A cost/efficacy analysis of oral antifungals indicated for the treatment of onychomycosis: griseofulvin, itraconazole, and terbinafine

This analysis was conducted at HIP Health plan of New Jersey (a Northeastern group model health maintenance organization) to determine the most cost-effective therapy among the three currently available oral antifungal drugs that are indicated for the treatment of onychomycosis: griseofulvin, itraconazole, and terbinafine. Costs of an appropriate and complete treatment regimen were calculated for each of the three drugs based on average wholesale price. Efficacy was determined by meta-analysis of the published literature for those studies where appropriate treatment regimens for onychomycosis were put to use. Efficacy outcome measures were limited to mycologic cure rates in the more recalcitrant cases of toenail onychomycosis. From these measures of cost and efficacy, a cost/efficacy ratio was calculated for each drug by dividing the cost per treatment by the weighted average mycological cure rate. This ratio represents the cost per mycologically cured infection. The final outcome measure (the cost per mycologically cured infection) was $2,721.28, $1,845.05, and $648.96, for griseofulvin, itraconazole, and terbinafine continuous therapies, respectively. For itraconazole and terbinafine pulse therapy, the costs were $855.88 and $388.50, respectively. For both continuous and pulse therapy, terbinafine is apparently the most cost-effective drug, followed by itraconazole and then by griseofulvin. Terbinafine has the fewest drug interactions and the highest treatment success rate.

Impact of CK-MB testing policies on hospital length of stay and laboratory costs for patients with myocardial infarction or chest pain

We obtained data on hospital length of stay (LOS) and total laboratory charges for Medicare patients admitted to 82 hospitals in Massachusetts during 1994. Five Diagnosis Related Groups (DRGs) were selected: surviving acute myocardial infarction (AMI) with, and without, complications; AMI with death; angina pectoris; and chest pain. The hospitals were grouped according to their laboratory policies for testing CK-MB (e.g., frequency of assay runs; information obtained by telephone survey). The study was conducted to determine whether there was an association between turnaround times for results and LOS for cardiac DRGs. The mean LOS for AMIs with complication for 1513 patients admitted to 22 hospitals whose laboratories perform CK-MB testing once or twice daily was 8.4 days [95% confidence interval (CI): 8.2-8.7]. In contrast, the mean LOS for hospitals with CK-MB test policies of at least 3 runs daily or random-access stat was significantly (P <0.05) lower, 7.7 days (CI: 7.4-8.0 and 7.5-7.9, respectively). Overall laboratory charges were lower in the hospitals with shorter LOS. With one exception, there was no significant difference in LOS between patients with DRGs of angina pectoris or chest pain or other AMI DRGs. For AMI, a CK-MB testing policy that produces shorter turnaround times may be justified because of an association with reductions in LOS and overall laboratory costs.

Economic impact of pertussis

OBJECTIVE

To assess the economic consequences of pertussis in Monroe County, New York (population, 713969), during a 6-year period (1989-1994).

METHODS

Cases of pertussis were identified retrospectively by passive reporting and diagnosis based on culture, positive results of direct fluorescent antibody testing, or Centers for Disease Control and Prevention clinical criteria (cough for > 14 days otherwise unexplained or for > 7 days with paroxysms or whoop epidemiologically linked to a laboratory-confirmed case). One hundred seven (50%) of 216 subjects with identified cases of pertussis completed questionnaires and had medical records reviewed to ascertain the costs of illness, including physician office visits, laboratory tests, medications, hospitalization, emergency department visits, additional child care, and lost days from school (children) or from work (parents or adult cases).

RESULTS

Ninety-three (87%) of the pertussis case occurred in children. The average duration of illness before diagnosis was 21.3 days (range, 12-37 days). One hundred one patients (94%) saw a physician at least once; overall, the average number of visits per case was 3.2 (range, 1-15). Ninety-seven patients (91%) received at least 1 course of antibiotic therapy (average cost for all antibiotics, $95/case), and all took symptomatic treatment (average cost, $48/case). Fifteen patients (14%) required hospitalization; average cost per admission was $13425 (range, $1732-$69637). Thirty patients (28%) were seen in emergency departments; average cost was $202 (range, $69-$289). Additional child care costs ranged from $12 to $2688. For 50 families, 1 adult lost workdays because of illness or to provide child care for an average of 8.3 days (range, 1-45 days). For 4 families, 2 adults lost an average of 44 days from work (range, 10-120 days). The cumulative number of lost workdays was 758 in association with the 107 cases of pertussis. The average full recovery time from illness was 72.9 days (range, 25-115 days).

CONCLUSIONS

Total direct and indirect cost for 107 cases of pertussis in Monroe County was $381052. The economic burden of pertussis is substantial and encourages broader use of vaccination to prevent disease.

Total clinical laboratory test volume in Connecticut, 1994-1995

OBJECTIVE

To measure the volume of clinical laboratory testing in Connecticut during a one-year period. To explore the potential value of such data.

DESIGN

Summary and analysis of federal and state clinical laboratory registration/licensure/inspection forms.

SETTING

2,333 clinical laboratory test facilities registered in Connecticut.

MAIN OUTCOME MEASURES

The total clinical laboratory output for Connecticut by type of facility and category of technology over a 12-month period.

RESULTS

During 1995, 2,333 registered clinical laboratory test facilities performed approximately 65,427,103 analyses in Connecticut. This represents approximately 20 tests per person per year. Thirty-five acute care hospitals performed 59.4%, nine large commercial laboratories 33.2%, 30 small commercial laboratories 1.7%, 1,491 physicians' offices 3.9%, and a miscellaneous group 1% of the tests. Test volumes are further segregated into eight major categories of technology: chemistry 59%, hematology 23.3%, microbiology 5.6%, blood banking 2.9%, coagulation 2.8%, waived tests 2.7%, urine analysis 1.8%, cytology 0.9%, and histology 0.8%.

CONCLUSION

For the first time mechanisms are in place to measure essentially all clinical testing for a given area. With minor changes the data collection system could be greatly improved. The possible uses for such a data bank are discussed.

The utility of preoperative laboratory testing in general surgery patients for outpatient procedures

The utility of obtaining routine preoperative laboratory (lab) screening tests was evaluated for a 1-year period in general surgery clinic patients undergoing ambulatory surgical procedures at a teaching hospital. This study sought to determine whether those lab tests not indicated by patient history or physical examination would identify abnormalities that might influence perioperative care of the ambulatory surgical patient or predict perioperative complications. The charts of 142 patients undergoing 155 procedures were reviewed. A total of 300 tests were ordered, with 92 (30.6%) being abnormal. Of the 125 tests indicated, 54 (43.2%) were abnormal, whereas in those lab tests not indicated, 38 (21.7%) were found to be abnormal. In four instances, an abnormal lab test (4 out of 300) result was clinically significant (1.3%), causing cancellation of the surgical procedure in two cases (both indicated lab tests) and diagnosis of urinary tract infection in two patients (both routine urinalyses). Forty-eight of the 142 patients had no preoperative lab tests ordered (34%), with no perioperative complications resulting. Patient charges totaled $15,725 for all lab tests ordered, with $8,573 in charges attributed to those tests not indicated. If lab tests for all general and subspecialty surgical outpatients had been ordered as dictated by patient medical history and physical examination rather than by either routine or by arbitrary criteria, our medical facility could have potentially reduced patient charges by more than $400,000 in the year reviewed, assuming a 52.4 per cent savings as noted above, with no expected adverse outcomes.

Reducing the inappropriate utilization of clinical laboratory tests

Reimbursement policies for health-care services in Connecticut and the U.S. have gradually shifted towards fixed reimbursements through implementation of managed care. As a result, there is an increasing need by physicians and other care givers to reduce costs without compromising the quality of the care being delivered. The clinical laboratory is one area where significant cost reductions may be realized. More effective utilization can be accomplished with the elimination of panels of tests, such as the general chemistry profile, removal of antiquated tests or those that provide redundant information, judicious use of drug assays, acceptance of clinical practice guidelines, and use of reflex testing algorithms. Physicians should also focus more on prognostic indicators for disease prevention. Point-of-care testing devices which have higher costs than incremental central laboratory expenses should be used only if it reduces overall operating expenses, as assessed by outcomes analyses. New technologies such as DNA probes can substantially improve diagnostic efficiency. Physicians and clinical laboratories must collaborate to achieve more efficient utilization practices.

The paradox of decreasing prices and increasing costs for diagnostic tests, imaging, and drugs in Japan

Analysis of the 1987-91 national outpatient claims data shows that the percentage of patients under going sophisticated diagnostic tests tended to increase and was greater if the hospital was larger, in the public sector, or affiliated with an university. For imaging, the percentage that had CAT scans performed increased, while the percentage undergoing x-rays using contrast medium and other tomography decreased. However, for drugs, newer and more expensive ones tended to be preferred irrespective of the providers' characteristics. Although costs arising from the shift to more expensive and sophisticated technologies have been largely contained by reducing their prices in the fee schedule, this cost-containment strategy faces structural problems. We advocate the establishment of an infra-structure that offers incentives for providers to conduct technology assessment and to use the results.

Developing a budget for the laboratory

Cost accounting is the basic "tool" for identifying the expenses associated with laboratory operations. A budget is a planning tool that allows the director and manager to visualize the evolution of expenses, assets, liabilities, and revenues over a period of time. It is a quantitative annual plan of activities and programs that helps an organization measure the progress toward its financial goals on a periodic basis. A knowledge of how to develop and understand a budget is essential for every director and manager.

Developing Medicare competitive bidding: a study of clinical laboratories

Competitive bidding to derive Medicare fees promises several advantages over administered fee systems. The authors show how incentives for cost savings, quality, and access can be incorporated into bidding schemes, and they report on a study of the clinical laboratory industry conducted in preparation for a bidding demonstration. The laboratory industry is marked by variable concentration across geographic markets and, among firms themselves, by social and economic heterogeneity. The authors conclude that these conditions can be accommodated by available bidding design options and by careful selection of bidding markets.

Routine individual feedback on requests for diagnostic tests: an economic evaluation

The authors assessed the economic cor sequences of routine individual feedback on test requests provided to 85 family physicians in a region with 187,000 inhabitants. In a retrospective study as part of a quasi-experiment, cost trends in a region where feedback was provided over a seven-year period were compared with cost trends elsewhere in The Netherlands without feedback. Data on variable costs were obtained for 400 individual tests that accounted for 90% of all requests. Differences in request trends thus were transformed to savings in costs of diagnostic testing, taking account of the extra costs of providing the feedback. Expenditures for diagnostic testing declined after the start of the feedback, despite the costs of providing the feedback. The savings increased as the feedback continued. Compared with the trend elsewhere without feedback, over seven years a total net sum of 1.4 million U.S. dollars was saved. Routine individual feedback is therefore economically worthwhile.

Successful implementation of laboratory budget holding by Pegasus Medical Group

AIMS

To evaluate the effectiveness of budget holding by Pegasus Medical Group for laboratory services expenditure and reasons for the successes observed.

METHODS

Two pilot groups and a nonpilot group of general practitioners were formed with the pilots receiving active feedback, educational programmes and test form redesign within the incentive of savings being retained by the group for improved primary care services.

RESULTS

Overall savings of 22.7% were achieved within the budget over a 13 month period. There was a highly significant reduction in expenditure per member especially in the mean and standard deviation of cost per consultation indicating a marked narrowing of the variance in cost between members in the pilot groups compared with the nonpilot group.

CONCLUSION

The study illustrates the effectiveness of a comprehensive strategy of education, active feedback and test form redesign and especially the importance of the incentive of retaining budgetary savings for service improvements. It also illustrates the importance of collaborative as compared with competitive strategies in achieving cost control and value for money gains in health services. However, more work is needed to establish the appropriateness of lower laboratory expenditure by linking test requests to diagnosis.

The Rochester Consortium

The laboratories of the six hospitals in Rochester, New York worked together to bid on laboratory services for local managed-care contracts. Their primary goal was to keep shrinking health-care dollars in the Rochester community while providing quality laboratory services for managed-care payers. The six laboratory providers formed a cooperative Consortium that enabled them to compete successfully with national commercial laboratories for referral laboratory testing for outpatients and nonpatients. In 1995, the Consortium was approached by a Rochester-based health maintenance organization (HMO) offering an exclusive contract opportunity based on requirements that included cost reduction and a switch from a fee schedule to a capitated payment method. The Rochester laboratories each agreed to contract terms with the HMO, then followed this success by working with a second, significantly larger HMO, agreeing to provide exclusive laboratory services under a similar, capitated arrangement. The formation and work of the Consortium may provide other hospitals facing daunting competition from large commercial laboratory enterprises with a cooperative arrangement model to provide community-wide laboratory services.

[Cardiovascular diseases: toward an optimal use of clinical biological laboratories]

Cardiovascular diseases are a frequent cause of morbidity and mortality in our country. The early detection of risk factors by laboratory tests and the subsequent preventive treatment may have a substantial beneficial effect on public health. However, since these tests are performed on large populations, they must be chosen with caution, in order to optimise their cost/ effectiveness ratio. Savings obtained by the judicious use of the clinical lab could allow, already in 1996, the reimbursement of some new informative tests, like the plasma homocysteine and the LDL-cholesterol, and later, of the lipoprotein (a), all tests which are presently at the charge of the patient.

Unnecessary preoperative investigations: evaluation and cost analysis

In keeping with national efforts to curb escalating health care costs, the necessity of multiple preoperative investigations was evaluated in 60 randomly selected ambulatory surgery patient records. Necessity for testing was assessed on clinical indications, and overall cost was calculated from the rates at both the local Department of Veterans Affairs Medical Center (VAMC) and a community hospital. Two thirds of the investigations were deemed to be inappropriate, with derived unnecessary average cost per patient of $47 and $80 for the VAMC and community hospital, respectively. Potential savings at the VAMC of $11,757.50 for the calendar year could have been realized. Education of staff and housestaff is crucial to changing obsolete practice habits. The quality and safety of care would not be compromised by limiting preoperative investigations to only those with clinical indications.