes less expensive than PureVu when compliance to screening for CRC using colonoscopy is ≤ 28%. Also, in order for SOC to be less expensive than PureVu, the list price of PureVu would need to exceed $1753. In incremental cost effectiveness analysis, PureVu dominated SOC. Conclusion Using the PureVu System to improve bowel prep can save the healthcare system $3.1–$3.7 billion per year, while ensuring a similar quality of life and reducing the incidence of CRCs.
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Importance Health care costs associated with diagnosis and care among older adults with multiple myeloma (MM) are substantial, with cost of care and the factors involved differing across various phases of the disease care continuum, yet little is known about cost of care attributable to MM from a Medicare perspective. Objective To estimate incremental phase-specific and lifetime costs and cost drivers among older adults with MM enrolled in fee-for-service Medicare. Design, Setting, and Participants A retrospective cohort study was conducted using population-based registry data from the 2007-2015 Surveillance, Epidemiology, and End Results database linked with 2006-2016 Medicare administrative claims data. Data analysis included 4533 patients with newly diagnosed MM and 4533 matched noncancer Medicare beneficiaries from a 5% sample of Medicare to assess incremental MM lifetime and phase-specific costs (prediagnosis, initial care, continuing care, and terminal care) and factors associated with phase-specific incremental MM costs. The study was conducted from June 1, 2019, to April 30, 2021. Main Outcomes and Measures Incremental MM costs were calculated for the disease lifetime and the following 4 phases of care: prediagnosis, initial, continuing care, and terminal. Results Of the 4533 patients with MM included in the study, 2374 were women (52.4%), 3418 (75.4%) were White, and mean (SD) age was 75.8 (6.8) years (2313 [51.0%] aged ≥75 years). The characteristics of the control group were similar; however, mean (SD) age was 74.2 (8.8) years (2839 [62.6%] aged ≤74 years). Mean adjusted incremental MM lifetime costs were $184 495 (95% CI, $183 099-$185 968). Mean per member per month phase-specific incremental MM costs were estimated to be $1244 (95% CI, $1216-$1272) for the prediagnosis phase, $11 181 (95% CI, $11 052-$11 309) for the initial phase, $5634 (95% CI, $5577-$5694) for the continuing care phase, and $6280 (95% CI, $6248-$6314) for the terminal phase. Although inpatient and outpatient costs were estimated as the major cost drivers for the prediagnosis (inpatient, 55.8%; outpatient, 40.2%), initial care (inpatient, 38.1%; outpatient, 35.5%), and terminal (inpatient, 33.0%; outpatient, 34.6%) care phases, prescription drugs (44.9%) were the largest cost drivers in the continuing care phase. Conclusions and Relevance The findings of this study suggest that there is substantial burden to Medicare associated with diagnosis and care among older adults with MM, and the cost of care and cost drivers vary across different phases of the cancer care continuum. The study findings might aid policy discussions regarding MM care and coverage and help further the development of alternative payment models for MM, accounting for differential costs across various phases of the disease continuum and their drivers.
Background Although the effect of the early detection of colorectal cancer (CRC) on medical costs needs to be clarified, there are few reports on the actual medical costs of CRC patients in Japan. We aimed to identify medical costs according to CRC stage, using health insurance claims.Methods This observational study included CRC patients who had received specific treatment for CRC, which was defined by the procedure code and the claim computer processing system code associated with the treatment of CRC. CRC patients who underwent endoscopic or radical surgical treatment were defined as the curable group and those with palliative treatment, including palliative chemotherapy, as the non-curable group. Total medical costs and medical costs of specific treatments for CRC for 3 years were measured using the claims held by Hachioji City from May 2014 to July 2019.ResultsThis study included 442 patients in the curable group, including 267 patients who underwent endoscopic treatment, and 175 patients who underwent radical surgical treatment, and 161 patients in the non-curable group. The mean (standard deviation) total medical costs in the curable and non-curable groups were 2,130 (2,494) and 8,279 (5,600) thousand Japanese Yen (JPY), respectively. The mean (standard deviation) medical costs for the specific treatment of CRC in the curable and non-curable groups were 408 (352) and 3,685 (3,479) thousand JPY, respectively.Conclusions We clarified the actual medical costs of CRC in curable and non-curable groups. These results suggest the effect of early detection of CRC in reducing medical costs.
Background: Tanning bed use is common among US adolescents, but is associated with increased melanoma risk. The decision to ban tanning bed use by adolescents should be made in consideration of the potential health benefits and costs. Methods: The US population aged 14 to 17 years was modeled by microsimulation, which compared ban versus no ban strategies. Lifetime quality-adjusted life years (QALYs) and costs were estimated from a health care sector perspective and two societal perspectives: with and without the costs of policy enforcement and the economic losses of the indoor-tanning bed industry. Results: Full adherence to the ban prevented 15,102 melanoma cases and 3299 recurrences among 17.1 million minors, saving $61in formal and informal health care costs per minor and providing an increase of 0.0002 QALYs. Despite the intervention costs of the ban and the economic losses to the indoor-tanning industry, banning was still the dominant strategy, with a savings of $12 per minor and $205.4 million among 17.1 million minors. Findings were robust against varying inspection costs and ban compliance, but were sensitive to lower excess risk of melanoma with early exposure to tanning beds. Conclusions: A ban on tanning beds for minors potentially lowers costs and increases cost effectiveness. Even after accounting for the costs of implementing a ban, it may be considered cost effective. Even after accounting for the costs of implementing a ban and economic losses in the indoor-tanning industry, a tanning bed ban for US minors may be considered cost effective. A ban has the potential to reduce the number of melanoma cases while decreasing health care costs. Lay summary: Previous meta-analyses have linked tanning bed use with an increased risk of melanoma, particularly with initial use at a young age. Yet, it remains unclear whether a ban of adolescents would be cost effective. Overall, a ban has the potential to reduce the number of melanoma cases while promoting a decrease in health care costs. Even after accounting for the costs of implementing a ban and the economic losses incurred by the indoor-tanning industry, a ban would be cost effective.
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CONTEXT: Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain. OBJECTIVES: To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon. DESIGN, SETTING, AND PATIENTS: Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996. MAIN OUTCOME MEASURE: Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services. RESULTS: For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states. CONCLUSIONS: Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.
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Objectives: this report presents complete period life tables by age, race, and sex for the United States based on age-specific death rates in 2006. Methods: Data used to prepare the 2006 life tables are 2006 final mortality statistics, July 1, 2006 population estimates based on the 2000 decennial census, and 2006 Medicare data for ages 66-100. The 2006 life tables were estimated using a recently revised methodology first applied to the final annual U.S. life tables series with the 2005 edition (1). For comparability, all life tables for the years 2000-2004 were reestimated using the revised methodology and were published in an appendix of the United States Life Tables, 2005 report (1). These revised tables replace all previously published life tables for years 2000-2004. Results: In 2006, the overall expectation of life at birth was 77.7 years, representing an increase of 0.3 years from life expectancy in 2005. From 2005 to 2006, life expectancy at birth increased for all groups considered. It increased for males (from 74.9 to 75.1) and females (from 79.9 to 80.2), the white (from 77.9 to 78.2) and black populations (from 72.8 to 73.2), black males (from 69.3 to 69.7) and females (from 76.1 to 76.5), and white males (from 75.4 to 75.7) and females (from 80.4 to 80.6).
After nearly 20 years of democratization, residents of Rio's favelas suffer high levels of civil and human rights abuse at the hands of both police and drug traffickers. The government is generally unable to guarantee the political order necessary to protect the rights of residents in these communities. Existing theories of democratization and advocacy networks offer little to explain how the types of endemic violence that affect poor neighborhoods in the developing world can be brought under control. Based on more than two years of participant observation and interviews in Rio de Janeiro, this article examines how democratic order can be extended to favelas. It argues that networks can link favela residents to organizations in civil society, and state actors can play a critical role in reducing violence and establishing democratic order.
Published cost-effectiveness analyses may overstate the cost-effectiveness ratio of preventive care if they do not explicitly model the costs of the last year of life, which is postponed by prevention. To determine the degree of overestimation, the authors built a statistical model using Medicare expenditure data on survivors and decedents. The model shows that the cost-effectiveness ratio of prevention may decrease by up to US$ 11,000 per quality-adjusted life year saved when expenditure data on the last year life are used. The model is able to explain more than half of the median cost increase of published cost-effectiveness analyses on clinical preventive services. (c) 2005 Elsevier B.V. All rights reserved.
OBJECTIVES:We aimed to determine cancer-related medical care costs for long term survivors of colorectal cancer.METHODS:The SEER-Medicare database was used to measure lifetime cancer-attributable costs of care for those with colorectal cancer surviving at least 5 yr versus age- and gender-matched controls. Costs were directly estimated, stratified by age at diagnosis and stage at diagnosis, for years 6–11 after diagnosis and then modeled to estimate lifetime costs. Cost differences between cancer cases and controls were compared to expected costs based on published guidelines for postcancer surveillance.RESULTS:Lifetime medical costs for long term survivors (future years not discounted) were up to $19,516 higher than control costs, and were highest for younger age groups and those with early-stage disease. Excess costs for cancer survivors exceeded expected surveillance costs by $2,223–8,822 for years 6–10 from the date of initial diagnosis.CONCLUSIONS:Cancer-attributable medical costs can be substantial for long term survivors, and exceed expected costs of surveillance. Future research is need to determine the components of excess cost in this survivor group.
Administrative databases are increasingly used for studying outcomes of medical care. Valid inferences from such data require the ability to account for disease severity and comorbid conditions. We adapted a clinical comorbidity index, designed for use with medical records, for research relying on International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes. The association of this adapted index with health outcomes and resource use was then examined with a sample of Medicare beneficiaries who underwent lumbar spine surgery in 1985 ( n = 27,111). The index was associated in the expected direction with postoperative complications, mortality, blood transfusion, discharge to nursing home, length of hospital stay,and hospital charges. These associations were observed whether the index incorporated data from multiple hospitalizations over a year's time, or just from the index surgical admission. They also persisted after controlling for patient age. We conclude that the adapted comorbidity index will be useful in studies of disease outcome and resource use employing administrative databases.
The identification and removal of adenomatous polyps and post-polypectomy surveillance are considered to be important for the control of colorectal cancer. In current practice, the intervals between colonoscopies after polypectomy are variable, often a year long, and not based on data from randomized clinical trials. We sought to determine whether follow-up colonoscopy at three years would detect important colonic lesions as well as follow-up colonoscopy at both one and three years. Patients were eligible if they had one or more adenomas, no previous polypectomy, and a complete colonoscopy and all their polyps had been removed. They were randomly assigned to have follow-up colonoscopy at one and three years or at three years only. The two study end points were the detection of any adenoma, and the detection of adenomas with advanced pathological features (defined as those > 1 cm in diameter and those with high-grade dysplasia or invasive cancer). Of 2632 eligible patients, 1418 were randomly assigned to the two follow-up groups, 699 to the two-examination group and 719 to the one-examination group. The percentage of patients with adenomas in the group examined at one and three years was 41.7 percent, as compared with 32.0 percent in the group examined at three years (P = 0.006). The percentage of patients with adenomas with advanced pathological features was the same in both groups (3.3 percent). Colonoscopy performed three years after colonoscopic removal of adenomatous polyps detects important colonic lesions as effectively as follow-up colonoscopy after both one and three years. An interval of at least three years is recommended before follow-up colonoscopy after both one and three years. An interval of at least three years is recommended before follow-up examination after colonoscopic removal of newly diagnosed adenomatous polyps. Adoption of this recommendation nationally should reduce the cost of post-polypectomy surveillance and screening.