Using Costs in Cost-Effectiveness Models for Chronic Diseases: Lessons From Diabetes

The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission

The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.

Costs and where to find them: identifying unit costs for health economic evaluations of diabetes in France, Germany and Italy

BACKGROUND

Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes.

METHODS

A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications.

RESULTS

An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources.

CONCLUSIONS

This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes.

Cost-Effectiveness of a Technology-Enhanced Diabetes Care Management Program in Mexico

BACKGROUND

The prevalence of diabetes has increased substantially in Mexico over the last 40 years, leading to significant impacts on population health and the healthcare system. Technology-based solutions may improve diabetes outcomes in areas where lack of efficient transportation creates barriers to care.

OBJECTIVES

To estimate the lifetime cost-effectiveness of a technology-based diabetes care management program from the perspective of the Mexican healthcare system.

METHODS

Clinical outcomes and cost data from a 3-arm randomized clinical trial of Dulce Wireless Tijuana, a diabetes care management program incorporating short-term mobile technology, were used as inputs in a validated simulation model for type 2 diabetes. Study arms included a control group (CG), Project Dulce diabetes care management (PD), and Project Dulce with technology enhancement (PD-TE).

RESULTS

Intervention costs were $1448 for PD and $1740 for PD-TE compared with $740 for CG. Both intervention arms increased quality-adjusted life-years and costs. The incremental cost-effectiveness ratio for PD was $1635 and for PD-TE was $2220, both compared with CG. The incremental cost-effectiveness ratio for PD-TE versus PD was $4299. The results were sensitive to the time horizon. The PE and PD-TE interventions were cost-effective under time horizons of 15 to 20 years, but were not cost-effective under time horizons of 5 to 10 years.

CONCLUSIONS

Both the PD and PD-TE were highly cost-effective from a Mexican health system perspective. Considering the economic impact of the diabetes epidemic and the widespread use of cellular technology in Mexico, implementation of PD-TE is warranted.

Health Care Costs Associated With Incident Complications in Patients With Type 2 Diabetes in Germany

OBJECTIVE

The aim of this study is to provide reliable regression-based estimates of costs associated with different type 2 diabetes complications.

RESEARCH DESIGN AND METHODS

We used nationwide statutory health insurance (SHI) data from 316,220 patients with type 2 diabetes. Costs for inpatient and outpatient care, pharmaceuticals, rehabilitation, and nonmedical aids and appliances were assessed in the years 2013-2015. Quarterly observations are available for each year. We estimated costs (in 2015 euro) for complications using a generalized estimating equations model with a normal distribution adjusted for age, sex, occurrence of different complications, and history of complications at baseline, 2012. Two- and threefold interactions were included in an extended model.

RESULTS

The base case model estimated total costs in the quarter of event for the example of a 60- to 69-year-old man as follows: diabetic foot €1,293, amputation €14,284, retinopathy €671, blindness €2,933, nephropathy €3,353, end-stage renal disease (ESRD) €22,691, nonfatal stroke €9,769, fatal stroke €11,176, nonfatal myocardial infarction (MI)/cardiac arrest (CA) €8,035, fatal MI/CA €8,700, nonfatal ischemic heart disease (IHD) €6,548, fatal IHD €20,942, chronic heart failure €3,912, and angina pectoris €2,695. In the subsequent quarters, costs ranged from €681 for retinopathy to €6,130 for ESRD.

CONCLUSIONS

Type 2 diabetes complications have a significant impact on total health care costs in the SHI system, not only in the quarter of event but also in subsequent years. Men and women from different age-groups differ in their costs for complications. Our comprehensive estimates may support the parametrization of diabetes models and help clinicians and policy makers to quantify the economic burden of diabetes complications in the context of new prevention and treatment programs.

Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care

Secondary prevention involves monitoring and screening to prevent negative sequelae from chronic diseases such as cancer. Breast cancer treatment sequelae, such as lymphedema, may occur early or late and often negatively affect function. Secondary prevention through prospective physical therapy surveillance aids in early identification and treatment of breast cancer-related lymphedema (BCRL). Early intervention may reduce the need for intensive rehabilitation and may be cost saving. This perspective article compares a prospective surveillance model with a traditional model of impairment-based care and examines direct treatment costs associated with each program. Intervention and supply costs were estimated based on the Medicare 2009 physician fee schedule for 2 groups: (1) a prospective surveillance model group (PSM group) and (2) a traditional model group (TM group). The PSM group comprised all women with breast cancer who were receiving interval prospective surveillance, assuming that one third would develop early-stage BCRL. The prospective surveillance model includes the cost of screening all women plus the cost of intervention for early-stage BCRL. The TM group comprised women referred for BCRL treatment using a traditional model of referral based on late-stage lymphedema. The traditional model cost includes the direct cost of treating patients with advanced-stage lymphedema. The cost to manage early-stage BCRL per patient per year using a prospective surveillance model is $636.19. The cost to manage late-stage BCRL per patient per year using a traditional model is $3,124.92. The prospective surveillance model is emerging as the standard of care in breast cancer treatment and is a potential cost-saving mechanism for BCRL treatment. Further analysis of indirect costs and utility is necessary to assess cost-effectiveness. A shift in the paradigm of physical therapy toward a prospective surveillance model is warranted.

Just enough measurement: a proposed paradigm for designing medical instrumentation

Our research group hypothesizes that one way to provide low-cost healthcare delivery efficiently is through the use of a large number of inexpensive sensors that can provide meaningful medical data. Typical development of medical instrumentation pursues increased resolution and higher accuracy - accompanied by a corresponding increase in cost; it is no secret that high costs impose a heavy burden on healthcare. We seek to invert the adage that quality is more important than quantity by extracting high quality biomedical information from a large quantity of low-cost measurements, and to demonstrate this using measurement instrumentation developed in our lab for extra-clinical assessment and rehabilitation tools. This will be discussed in terms of our initial experiments in evaluating balance and postural stability. This is an area of critical clinical importance: 2.6 million non-fatal fall injuries in persons over age 65 resulted in direct health care costs of $19 billion (in 2000) in the U.S., and the number of persons over age 65 in the U.S. is projected to more than double between 2000 and 2030.

Cost-effectiveness of aspirin use among persons with newly diagnosed type 2 diabetes

OBJECTIVE

To assess the long-term cost-effectiveness of aspirin use among adults aged >or=40 years with newly diagnosed type 2 diabetes.

RESEARCH DESIGN AND METHODS

We used a validated cost-effectiveness model of type 2 diabetes to assess the lifetime health and cost consequences of use or nonuse of aspirin. The model simulates the progression of diabetes and accompanying complications for a cohort of subjects with type 2 diabetes. The model predicts the outcomes of type 2 diabetes along five disease paths (nephropathy, neuropathy, retinopathy, coronary heart disease, and stroke) from the time of diagnosis until age 94 years or until death.

RESULTS

Over a lifetime, aspirin users gained 0.31 life-years (LY) or 0.19 quality-adjusted LYs (QALYs) over nonaspirin users, at an incremental cost of $1,700; the incremental cost-effectiveness ratio (ICER) of aspirin use was $5,428 per LY gained or $8,801 per QALY gained. In probabilistic sensitivity analyses, the ICER was <$30,000 per QALY in all of 2,000 realizations in two scenarios.

CONCLUSIONS

Regular use of aspirin among people with newly diagnosed diabetes is cost-effective.

A comparison of diabetes medication adherence and healthcare costs in patients using mail order pharmacy and retail pharmacy

OBJECTIVE

To compare long-term diabetes medication adherence and healthcare costs in patients using mail order pharmacy versus retail pharmacy.

METHODS

The MarketScan database was used to identify patients who filled prescriptions for oral anti-diabetes medications in a retail pharmacy for at least 6 months before switching to mail order pharmacy for at least 12 months. These patients were matched to others who used retail pharmacy continuously for at least 18 months. A propensity score was used to create matched groups of patients comparable on probability of switching to mail order, weighted Poisson regression was used to analyze differences in medication adherence, and Tobit regression was used to compare costs.

RESULTS

A total of 14,600 patients who switched to mail order were matched to 43,800 patients who used retail pharmacy continuously. The average adjusted adherence in retail pharmacy was 63.4% compared to 84.8% after switching to mail order. Per-member-per-month total healthcare and total medical costs were on average $34.32 and $37.54 lower in the mail order group, respectively. Diabetes-related medical costs were on average $19.14 lower in the mail order group, while pharmacy costs were $14.13 higher.

LIMITATIONS

Limitations include a patient population under the age of 65, no information on pharmacy benefit design, and limited follow-up time relative to that necessary to identify long-term diabetes complications.

CONCLUSIONS

After adjusting for measured confounders of medication adherence and disease severity, individuals who switched to mail order pharmacy had higher medication possession ratios and trended toward lower total and diabetes-related medical costs over time.

Inventory of data sources for estimating health care costs in the United States

OBJECTIVE

To develop an inventory of data sources for estimating health care costs in the United States and provide information to aid researchers in identifying appropriate data sources for their specific research questions.

METHODS

We identified data sources for estimating health care costs using 3 approaches: (1) a review of the 18 articles included in this supplement, (2) an evaluation of websites of federal government agencies, non profit foundations, and related societies that support health care research or provide health care services, and (3) a systematic review of the recently published literature. Descriptive information was abstracted from each data source, including sponsor, website, lowest level of data aggregation, type of data source, population included, cross-sectional or longitudinal data capture, source of diagnosis information, and cost of obtaining the data source. Details about the cost elements available in each data source were also abstracted.

RESULTS

We identified 88 data sources that can be used to estimate health care costs in the United States. Most data sources were sponsored by government agencies, national or nationally representative, and cross-sectional. About 40% were surveys, followed by administrative or linked administrative data, fee or cost schedules, discharges, and other types of data. Diagnosis information was available in most data sources through procedure or diagnosis codes, self-report, registry, or chart review. Cost elements included inpatient hospitalizations (42.0%), physician and other outpatient services (45.5%), outpatient pharmacy or laboratory (28.4%), out-of-pocket (22.7%), patient time and other direct nonmedical costs (35.2%), and wages (13.6%). About half were freely available for downloading or available for a nominal fee, and the cost of obtaining the remaining data sources varied by the scope of the project.

CONCLUSIONS

Available data sources vary in population included, type of data source, scope, and accessibility, and have different strengths and weaknesses for specific research questions.