Advancing the Science of Health Care Costing

Disease-Related Loss to Government Funding: Longitudinal Analysis of Individual-Level Health and Tax Data for an Entire Country

OBJECTIVES

The objective of this longitudinal analysis was to estimate funding loss in terms of tax revenue to the New Zealand (NZ) government from disease and injury among working age adults.

METHODS

Linked national health and tax data sets of the usually resident population between 2006 and 2016 were used to model 40 disease states simultaneously in a fixed-effects regression analysis to estimate population-level tax loss from disease and injury. To estimate tax revenue loss to the NZ government, we modeled a counterfactual scenario where all disease/injury was cause deleted.

RESULTS

The estimated tax paid by all 25- to 64-year-olds in the eligible NZ population was $15 773 million (m) per annum (US dollar 2021), or $16 446 m for a counterfactual as though no one had any disease disease-related income loss (a 4.3% or $672.9 m increase in tax revenue per annum). The disease that-if it had no impact on income-generated the greatest impact was mental illness, contributing 34.7% ($233.3 m) of all disease-related tax loss, followed by cardiovascular (14.7%, $99.0 m) and endocrine (10.2%, $68.8 m). Tax revenue gains after deleting all disease/injury increased up to 65 years of age, with the largest contributor occurring among 60- to 64-year-olds ($131.7 m). Varied results were also observed among different ethnicities and differing levels of deprivation.

CONCLUSIONS

This study finds considerable variation by disease on worker productivity and therefore tax revenue in this high-income country. These findings strengthen the economic and government case for prevention, particularly the prevention of mental health conditions and cardiovascular disease.

Disease-related income and economic productivity loss in New Zealand: A longitudinal analysis of linked individual-level data

BACKGROUND

Reducing disease can maintain personal individual income and improve societal economic productivity. However, estimates of income loss for multiple diseases simultaneously with thorough adjustment for confounding are lacking, to our knowledge. We estimate individual-level income loss for 40 conditions simultaneously by phase of diagnosis, and the total income loss at the population level (a function of how common the disease is and the individual-level income loss if one has the disease).

METHODS AND FINDINGS

We used linked health tax data for New Zealand as a high-income country case study, from 2006 to 2007 to 2015 to 2016 for 25- to 64-year-olds (22.5 million person-years). Fixed effects regression was used to estimate within-individual income loss by disease, and cause-deletion methods to estimate economic productivity loss at the population level. Income loss in the year of diagnosis was highest for dementia for both men (US$8,882; 95% CI $6,709 to $11,056) and women ($7,103; $5,499 to $8,707). Mental illness also had high income losses in the year of diagnosis (average of about $5,300 per year for males and $4,100 per year for females, for 4 subcategories of: depression and anxiety; alcohol related; schizophrenia; and other). Similar patterns were evident for prevalent years of diagnosis. For the last year of life, cancers tended to have the highest income losses, (e.g., colorectal cancer males: $17,786, 95% CI $15,555 to $20,018; females: $14,192, $12,357 to $16,026). The combined annual income loss from all diseases among 25- to 64-year-olds was US$2.72 billion or 4.3% of total income. Diseases contributing more than 4% of total disease-related income loss were mental illness (30.0%), cardiovascular disease (15.6%), musculoskeletal (13.7%), endocrine (8.9%), gastrointestinal (7.4%), neurological (6.5%), and cancer (4.5%). The limitations of this study include residual biases that may overestimate the effect of disease on income loss, such as unmeasured time-varying confounding (e.g., divorce leading to both depression and income loss) and reverse causation (e.g., income loss leading to depression). Conversely, there may also be offsetting underestimation biases, such as income loss in the prodromal phase before diagnosis that is misclassified to "healthy" person time.

CONCLUSIONS

In this longitudinal study, we found that income loss varies considerably by disease. Nevertheless, mental illness, cardiovascular, and musculoskeletal diseases stand out as likely major causes of economic productivity loss, suggesting that they should be prioritised in prevention programmes.

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.

Health system costs for individual and comorbid noncommunicable diseases: An analysis of publicly funded health events from New Zealand

BACKGROUND

There is little systematic assessment of how total health expenditure is distributed across diseases and comorbidities. The objective of this study was to use statistical methods to disaggregate all publicly funded health expenditure by disease and comorbidities in order to answer three research questions: (1) What is health expenditure by disease phase for noncommunicable diseases (NCDs) in New Zealand? (2) Is the cost of having two NCDs more or less than that expected given the independent costs of each NCD? (3) How is total health spending disaggregated by NCDs across age and by sex?

METHODS AND FINDINGS

We used linked data for all adult New Zealanders for publicly funded events, including hospitalisation, outpatient, pharmaceutical, laboratory testing, and primary care from 1 July 2007 to 30 June 2014. These data include 18.9 million person-years and $26.4 billion in spending (US$ 2016). We used case definition algorithms to identify if a person had any of six NCDs (cancer, cardiovascular disease [CVD], diabetes, musculoskeletal, neurological, and a chronic lung/liver/kidney [LLK] disease). Indicator variables were used to identify the presence of any of the 15 possible comorbidity pairings of these six NCDs. Regression was used to estimate excess annual health expenditure per person. Cause deletion methods were used to estimate total population expenditure by disease. A majority (59%) of health expenditure was attributable to NCDs. Expenditure due to diseases was generally highest in the year of diagnosis and year of death. A person having two diseases simultaneously generally had greater health expenditure than the expected sum of having the diseases separately, for all 15 comorbidity pairs except the CVD-cancer pair. For example, a 60-64-year-old female with none of the six NCDs had $633 per annum expenditure. If she had both CVD and chronic LLK, additional expenditure for CVD separately was $6,443/$839/$9,225 for the first year of diagnosis/prevalent years/last year of life if dying of CVD; additional expenditure for chronic LLK separately was $6,443/$1,291/$9,051; and the additional comorbidity expenditure of having both CVD and LLK was $2,456 (95% confidence interval [CI] $2,238-$2,674). The pattern was similar for males (e.g., additional comorbidity expenditure for a 60-64-year-old male with CVD and chronic LLK was $2,498 [95% CI $2,264-$2,632]). In addition to this, the excess comorbidity costs for a person with two diseases was greater at younger ages, e.g., excess expenditure for 45-49-year-old males with CVD and chronic LLK was 10 times higher than for 75-79-year-old males and six times higher for females. At the population level, 23.8% of total health expenditure was attributable to higher costs of having one of the 15 comorbidity pairs over and above the six NCDs separately; of the remaining expenditure, CVD accounted for 18.7%, followed by musculoskeletal (16.2%), neurological (14.4%), cancer (14.1%), chronic LLK disease (7.4%), and diabetes (5.5%). Major limitations included incomplete linkage to all costed events (although these were largely non-NCD events) and missing private expenditure.

CONCLUSIONS

The costs of having two NCDs simultaneously is typically superadditive, and more so for younger adults. Neurological and musculoskeletal diseases contributed the largest health system costs, in accord with burden of disease studies finding that they contribute large morbidity. Just as burden of disease methodology has advanced the understanding of disease burden, there is a need to create disease-based costing studies that facilitate the disaggregation of health budgets at a national level.

Cost of breast cancer based on real-world data: a cancer registry study in Italy

BACKGROUND

In European countries, it is difficult for local health organizations to determine the resources allocated to different hospitals for breast cancer. The aim of the current study was to examine the costs of breast cancer during the different phases of the diagnostictherapeutic sequence based on real world data.

METHODS

To identify breast cancer cases diagnosed between 2007 and 2011, we used the cancer registry of the Agency for Health Protection of the Province of Milan (3.2 million inhabitants). A generalized linear model controlling for patient age, cancer stage and Charlson co-morbidity index was used to calculate the adjusted mean costs for each hospital and for each study phase. Regression analyses were based on dependent variables of individual costs (diagnosis, treatment, follow-up and total cost were logtransformed. The following independent variables were included as covariates: age at diagnosis, hospital volume, stage, job category, educational level, marital status, comorbidities, deprivation index. Total and mean costs were computed for several variables and for each phase. On average for each subject, the costs were collected over 2.5 years.

RESULTS

A total of 12,580 breast cancer cases were studied. The mean cost of diagnosis was €414, the mean cost of treatment was €8,780, the mean overall cost of follow-up was approximately €2,351, and the mean total direct medical cost was €10,970. The age of the patients, stage of tumor and employment level of the patient were significantly correlated with the variability of the costs. The highest variability in costs was observed for the follow-up costs, in which 38% of hospitals fell outside the 95% confidence interval. In the overspending-hospitals, patients received an intensive follow-up regimen with scintigraphy and thoracic CAT (computerized axial tomography).

CONCLUSIONS

In this study, which represents the first population-level study of its kind in Italy, we estimated all direct medical costs for the 6-month period before the diagnosis of breast cancer and the first two years after diagnosis. Patients were identified from the local cancer registry. The analysis offers insight into the utilization of resources incurred by one major area of interest of cancer care in Italy.

Multiple chronic conditions and healthcare costs among adults

The prevalence of multiple chronic conditions (MCC) is increasing among individuals of all ages. MCC are associated with poor health outcomes. The presence of MCC has profound healthcare utilization and cost implications for public and private insurance payers, individuals, and families. Investigators have used a variety of definitions for MCC to evaluate costs associated with MCC. The objective of this article is to examine the current literature in estimating excess costs associated with MCC among adults. The discussion highlights some of the theoretical and technical merits of various MCC definitions and models used to estimate the excess costs associated with MCC.

The economic burden of incident venous thromboembolism in the United States: A review of estimated attributable healthcare costs

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is an important cause of preventable mortality and morbidity. In this study, we summarize estimates of per-patient and aggregate medical costs or expenditures attributable to incident VTE in the United States. Per-patient estimates of incremental costs can be calculated as the difference in costs between patients with and without an event after controlling for differences in underlying health status. We identified estimates of the incremental per-patient costs of acute VTEs and VTE-related complications, including recurrent VTE, post-thrombotic syndrome, chronic thromboembolic pulmonary hypertension, and anticoagulation-related adverse drug events. Based on the studies identified, treatment of an acute VTE on average appears to be associated with incremental direct medical costs of $12,000 to $15,000 (2014 US dollars) among first-year survivors, controlling for risk factors. Subsequent complications are conservatively estimated to increase cumulative costs to $18,000-23,000 per incident case. Annual incident VTE events conservatively cost the US healthcare system $7-10 billion each year for 375,000 to 425,000 newly diagnosed, medically treated incident VTE cases. Future studies should track long-term costs for cohorts of people with incident VTE, control for comorbid conditions that have been shown to be associated with VTE, and estimate incremental medical costs for people with VTE who do not survive. The costs associated with treating VTE can be used to assess the potential economic benefit and cost-savings from prevention efforts, although costs will vary among different patient groups.

Patterns of cancer care costs in a country with detailed individual data

Supplemental Digital Content is available in the text.

Objective:

To determine health system expenditure on cancers by time since diagnosis using data for an entire country.

Methods:

New Zealand cancer registry data was linked to hospitalization, pharmaceutical, outpatient, general practice, laboratory, and other datasets, with costs ascribed to each event occurring in 2006–2011. “Excess” cancer costs were estimated by subtracting “expected costs” for citizens without cancer from the “total cost” for cancer patients ($2011 inflation-adjusted). Gamma regressions were used to estimate costs per person-month.

Results:

For first adult cancer diagnosed that the excess cost per person was between US$3400 and US$4300 in the first month postdiagnosis (varied by sex and age), fell to US$50–US$150 per month at 2 or more years postdiagnosis (excluding those within a year of death), but increased again if dying from their cancer (US$3800–US$8300 in the last month of life). Such patterns varied by cancer, for example, in the first month postdiagnosis for 65 year olds it varied 20-fold from US$800 for prostate to US$15,900 for brain cancer.

Per diagnosed case, total excess costs varied from US$8000 (melanoma) to US$98,000 (bone and connective tissue).

Excess cancer costs made up 6.5% of total Vote:Health expenditure in 2010–2011, with colorectal (14.7%), breast (14.4%) being the top 2 contributors, and prostate, non-Hodgkin lymphoma, leukemia, and lung each contributing about 6%.

Conclusions:

Costs vary substantially by time since diagnosis and cancer type. The results and regression equations reported in this paper can be used in modeling requiring cancer costs by time since diagnosis and proximity to death.

Economic studies in colorectal cancer: challenges in measuring and comparing costs

Estimates of the costs associated with cancer care are essential both for assessing burden of disease at the population level and for conducting economic evaluations of interventions to prevent, detect, or treat cancer. Comparisons of cancer costs between health systems and across countries can improve understanding of the economic consequences of different health-care policies and programs. We conducted a structured review of the published literature on colorectal cancer (CRC) costs, including direct medical, direct nonmedical (ie, patient and caregiver time, travel), and productivity losses. We used MEDLINE to identify English language articles published between 2000 and 2010 and found 55 studies. The majority were conducted in the United States (52.7%), followed by France (12.7%), Canada (10.9%), the United Kingdom (9.1%), and other countries (9.1%). Almost 90% of studies estimated direct medical costs, but few studies estimated patient or caregiver time costs or productivity losses associated with CRC. Within a country, we found significant heterogeneity across the studies in populations examined, health-care delivery settings, methods for identifying incident and prevalent patients, types of medical services included, and analyses. Consequently, findings from studies with seemingly the same objective (eg, costs of chemotherapy in year following CRC diagnosis) are difficult to compare. Across countries, aggregate and patient-level estimates vary in so many respects that they are almost impossible to compare. Our findings suggest that valid cost comparisons should be based on studies with explicit standardization of populations, services, measures of costs, and methods with the goal of comparability within or between health systems or countries. Expected increases in CRC prevalence and costs in the future highlight the importance of such studies for informing health-care policy and program planning.

Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial

BACKGROUND & AIMS

Although surgery is the standard technique for drainage of pancreatic pseudocysts, use of endoscopic methods is increasing. We performed a single-center, open-label, randomized trial to compare endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage.

METHODS

Patients with pancreatic pseudocysts underwent endoscopic (n = 20) or surgical cystogastrostomy (n = 20). The primary end point was pseudocyst recurrence after a 24-month follow-up period. Secondary end points were treatment success or failure, complications, re-interventions, length of hospital stay, physical and mental health scores, and total costs.

RESULTS

At the end of the follow-up period, none of the patients who received endoscopic therapy had a pseudocyst recurrence, compared with 1 patient treated surgically. There were no differences in treatment successes, complications, or re-interventions between the groups. However, the length of hospital stay was shorter for patients who underwent endoscopic cystogastrostomy (median, 2 days, vs 6 days in the surgery group; P < .001). Although there were no differences in physical component scores and mental health component scores (MCS) between groups at baseline on the Medical Outcomes Study 36-Item Short-Form General Survey questionnaire, longitudinal analysis showed significantly better physical component scores (P = .019) and mental health component scores (P = .025) for the endoscopy treatment group. The total mean cost was lower for patients managed by endoscopy than surgery ($7011 vs $15,052; P = .003).

CONCLUSIONS

In a randomized trial comparing endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage, none of the patients in the endoscopy group had pseudocyst recurrence during the follow-up period, therefore there is no evidence that surgical cystogastrostomy is superior. However, endoscopic treatment was associated with shorter hospital stays, better physical and mental health of patients, and lower cost.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00826501.

Comparison of methods for estimating the cost of human immunodeficiency virus-testing interventions

CONTEXT

The Centers for Disease Control and Prevention (CDC), Division of HIV/AIDS Prevention, spends approximately 50% of its $325 million annual human immunodeficiency virus (HIV) prevention funds for HIV-testing services. An accurate estimate of the costs of HIV testing in various settings is essential for efficient allocation of HIV prevention resources.

OBJECTIVES

To assess the costs of HIV-testing interventions using different costing methods.

DESIGN, SETTINGS, AND PARTICIPANTS

We used the microcosting-direct measurement method to assess the costs of HIV-testing interventions in nonclinical settings, and we compared these results with those from 3 other costing methods: microcosting-staff allocation, where the labor cost was derived from the proportion of each staff person's time allocated to HIV testing interventions; gross costing, where the New York State Medicaid payment for HIV testing was used to estimate program costs, and program budget, where the program cost was assumed to be the total funding provided by Centers for Disease Control and Prevention.

MAIN OUTCOME MEASURES

Total program cost, cost per person tested, and cost per person notified of new HIV diagnosis.

RESULTS

The median costs per person notified of a new HIV diagnosis were $12 475, $15 018, $2697, and $20 144 based on microcosting-direct measurement, microcosting-staff allocation, gross costing, and program budget methods, respectively. Compared with the microcosting-direct measurement method, the cost was 78% lower with gross costing, and 20% and 61% higher using the microcosting-staff allocation and program budget methods, respectively.

CONCLUSIONS

Our analysis showed that HIV-testing program cost estimates vary widely by costing methods. However, the choice of a particular costing method may depend on the research question being addressed. Although program budget and gross-costing methods may be attractive because of their simplicity, only the microcosting-direct measurement method can identify important determinants of the program costs and provide guidance to improve efficiency.

Cost-of-illness studies: a guide to critical evaluation

Cost-of-illness (COI) studies aim to assess the economic burden of health problems on the population overall, and they are conducted for an ever widening range of health conditions and geographical settings. While they attract much interest from public health advocates and healthcare policy makers, inconsistencies in the way in which they are conducted and a lack of transparency in reporting have made interpretation difficult, and have ostensibly limited their usefulness. Yet there is surprisingly little in the literature to assist the non-expert in critically evaluating these studies. This article aims to provide non-expert readers with a straightforward guide to understanding and evaluating traditional COI studies. The intention is to equip a general audience with an understanding of the most important issues that influence the validity of a COI study, and the ability to recognize the most common limitations in such work.