Comparing top-down and bottom-up costing approaches for economic evaluation within social welfare

Economic burden of patients with leading cancers in China: a cost-of-illness study

BACKGROUND

China accounts for 24% of newly diagnosed cancer cases and 30% of cancer-related deaths worldwide. Comprehensive analyses of the economic burden on patients across different cancer treatment phases, based on empirical data, are lacking. This study aims to estimate the financial burden borne by patients and analyze the cost compositions of the leading cancers with the highest number of new cases in China.

METHODS

This cross-sectional cost-of-illness study analyzed patients diagnosed with lung, breast, colorectal, esophageal, liver, or gastric cancer, identified through electronic health records (EHRs) from 84 hospitals across 17 provinces in China. Patients completed any one of the initial treatment phase, follow-up phase, and relapse/metastasis phase were recruited by trained attending physicians through a stratified sampling procedure to ensure enough cases for each cancer progression stage and cancer treatment phase. Direct and indirect costs by treatment phase were collected from the EHRs and self-reported surveys. We estimated per case cost for each type of cancer, and employed subgroup analyses and multiple linear regression models to explore cost drivers.

RESULTS

We recruited a total of 13,745 cancer patients across three treatment phases. The relapse/metastasis phase incurred the highest per case costs, varying from $8,890 to $14,572, while the follow-up phase was the least costly, ranging from $1,840 to $4,431. Being in the relapse/metastasis phase and having an advanced clinical stage of cancer at diagnosis were associated with significantly higher cost, while patients with low socioeconomic status borne lower costs.

CONCLUSIONS

There were substantial financial burden on patients with six leading cancers in China. Health policymakers should emphasize comprehensive healthcare coverage for marginalized populations such as the uninsured, less educated, and those living in underdeveloped regions.

Process mining for healthcare decision analytics with micro-costing estimations

Managing constrained healthcare resources is an important and inescapable role of healthcare decision makers. Allocative decisions are based on downstream consequences of changes to care processes: judging whether the costs involved are offset by the magnitude of the consequences, and therefore whether the change represents value for money. Process mining techniques can inform such decisions by quantitatively discovering, comparing and detailing care processes using recorded data, however the scope of techniques typically excludes anything 'after-the-process' i.e., their accumulated costs and resulting consequences. Cost considerations are increasingly incorporated into process mining techniques, but the majority of healthcare costs for service and overhead components are commonly apportioned and recorded at the patient (trace) level, hiding event level detail. Within decision-analysis, event-driven and individual-level simulation models are sometimes used to forecast the expected downstream consequences of process changes, but are expensive to manually operationalise. In this paper, we address both of these gaps within and between process mining and decision analytics, by better linking them together. In particular, we introduce a new type of process model containing trace data that can be used in individual-level or cohort-level decision-analytical model building. Furthermore, we enhance these models with process-based micro-costing estimations. The approach was evaluated with health economics and decision modelling experts, with discussion centred on how the outputs could be used, and how similar information would otherwise be compiled.

Financing Comprehensive Immunization Services in Lao PDR: A Fiscal Space Analysis From a Public Policy Perspective

INTRODUCTION

A comprehensive package of immunization services is an internal component of the Essential Health Service Package (ESP) implemented by Government of Lao People's Democratic Republic (Lao PDR). Thus, the cost of delivering the immunization program and its feasibility given the fiscal space emerges as an important policy question. The present analysis was undertaken to estimate the total cost of implementing the immunization program under ESP, determinants of total cost and the program's fiscal implications from the government's perspective.

METHODOLOGY

We employed a normative costing approach for costing of immunization services under ESP. Standard treatment guidelines (STGs) from both within and outside Lao PDR were considered to identify the resource use for each vaccine delivery. Subsequently, cost per dose administered and fully immunized beneficiary were computed. We assessed the fiscal space for financing immunization services in Lao PDR by adapting the decomposition method given by Tandon et al. RESULTS: In 2019, the estimated total cost of financing immunization in Lao PDR was US$12 million, which will increase in 2025 by 1.75 times, to US$21 million. The per capita budget for immunization needs to increase from about US$2 to US$7. Introduction of newer vaccines in the immunization schedule accounts for the major share (60%) of the increased cost for financing immunization. In view of current fiscal space, the government immunization expenditure (GIE) allocations will be adequate only in a scenario where no new vaccine is introduced under ESP in future years.

CONCLUSION

The current fiscal space would fall short of meeting the aspirational goals of ESP-Immunization for the introduction of newer vaccines in Lao PDR. The present analysis of the fiscal space provides important evidence to support a greater role for the Global Alliance for Vaccine Initiative (GAVI) to continue to finance immunization in Lao PDR. A publicly financed immunization model in Lao PDR would require significant strategic amendments with low short-term viability.

Costs of treating childhood malaria, diarrhoea and pneumonia in rural Mozambique and Uganda

Background

Globally, nearly half of all deaths among children under the age of 5 years can be attributed to malaria, diarrhoea, and pneumonia. A significant proportion of these deaths occur in sub-Saharan Africa. Despite several programmes implemented in sub-Saharan Africa, the burden of these illnesses remains persistently high. To mobilise resources for such programmes it is necessary to evaluate their costs, costs-effectiveness, and affordability. This study aimed to estimate the provider costs of treating malaria, diarrhoea, and pneumonia among children under the age of 5 years in routine settings at the health facility level in rural Uganda and Mozambique.

Methods

Service and cost data was collected from health facilities in midwestern Uganda and Inhambane province, Mozambique from private and public health facilities. Financial and economic costs of providing care for childhood illnesses were investigated from the provider perspective by combining a top-down and bottom-up approach to estimate unit costs and annual total costs for different types of visits for these illnesses. All costs were collected in Ugandan shillings and Mozambican meticais. Costs are presented in 2021 US dollars.

Results

In Uganda, the highest number of outpatient visits were for children with uncomplicated malaria and of inpatient admissions were for respiratory infections, including pneumonia. The highest unit cost for outpatient visits was for pneumonia (and other respiratory infections) and ranged from $0.5 to 2.3, while the highest unit cost for inpatient admissions was for malaria ($19.6). In Mozambique, the highest numbers of outpatient and inpatient admissions visits were for malaria. The highest unit costs were for malaria too, ranging from $2.5 to 4.2 for outpatient visits and $3.8 for inpatient admissions. The greatest contributors to costs in both countries were drugs and diagnostics, followed by staff.

Conclusions

The findings highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient cases, particularly at higher level health facilities. Timely treatment to prevent severe complications associated with these illnesses can also avoid high costs to health providers, and households.

Trial registration: ClinicalTrials.gov, identifier: NCT01972321.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04254-y.

Harmonization issues in unit costing of service use for multi-country, multi-sectoral health economic evaluations: a scoping review

BACKGROUND

Valuation is a critical part of the costing process in health economic evaluations. However, an overview of specific issues relevant to the European context on harmonizing methodological requirements for the valuation of costs to be used in health economic evaluation is lacking. We aimed to inform the development of an international, harmonized and multi-sectoral costing framework, as sought in the European PECUNIA (ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions) project.

METHODS

We conducted a scoping review (information extraction 2008-2021) to a) to demonstrate the degree of heterogeneity that currently exists in the literature regarding central terminology, b) to generate an overview of the most relevant areas for harmonization in multi-sectoral and multi-national costing processes for health economic evaluations, and c) to provide insights into country level variation regarding economic evaluation guidance. A complex search strategy was applied covering key publications on costing methods, glossaries, and international costing recommendations augmented by a targeted author and reference search as well as snowballing. Six European countries served as case studies to describe country-specific harmonization issues. Identified information was qualitatively synthesized and cross-checked using a newly developed, pilot-tested data extraction form.

RESULTS

Costing methods for services were found to be heterogeneous between sectors and country guidelines and may, in practice, be often driven by data availability and reimbursement systems in place. The lack of detailed guidance regarding specific costing methods, recommended data sources, double-counting of costs between sectors, adjustment of unit costs for inflation, transparent handling of overhead costs as well as the unavailability of standardized unit costing estimates in most countries were identified as main drivers of country specific differences in costing methods with a major impact on valuation and cost-effectiveness evidence.

CONCLUSION

This review provides a basic summary of existing costing practices for evaluative purposes across sectors and countries and highlights several common methodological factors influencing divergence in cost valuation methods that would need to be systematically incorporated and addressed in future costing practices to achieve more comparable, harmonized health economic evaluation evidence.

The process of estimating the cost of surgery: Providing a practical framework for surgeons

Over the last decades, health care costs have been increasing at an alarming, exponential rate which is considered unsustainable. Surgical care utilizes one-third of health care costs. Estimating, evaluating, and understanding the cost of surgery is a vital step towards cost management and reduction. Current cost estimation studies and cost-effectiveness studies have vast disparities in their methodology, with published costs of Operating Room varying from as low as $7 and as high as $113 per minute. Costs in surgery are distinguished as direct and indirect. Allocation of direct costs involves identification, measurement, and valuation processes. Allocation of indirect costs involves the allocation of capital and overhead costs and of indirect department costs. Annualised capital costs and overhead hospital costs are then allocated to surgery by either the cost-centre allocation or the activity-based allocation frameworks. Indirect department costs are allocated to a specific surgery by weighted service allocation or hourly rate allocation or inpatient day allocation, or marginal markup allocation. The growing societal, financial and political pressure for cost reduction has brought cost analysis to the forefront of healthcare discussions. Thus, we believe that almost every single surgeon will eventually enter the field of healthcare economics by necessity. This review aims to provide surgeons with a practical framework for engaging in cost estimation studies.

Current costs of dialysis modalities: A comprehensive analysis within the United Kingdom

Background:

Previous evidence suggests home-based dialysis to be more cost-effective than unit-based or hospital-based dialysis. However, previous analyses to quantify the costs of different dialysis modalities have used varied perspectives, different methods, and required assumptions due to lack of available data. The National Institute for Health and Care Excellence reports uncertainty about the differences in costs between home-based and unit-based dialysis. This uncertainty limits the ability of policy makers to make recommendations based on cost effectiveness, which also impacts on the ability of budget holders to model the impact of any service redesign and to understand which therapies deliver better value. The aim of our study was to use a combination of top-down and bottom-up costing methods to determine the direct medical costs of different dialysis modalities in one UK nation (Wales) from the perspective of the National Health Service (NHS).

Methods:

Detailed hybrid top-down and bottom-up micro-costing methods were applied to estimate the direct medical costs of dialysis modalities across Wales. Micro-costing data was obtained from commissioners of the service and from interviews with renal consultants, nurses, accountants, managers and allied health professionals. Top-down costing information was obtained from the Welsh Renal Clinical Network (who commission renal services across Wales) and the Welsh Ambulance Service Trust.

Results:

The annual direct cost per patient for home-based modalities was £16,395 for continuous ambulatory peritoneal dialysis (CAPD), £20,295 for automated peritoneal dialysis (APD) and £23,403 for home-based haemodialysis (HHD). The annual cost per patient for unit-based modalities depended on whether or not patients required ambulance transport. Excluding transport, the cost of dialysis was £19,990 for satellite units run in partnership with independent sector providers and £23,737 for hospital units managed and staffed by the NHS. When ambulance transport was included, the respective costs were £28,931 and £32,678, respectively.

Conclusion:

Our study is the most comprehensive analysis of the costs of dialysis undertaken thus far in the United Kingdom and clearly demonstrate that CAPD is less costly than other dialysis modalities. When ambulance transport costs are included, other home therapies (APD and HHD) are also less costly than unit-based dialysis. This detailed analysis of the components that contribute to dialysis costs will help inform future cost-effectiveness studies, inform healthcare policy and drive service redesign.

A Dynamic Approach to Economic Priority Setting to Invest in Youth Mental Health and Guide Local Implementation: Economic Protocol for Eight System Dynamics Policy Models

BACKGROUND

Mental illness costs the world economy over US2.5 Bn each year, including premature mortality, morbidity, and productivity losses. Multisector approaches are required to address the systemic drivers of mental health and ensure adequate service provision. There is an important role for economics to support priority setting, identify best value investments and inform optimal implementation. Mental health can be defined as a complex dynamic system where decision makers are challenged to prospectively manage the system over time. This protocol describes the approach to equip eight system dynamics (SD) models across Australia to support priority setting and guide portfolio investment decisions, tailored to local implementation context.

METHODS

As part of a multidisciplinary team, three interlinked protocols are developed; (i) the participatory process to codesign the models with local stakeholders and identify interventions for implementation, (ii) the technical protocol to develop the SD models to simulate the dynamics of the local population, drivers of mental health, the service system and clinical outcomes, and (iii) the economic protocol to detail how the SD models will be equipped to undertake a suite of economic analysis, incorporating health and societal perspectives. Models will estimate the cost of mental illness, inclusive of service costs (health and other sectors, where necessary), quality-adjusted life years (QALYs) lost, productivity costs and carer costs. To assess the value of investing (disinvesting) in interventions, economic analysis will include return-on-investment, cost-utility, cost benefit, and budget impact to inform affordability. Economic metrics are expected to be dynamic, conditional upon changing population demographics, service system capacities and the mix of interventions when synergetic or antagonistic interactions. To support priority setting, a portfolio approach will identify best value combinations of interventions, relative to a defined budget(s). User friendly dashboards will guide decision makers to use the SD models to inform resource allocation and generate business cases for funding.

DISCUSSION

Equipping SD models to undertake economic analysis is intended to support local priority setting and help optimise implementation regarding the best value mix of investments, timing and scale. The objectives are to improve allocative efficiency, increase mental health and economic productivity.

Economic evaluation methods used in home-visiting interventions: A systematic search and review

Home-visiting interventions are used to improve outcomes for families experiencing disadvantage. As scarce resources must be allocated carefully, appropriate methods are required to provide accurate information on the effect of these programmes. We aimed to investigate: economic evaluation/analysis methods used in home-visiting programmes for children, young people and families, study designs and methods suitable in situations where randomised-controlled-trials are not feasible, and type of costs included in analyses, including any implementation costs stated. A systematic search and review was conducted of existing full economic evaluation/analysis methods in home-visiting programmes for children, young people and/or families. We included studies published in English between January 2000 and mid-November 2020. Of the 4,742 papers sourced, 60 were retained for full-text review, and 21 included. Economic-analysis methods found in the included studies were: within trial economic evaluation, economic evaluation using decision analytic modelling (i.e. cost-utility, cost-benefit analysis), cost comparison and cost-consequence. Studies incorporating return on investment and budget impact analysis were also found. Study designs suitable when randomisation was not feasible included parallel cluster randomised trials and using pre-post intervention data. Costs depended mainly on study context and only one study reported implementation costs. We hope this information will help guide future economic evaluations of home-visiting interventions.

Unit costs for non-acute care in Ireland 2016—2019

Background: This paper presents detailed unit costs for 16 healthcare professionals in community-based non-acute services in Ireland for the years 2016—2019. Unit costs are important data inputs for assessments of health service performance and value for money. Internationally, while some countries have an established database of unit costs for healthcare, there is need for a more coordinated approach to calculating healthcare unit costs. In Ireland, detailed cost analysis of acute care is undertaken by the Healthcare Pricing Office but to date there has been no central database of unit costs for community-based non-acute healthcare services.

Methods: Unit costs for publicly employed allied healthcare professionals, Public Health Nurses and Health Care Assistant staff are calculated using a bottom-up micro-costing approach, drawing on methods outlined by the Personal Social Services Research Unit in the UK, and on available Irish and international costing guidelines. Data on salaries, working hours and other parameters are drawn from secondary datasets available from Department of Health, Health Service Executive and other public sources. Unit costs for public and private General Practitioner, dental, and long-term residential care (LTRC) are estimated drawing on available administrative and survey data.

Results: The unit costs for the publicly employed non-acute healthcare professionals have changed by 2–6% over the timeframe 2016–2019 while larger percentage changes are observed in the unit costs for public GP visits and public LTRC (14-15%).

Conclusions: The costs presented here are a first step towards establishing a central database of unit costs for non-acute healthcare services in Ireland. The database will help ensure consistency across Irish health costing studies and facilitate cross-study and cross-country comparisons. Future work will be required to update and expand on the range of services covered and to incorporate new data and methodological developments in cost estimation as they become available.

Taking a local government perspective for economic evaluation of a population-level programme to promote exercise

BACKGROUND

In order to tackle the issue of physical inactivity, local governments have implemented population-level programmes to promote exercise. While evidence is accumulating on the cost-effectiveness of these interventions, studies have typically adopted a health sector perspective for economic evaluation. This approach has been challenged as it does not allow for key concerns by local governments, which are primary stakeholders, to be addressed.

OBJECTIVES

To show how taking a local government perspective for economic evaluation can be implemented in practice and this may affect the economic conclusions.

METHODS

Based on data from a case study, the health equity impact of the intervention and its opportunity cost from a service provider viewpoint were assessed. The cost-effectiveness implications of a change in perspective were subsequently estimated by means of scenario analysis.

FINDINGS

The intervention was found to provide adult residents living in the most deprived city areas with greater health benefits compared with the rest of the population. However, a negative net equity impact was found in the short-term. The opportunity cost of the intervention was estimated to be substantially lower than its financial cost (£2.77 per person/year), with significant implications for decision-making.

CONCLUSIONS

Taking a local government perspective can affect the conclusions drawn from the economic evaluation of population-level programmes to promote exercise, and therefore influence decision making.

Micro-costing in health and medicine: a critical appraisal

BACKGROUND

Concerns about rising health care costs require rigorous economic study to inform clinical and policy decision-making. Micro-costing is a cost estimation methodology employing detailed resource utilization and unit cost data to generate precise estimates of economic costs. Micro-costing studies have not been critically appraised.

METHODS

Critical appraisal of micro-costing studies in English. Studies fully or predominantly employing micro-costing were appraised for methodological and reporting quality through economic evaluation guidelines (Evers, Drummond, Consolidated Health Economic Evaluation Reporting Standards (CHEERS), Fukuda and Imanaka checklists). Following the Panel on Cost Effectiveness in Health and Medicine, micro-costing studies were defined as involving "direct enumeration and costing out of every input consumed in the treatment of a particular patient."

RESULTS

Full or predominant micro-costing studies included  neoplasms (18.5%), infectious and parasitic diseases (17.9%), and diseases of circulatory systems (10.8%) as the  most studied diseases. 36.9% were in the United States and 34.9% were in Europe. 33.8% did not report analytic perspective, 32.8% did not report price year, 3.6% did not inflation adjust cost data, and 44.1% did not specify inflation adjustment. 86.2% did not separately report unit costs and resource utilization quantity, 14.9 and 19.5% did not provide sufficient detail to assess appropriateness of measured physical units or valued costs.

CONCLUSIONS

Micro-costing studies vary widely in methodological and reporting quality, highlighting the need to standardize methods and reporting of micro-costing studies and develop tools for their evaluation.

H-WORK Project: Multilevel Interventions to Promote Mental Health in SMEs and Public Workplaces

The paper describes the study design, research questions and methods of a large, international intervention project aimed at improving employee mental health and well-being in SMEs and public organisations. The study is innovative in multiple ways. First, it goes beyond the current debate on whether individual- or organisational-level interventions are most effective in improving employee health and well-being and tests the cumulative effects of multilevel interventions, that is, interventions addressing individual, group, leader and organisational levels. Second, it tailors its interventions to address the aftermaths of the Covid-19 pandemic and develop suitable multilevel interventions for dealing with new ways of working. Third, it uses realist evaluation to explore and identify the working ingredients of and the conditions required for each level of intervention, and their outcomes. Finally, an economic evaluation will assess both the cost-effectiveness analysis and the affordability of the interventions from the employer perspective. The study integrates the training transfer and the organisational process evaluation literature to develop toolkits helping end-users to promote mental health and well-being in the workplace.

Are Unit Costs the Same? A Case Study Comparing Different Valuation Methods for Unit Cost Calculation of General Practitioner Consultations

OBJECTIVES

To inform allocation decisions in any healthcare system, robust cost data are indispensable. Nevertheless, recommendations on the most appropriate valuation approaches vary or are nonexistent, and no internationally accepted gold standard exists. This costing analysis exercise aims to assess the impact and implications of different calculation methods and sources based on the unit cost of general practitioner (GP) consultations in Austria.

METHODS

Six costing methods for unit cost calculation were explored, following 3 Austrian methodological approaches (AT-1, AT-2, AT-3) and 3 approaches applied in 3 other European countries (Germany, The Netherlands, United Kingdom). Drawing on Austrian data, mean unit costs per GP consultation were calculated in euros for 2015.

RESULTS

Mean unit costs ranged from €15.6 to €42.6 based on the German top-down costing approach (DE) and the Austrian Physicians' Chamber's price recommendations (AT-3), respectively. The mean unit cost was estimated at €18.9 based on Austrian economic evaluations (AT-1) and €17.9 based on health insurance payment tariffs (AT-2). The Dutch top-down (NL) and the UK bottom-up approaches (UK) yielded higher estimates (NL: €25.3, UK: €29.8). Overall variation reached 173%.

CONCLUSIONS

Our study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates. It shows large variations with potential impact on the conclusions in an economic evaluation. Although different methodological choices may be justified by the adopted study perspective, different costing approaches introduce variation in cross-study/cross-country cost estimates, leading to decreased confidence in data quality in economic evaluations.

Cost-Effectiveness and Return-on-Investment of the Dynamic Work Intervention Compared With Usual Practice to Reduce Sedentary Behavior

OBJECTIVE

To assess the cost-effectiveness and return-on-investment (ROI) of the Dynamic Work (DW) Intervention, a worksite intervention aimed at reducing sitting time among office workers.

METHODS

In total, 244 workers were randomized to the intervention or control group. Overall sitting time, standing time, step counts, quality-adjusted life years (QALYs), and costs were measured over 12 months. The cost-effectiveness analysis was performed from the societal perspective and the ROI analysis from the employers' perspective.

RESULTS

No significant differences in effects and societal costs were observed between groups. Presenteeism costs were significantly lower in the intervention group. The probability of the intervention being cost-effective was 0.90 at a willingness-to-pay of 20,000&OV0556;/QALY. The probability of financial savings was 0.86.

CONCLUSION

The intervention may be considered cost-effective from the societal perspective depending on the willingness-to-pay. From the employer perspective, the intervention seems cost-beneficial.

A general framework for classifying costing methods for economic evaluation of health care

According to the most traditional economic evaluation manuals, all "relevant" costs should be included in the economic analysis, taking into account factors such as the patient population, setting, location, year, perspective and time horizon. However, cost information may be designed for other purposes. Health care organisations may lack sophisticated accounting systems and consequently, health economists may be unfamiliar with cost accounting terminology, which may lead to discrepancy in terms used in the economic evaluation literature and management accountancy. This paper identifies new tendencies in costing methodologies in health care and critically comments on each included article. For better clarification of terminology, a pragmatic glossary of terms is proposed. A scoping review of English and Spanish language literature (2005-2018) was conducted to identify new tendencies in costing methodologies in health care. The databases PubMed, Scopus and EconLit were searched. A total of 21 studies were included yielding 43 costing analysis. The most common analysis was top-down micro-costing (49%), followed by top-down gross-costing (37%) and bottom-up micro-costing (14%). Resource data were collected prospectively in 12 top-down studies (32%). Hospital database was the most common way of collection of resource data (44%) in top-down gross-costing studies. In top-down micro-costing studies, the most resource use data collection was the combination of several methods (38%). In general, substantial inconsistencies in the costing methods were found. The convergence of top-down and bottom-up methods may be an important topic in the next decades.

Estimating comparable English healthcare costs for multiple diseases and unrelated future costs for use in health and public health economic modelling

OBJECTIVES

Healthcare interventions, and particularly those in public health may affect multiple diseases and significantly prolong life. No consensus currently exists for how to estimate comparable healthcare costs across multiple diseases for use in health and public health cost-effectiveness models. We aim to describe a method for estimating comparable disease specific English healthcare costs as well as future healthcare costs from diseases unrelated to those modelled.

METHODS

We use routine national datasets including programme budgeting data and cost curves from NHS England to estimate annual per person costs for diseases included in the PRIMEtime model as well as age and sex specific costs due to unrelated diseases.

RESULTS

The 2013/14 annual cost to NHS England per prevalent case varied between £3,074 for pancreatic cancer and £314 for liver disease. Costs due to unrelated diseases increase with age except for a secondary peak at 30-34 years for women reflecting maternity resource use.

CONCLUSIONS

The methodology described allows health and public health economic modellers to estimate comparable English healthcare costs for multiple diseases. This facilitates the direct comparison of different health and public health interventions enabling better decision making.

Emergent Challenges in Determining Costs for Economic Evaluations

This paper describes methods of determining costs for economic evaluations of healthcare and considers how cost determination is being affected by recent developments in healthcare. The literature was reviewed to identify the strengths and weaknesses of the four principal methods of cost determination: micro-costing, activity-based costing, charge-based costing, and gross costing. A scoping review was conducted to identify key trends in healthcare delivery and to identify costing issues associated with these changes. Existing guidelines provide information on how to implement various costing methods. Bottom-up costing is needed when accuracy is paramount, but top-down approaches are often the only feasible approach. We describe six healthcare trends that have important implications for costing methodology: (1) reform in payment mechanisms; (2) care delivery in less restrictive settings; (3) the growth of telehealth interventions; (4) the proliferation of new technology; (5) patient privacy concerns; and (6) growing efforts to implement guidelines. Some costs are difficult to measure and have been overlooked. These include physician services for inpatients, facility costs for outpatient services, the cost of developing treatment innovations, patient and caregiver costs, and the indirect costs of organizational interventions. Standardized methods are needed to determine social welfare and productivity costs. In the future, cost determination will be facilitated by technological advances but hindered by the shift to capitated payment, to the provision of care in less restrictive settings, and by heightened concern for medical record privacy.

Direct, indirect and intangible costs of acute hand and wrist injuries: A systematic review

BACKGROUND

Injuries sustained to the hand and wrist are common, accounting for 20% of all emergency presentations. The economic burden of these injuries, comprised of direct (medical expenses incurred), indirect (value of lost productivity) and intangible costs, can be extensive and rise sharply with the increase of severity.

OBJECTIVE

This paper systematically reviews cost-of-illness studies and health economic evaluations of acute hand and wrist injuries with a particular focus on direct, indirect and intangible costs. It aims to provide economic cost estimates of burden and discuss the cost components used in international literature.

MATERIALS AND METHODS

A search of cost-of-illness studies and health economic evaluations of acute hand and wrist injuries in various databases was conducted. Data extracted for each included study were: design, population, intervention, and estimates and measurement methodologies of direct, indirect and intangible costs. Reported costs were converted into US-dollars using historical exchange rates and then adjusted into 2015 US-dollars using an inflation calculator RESULTS: The search yielded 764 studies, of which 21 met the inclusion criteria. Twelve studies were cost-of-illness studies, and seven were health economic evaluations. The methodology used to derive direct, indirect and intangible costs differed markedly across all studies. Indirect costs represented a large portion of total cost in both cost-of-illness studies [64.5% (IQR 50.75-88.25)] and health economic evaluations [68% (IQR 49.25-73.5)]. The median total cost per case of all injury types was US$6951 (IQR $3357-$22,274) for cost-of-illness studies and US$8297 (IQR $3858-$33,939) for health economic evaluations. Few studies reported intangible cost data associated with acute hand and wrist injuries.

CONCLUSIONS

Several studies have attempted to estimate the direct, indirect and intangible costs associated with acute hand and wrist injuries in various countries using heterogeneous methodologies. Estimates of the economic costs of different acute hand and wrist injuries varied greatly depending on the study methodology, however, by any standards, these injuries should be considered a substantial burden on the individual and society. Further research using standardised methodologies could provide guidance to relevant policy makers on how to best distribute limited resources by identifying the major disorders and exposures resulting in the largest burden.

The cost of chronic pain: an analysis of a regional pain management service in Ireland

OBJECTIVE

The objective of the study was to collect data on the direct and indirect economic cost of chronic pain among patients attending a pain management clinic in Ireland.

SETTING

A tertiary pain management clinic serving a mixed urban and rural area in the West of Ireland.

DESIGN

Data were collected from 100 patients using the Client Services Receipt Inventory and focused on direct and indirect costs of chronic pain.

METHODS

Patients were questioned about health service utilization, payment methods, and relevant sociodemographics. Unit costs were multiplied by resource use data to obtain full costs. Cost drivers were then estimated.

RESULTS

Our study showed a cost per patient of US$24,043 over a 12-month period. Over half of this was attributable to wage replacement costs and lost productivity in those unable to work because of pain. Hospital stays and outpatient hospital services were the main drivers for health care utilization costs, together accounting for 63% of the direct medical costs per study participant attending the pain clinic.

CONCLUSION

The cost of chronic pain among intensive service users is significant, and when extrapolated to a population level, these costs represent a very substantial economic burden.