Cost of illness of leukemia in Japan - Trend analysis and future projections

BACKGROUND

Leukemia is a deadly hematological malignancy that usually affects all age groups and imposes significant burden on public funds and society. The objective of this study was to analyze the cost of illness (COI) of leukemia, and to mark out the underlying driving factors, in Japan.

METHODS

COI method was applied to the data from government statistics. We first summed up the direct and indirect costs from 1996 to 2014; then future COI for the year 2017-2029 was projected.

RESULTS

Calculated COI showed an upward trend with a 13% increase from 1996 to 2014 (270-305 billion yen). Increased COI was attributed to an increase in direct costs. Although mortality cost accounted for the largest proportion of COI, but followed a downward trend. Decreased mortality costs reflected the effects of aging. Mortality cost per person also decreased, however, the percentage of mortality cost for individuals ≥65 years of age increased consistently from 1996 to 2014. If a similar trend in health-related indicators continue, COI would remain stable from 2017 to 2029 regardless of models.

CONCLUSION

COI of leukemia increased from 1996 to 2014, but was projected to decrease in foreseeable future. With advancement of new therapies, leukemia has become potentially curable and require long-term care; so direct cost and morbidity cost will remain unchanged. This reveal the further continuing burden on public funds. Thus, the information obtained from this study can be regarded as beneficial to future policy making with respect to government policies in Japan.

Costs for Childhood and Adolescent Cancer, 90 Days Prediagnosis and 1 Year Postdiagnosis: A Population-Based Study in Ontario, Canada

BACKGROUND

Childhood and adolescent cancers are uncommon, but they have important economic and health impacts on patients, families, and health care systems. Few studies have measured the economic burden of care for childhood and adolescent cancers.

OBJECTIVES

To estimate costs of cancer care in population-based cohorts of children and adolescents from the public payer perspective.

METHODS

We identified patients with cancer, aged 91 days to 19 years, diagnosed from 1995 to 2009 using cancer registry data, and matched each to three noncancer controls. Using linked administrative health care records, we estimated total and net resource-specific costs (in 2012 Canadian dollars) during 90 days prediagnosis and 1 year postdiagnosis.

RESULTS

Children (≤14 years old) numbered 4,396: 36% had leukemia, 21% central nervous system tumors, 10% lymphoma, and 33% other cancers. Adolescents (15-19 years old) numbered 2,329: 28.9% had lymphoma. Bone and soft tissue sarcoma, germ cell tumor, and thyroid carcinoma each comprised 12% to 13%. Mean net prediagnosis costs were $5,810 and $1,127 and mean net postdiagnosis costs were $136,413 and $62,326 for children and adolescents, respectively; the highest were for leukemia ($157,764 for children and $172,034 for adolescents). In both cohorts, costs were much higher for patients who died within 1 year of diagnosis. Inpatient hospitalization represented 69% to 74% of postdiagnosis costs.

CONCLUSIONS

Treating children with cancer is costly, more costly than treating adolescents or adults. Substantial survival gains in children mean that treatment may still be very cost-effective. Comprehensive age-specific population-based cost estimates are essential to reliably assess the cost-effectiveness of cancer care for children and adolescents, and measure health system performance.

Nosocomial infections among acute leukemia patients in China: An economic burden analysis

BACKGROUND

The economic burden associated nosocomial infections (NIs) in patients with acute leukemia (AL) in China was unclear. A prospective study was conducted to quantify the medical cost burden of NIs among AL patients.

METHODS

Nine hundred ninety-four patients diagnosed with AL between January 2011 and December 2013 were included. Relevant necessary information was extracted from the hospital information system and hospital infection surveillance system. The primary outcome was incidence of NIs and the secondary was economic burden results, including extra medical costs and prolonged length of stay (LOS). We estimated the total incremental cost of NIs by comparing all-cause health care costs in patients with versus without infections. Prolonged duration of stay was compared in patients with different infections.

RESULTS

Of 994 patients with AL, 277 (27.9%) experienced NIs. NI was associated with a total incremental cost of $3,092 per patient ($5,227 vs $2,135; P < .01) and infected patients experienced a longer LOS (21 vs 10 days; P < .01). Patients with multisite infection had the highest total medical cost ($8,474.90 vs $2,209.90; P < .01) and the longest LOS (25 vs 15 days; P < .01). Western medicine was the main contributor to the rise of total cost in all kinds of infections.

CONCLUSIONS

NI was associated with higher medical costs, which imposed an economic burden on patients with AL. The study highlights the influence of NIs on LOS and health care costs and appeal to the establishment of prophylactic measures for NIs to reduce the unnecessary waste of medical resources in the long run.

Scientific Achievements May Not Reach Everyone: Understanding Disparities in Acute Leukemia

Over the past decade, scientific advancements have resulted in improved survival from acute leukemia. Continued advancements are expected given the attention to precision medicine and the resulting growth in development and adoption of risk-stratified, personalized therapies. While precision medicine has great potential to improve acute leukemia outcomes, there remain significant barriers to ensuring equitable access to these technologies and receipt of these prescribed targeted, personalized therapies. Over the past 3 years, studies report persistent outcome disparities among patients from specific racial and ethnic backgrounds, insurance and socioeconomic status, and other socio-demographic factors after a diagnosis of acute leukemia. A few recent studies examine etiologies for acute leukemia disparities and highlight the importance of ensuring access and equitable delivery of scientific advancements. In the context of continued scientific progress, future strategies require thoughtfully considered improvements in the delivery of care that can overcome the current challenges our patients face.

Socioeconomic disparities in survival from childhood leukemia in the United States and globally: a meta-analysis

BACKGROUND

Despite advancements in the treatment of childhood leukemia, socioeconomic status (SES) may potentially affect disease prognosis. This study aims to evaluate whether SES is associated with survival from childhood leukemia.

METHODS

The US National Cancer Institute Surveillance, Epidemiology and End Results Program (SEER) 1973-2010 data were analyzed; thereafter, results were meta-analyzed along with those from survival (cohort) studies examining the association between SES indices and survival from childhood leukemia (end-of-search date: 31 March 2014). Random-effects models were used to calculate pooled effect estimates (relative risks, RRs); meta-regression was also used.

RESULTS

We included 29 studies yielding 28 804 acute lymphoblastic leukemia (ALL), 3208 acute myeloblastic leukemia (AML) and 27 650 'any' leukemia (denoting joint reporting of all subtypes) cases. According to individual-level composite SES indices, children from low SES suffered from nearly twofold higher death rates from ALL (pooled RR: 1.83, 95% confidence interval 1.00-3.34, based on four study arms); likewise, death RRs derived from an array of lower area-level SES indices ranged between 1.17 and 1.33 (based on 11 study arms). Importantly, the survival gap between higher and lower SES seemed wider in the United States, with considerably (by 20%-82%) increased RRs for death from ALL in lower SES. Regarding AML, poorer survival was evident only when area-level SES indices were used. Lastly, remoteness indices were not associated with survival from childhood leukemia.

CONCLUSION

Children with lower SES suffering childhood leukemia do not seem to equally enjoy the impressive recent survival gains. Special health policy strategies and increased awareness of health providers might minimize the effects of socioeconomic disparities.

The Incidence and Survival of AcuteDe NovoLeukaemias in Estonia and in a Well Defined Region of Western Sweden During 1982 – 1996: A Survey of Patients Aged 16 – 64 Years

In the present work the incidence and survival of acute de novo leukaemias in two neighbouring countries, were studied retrospectively over three 5-year periods, 1982-1996. The aim was to compare the above variables, particularly with respect to political/socio-economic and environmental factors, in a well defined area of Sweden, the so-called Western Swedish Health Care Region, with Estonia. Population-wise the Western Swedish Region and Estonia are very similar; area-wise they are also well comparable. The present report covers only patients diagnosed between the ages of 16-64 years. The number of acute de novo leukaemias in the two regions was quite similar (Western Sweden n = 282 and Estonia n = 237). The age standardized incidence rate regarding total acute de novo leukaemias was slightly lower in Estonia than in Western Sweden (1.49/100,000 inhabitants/year for Estonia and 1.76 for Sweden, respectively), the difference being not statistically significant. However, the survival data for the two countries were highly different (P < 0.001). Thus, the relative survival for the total group of patients aged 16-64 years in Estonia at 1 year was 20.7% and at 5 years 3.6%, respectively. The corresponding figures for the Swedish patients were considerably higher, 65.2 and 29.4%, respectively. Further, the 5 year survival significantly (P < 0.05) increased for the Swedish patients over the 3 consecutive 5-year periods. No such improvement was recorded for the Estonian patients.

Manhattan transfer: lethal radiation, bone marrow transplantation, and the birth of stem cell biology, ca. 1942-1961

This study investigates how, in the late 1940s and 1950s, fears of nuclear accidents and nuclear warfare shaped postwar radiobiology. The new and intense forms of radiation generated by nuclear reactor technology, and which would be released in the event of a nuclear war, created concerns about a public-health hazard unprecedented in form and scale. Fears of inadvertent exposure to acute and potentially lethal radiation launched a search for anti-radiation therapies, out of which emerged the new technique of bone marrow transplantation (BMT). This study analyzes the use of BMT first as a research tool to explore the biological effects of ionizing radiation, and then as an adjunct to radiotherapy for the treatment of cancer. In highlighting how BMT became the province of different research and clinical constituencies, this study develops an understanding of the forces and contingencies that shaped its development. Exploring the emergence of BMT and the uses to which it was put, it reveals that BMT remained a technique in the making -- unstable and far from standardized, even as it became both a widely used research tool and rapidly made its way into the clinic. More broadly, it casts new light on one route through which the Manhattan Project influenced postwar radiobiology; it also affords new insights into one means by which radiobiology came to serve the interests of the Cold War state. In its focus on BMT this paper provides a new perspective on the evolving relationship between radiobiology and biomedicine in the postwar period.

Patterns of hospital resource utilization of children with leukemia and CNS tumors: a comparison of children who survive and those who die within 3 years of diagnosis

Hospital admissions for children with cancer tend to be longer than admissions for adults with cancer and longer, more frequent, and more costly than other pediatric admissions. The two childhood cancers most commonly requiring hospitalization are leukemia and tumors of the central nervous system (CNS tumors). Determining the best use of limited financial resources and preparing children and their parents for what to expect requires a better understanding of the patterns and cost of hospital resource utilization by children with cancer. Both hospital administrators and third-party payers can use this understanding to better allocate resources and plan the care of children with cancer in the future. Because many parents of children with cancer struggle financially due to the high cost of treatments, time off of work, and other non-medical expenses, more education in this area may help parents to prepare, thus alleviating some of the uncertainty and unexpected financial costs associated with childhood cancer.

[Cost-effectiveness analysis of the empirical antifungal strategy in oncohaematological patients]

OBJECTIVE

Observational study performing a cost-effectiveness analysis of the empirical antifungal strategy in high-risk oncohaematological patients, from the hospital perspective and with an average time horizon of 10.8 days of treatment.

METHOD

Data gathered: effectiveness, purchase costs and other costs (diagnostic tests, hospitalisation, and second-line antifungal therapy). A total of 107 patients were analysed, 115 invasive fungal infection sub-episodes and 138 empirical treatments.

RESULTS

The effectiveness and average cost/treatment were: voriconazole 88% and 20,108.8 euro, caspofungin 68% and 49,067.7 euro, Amphotericin B Lipid Complex (ABLC) 58% and 30,375.2 euro, and Amphotericin B Liposome (AB-L) 50% and 38,234.5 euro. The first tree designed shows voriconazole as the dominant option, although there are few case studies. The second tree selects ABLC in comparison to AB-L and caspofungin, with an average CE of 52,371 euro, the nearest figure to the established availability to pay (50,000 euro). The sensitivity analysis evaluates the most influential parameters. The variation in the cost of purchasing do not modify the sense of the analysis, and the modification of 25% in other costs for caspofungin reverses the ratio, making this the most cost-effective option. The ICE indicates that using voriconazole instead of caspofungin saves 144,794 euro. With regard to caspofungin, ABLC increases the cost by 186,925 euro, a deceptive figure influenced by a level of effectiveness that is not very different; and AB-L increases the cost by 60,184 euro.

CONCLUSIONS

The analysis provides relevant information from the perspective of clinical practice in spite of the limitations of the unconsidered costs (nephrotoxicity). This type of analysis contributes to rationalising the use of antifungal agents in the hospital setting and in high-risk patients such as oncohaematological ones.

A carga das neoplasias no Brasil: mortalidade e morbidade hospitalar entre 2002-2004

OBJECTIVE

To describe mortality and the hospital morbidity by neoplasias in Brazil and regions according to gender.

METHODS

Data of deaths were obtained from the Mortality Information System and of hospital morbidity from the Hospital Information System. Deaths were categorized according to primary tumor sites, selected in accordance with the tenth revision of the International Classification of Diseases. The population data were drawn from the inter census estimates of the IBGE (Brazilian Institute of Geography and Statistics). The period of analysis was the triennial 2002-2004, with the most recent mortality data in Brazil. The average of this period was calculated to ensure greater stability of the rates.

RESULTS

Between 2002 and 2004, 405,415 deaths from neoplasias occurred in Brazil. The highest rates of mortality were identified in the South and South-East regions. For men, cancer of the trachea, bronchi and lungs were the malignant neoplasias with the highest mortality rate while for women breast cancer was highest. Breast cancer and cancer of the uterine cervix are those requiring the largest number of in-hospital admissions. In internments, leukemia presented the highest average cost and total cost.

CONCLUSION

The burden of neoplasms is extremely high in Brazil and public policies focused on the population must be given priority for an effective control of mortality and morbidity.

Economic evaluations of leukemia: A review of the literature

Objectives:Leukemia, together with lymphoma and multiple myeloma, are hematological malignancies, malignancies of the blood-forming organs. There are four major types of leukemia: acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and chronic lymphocytic leukemia (CLL). There is a growing amount of literature of the health economic aspects of leukemia. However, no comprehensive review is yet performed on the health economic evidence for the disease. Hence, our aim was to review and analyze the existing literature on economic evaluations of the different types of leukemia.

Methods:A systematic literature search used electronic databases to identify published cost analyses and economic evaluations of leukemia treatments. After reviewing all identified studies, sixty studies were considered relevant for the purpose of the review.

Results:The identified studies were published after 1990, with a few exceptions. Many of the identified economic evaluations in leukemia, particularly for ALL and AML, may be defined as cost-minimization analyses, where only the costs of different treatment strategies are compared. In CML, a new treatment, imatinib, was introduced in 2001 and several cost-effectiveness analyses have since then been conducted comparing imatinib with previous first line treatments.

Conclusions:This review indicates that there is a shortage of cost-effectiveness information in leukemia. The introduction of new therapies will stress the need for new economic evaluations in this group of diseases. More information about the total costs, that is, including indirect costs, and quality of life effects would be valuable in future evaluations in leukemia.

An approach to the management of leukemia in the developing world

Management of leukemia is expensive. In the developing world where there are significant resource constraints, how does the physician manage leukemia? Government health budgets need to put their money into areas where a small investment is likely to benefit a large proportion of its people and these would include immunization, sanitation, family planning and treatment of communicable diseases and the cost of expensive treatments would have to be borne by the patient and family. However, in many of the emerging economies in the developing world, society is three-tiered in terms of resources with a small proportion being able to afford the best treatment, the middle class with the ability to meet a significant proportion of the healthcare costs on their own and the poor who depend wholly on what the Government health budget can afford. Providing an accurate diagnosis is possible even with limited resources and this must be made available to all. Sometimes a precise diagnosis even at the molecular level is more important in the developing world so that resources are not wasted on inappropriate treatments. Choosing a protocol for management based on resources available for the individual patient would appear ethically unacceptable, but is probably the only solution when wealth is unevenly distributed in society. This paper illustrates an approach to the management of leukemia in the developing world that has evolved with experience over two decades in a tertiary referral hospital in India.

Childhood Leukemia and Socioeconomic Status in Canada

BACKGROUND

Leukemia is one of the most common potentially fatal illnesses in children, and its causes are not well understood. Although socioeconomic status (SES) has been related to leukemia in some studies, this apparent association may be attributable to ascertainment or participation bias. This study was undertaken to determine whether there is a difference in incidence of childhood leukemia for different levels of SES, as measured by neighborhood income, in an unselected population case group.

METHODS

All cases of childhood leukemia diagnosed in the years 1985-2001 were identified from population-based cancer registries in Canada. Postal codes for the place of residence at diagnosis were used to ascertain the census neighborhoods for cases. We constructed neighborhood-based income quintiles from census population data, and stratified the population at risk by sex and 5-year age groupings. Age-standardized incidence rates and 95% confidence intervals (CIs) were calculated. We used Poisson regression to compare incidence rate ratios (RRs) across income quintiles.

RESULTS

A slightly lower relative risk of childhood leukemia was observed in the poorest quintile compared with the richest (RR = 0.87; 95% CI = 0.80-0.95). The lower risk in the poorest quintile was restricted to acute lymphoid leukemia (0.86; 0.78-0.95) and was strengthened slightly by restriction to urban areas (0.83; 0.74-0.93).

CONCLUSIONS

This analysis suggests that high SES is a true risk factor for childhood leukemia and that inconsistent results from other studies may be related to differences in case ascertainment or study participation.

Cost effectiveness of myeloid growth factors in cancer chemotherapy

Healthcare costs continue to rise and hospitalization represents the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications, including febrile neutropenia (FN), remain the major dose-limiting toxicity of systemic cancer chemotherapy. Although under-reported, FN often occurs early in the course of chemotherapy and contributes substantially to the morbidity, mortality, and cost of treatment. The risk of FN and its complications are associated with treatment intensity, age, and various comorbidities. Myeloid growth factors (MGFs) have been used effectively in a variety of clinical settings to prevent or treat FN and assist patients receiving dose-intensive chemotherapy with or without stem cell support. A meta-analysis of the available randomized controlled trials has confirmed the efficacy of prophylactic MGFs. The cost of these agents, along with their large-scale clinical use, has prompted several economic investigations. Economic models based on measures of resource use derived from randomized controlled trials have provided estimates of expected treatment costs, along with FN risk threshold estimates for the cost-saving use of prophylactic MGF. Recent studies have demonstrated the potential value of targeting MGFs toward patients at greatest risk based on accurate and valid predictive models. Although an emerging role has become apparent for MGFs in managing adult leukemia and supporting high-dose therapy with stem cell transplantation in adults, their value in the support of children in these settings remains unclear. Continuing clinical and economic evaluation, along with an updating of clinical practice guidelines because of rapid technologic and clinical advances, is encouraged.

[Out-of- pocket expenditures during hospitalization of young leukemia patients with state medical insurance in two Mexican hospitals]

OBJECTIVE

To estimate out-of-pocket expenditures for health care during the first hospitalization of children treated for leukemia in two hospitals of the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social-IMSS-).

MATERIAL AND METHODS

A cross-sectional study was conducted in Mexico City and Leon, Guanajato, Mexico in 1997. The study population consisted of the parents of 51 children under 15 years of age diagnosed with leukemia, who were hospitalized for the first time in two IMSS hospitals. A questionnaire was applied to participants to obtain direct and indirect expenditures during that period. Consumer price indexes (1997-2002) were used to estimate expenditure prices for 2002. Average expenditures and catastrophic expenditures were estimated. Factors associated with expenditures were analyzed using a linear regression model in which the dependent variable was the total household expenditures during hospitalization.

RESULTS

The average household cost per hospitalization was 7,318 pesos, 86% of which corresponded to medical care and 14% to indirect costs. Catastrophic expenditures occurred in 14% of households. In 47% of household expenditures exceeded 100% of the total household income during the hospitalization period. Expenditures during hospitalization were associated with place of residence, income level, and type of medical insurance.

CONCLUSIONS

Being an IMSS policyholder decreased out-of-pocket expenditures, but not complementary expenditures, which may still be unaffordable for a large segment of the population. For more than a half of the households studied, continuity of care was compromised, as expenditures during the first hospitalization entailed using up savings, going into debt, and/or selling household property.

Impact of infection by vancomycin-resistant Enterococcus on survival and resource utilization for patients with leukemia

We estimated the impact of vancomycin-resistant Enterococcus (VRE) infection on the outcomes of patients with leukemia in a case-control study. Compared with their matched controls (n = 45), cases (n = 23) had 22% greater total charges and shorter survival (P = .04). These findings substantiate the need for aggressive interventions to prevent VRE transmission.

New strategies for prophylactic platelet transfusion in patients with hematologic diseases

There is an increasing demand for platelet transfusions due to intensive chemotherapy and blood stem cell or bone marrow transplantation for the treatment of hematologic and oncologic diseases. There has been a long-lasting debate over whether the traditional threshold for prophylactic platelet transfusion of 20,000/microl is really necessary to prevent hemorrhagic complications. During the last 10 years several studies with more than 1,000 patients together have proven the safety of a platelet transfusion trigger of 10,000/microl or even lower when patients are clinically stable without active bleeding. This experience has been mostly gathered in patients with acute leukemia. But this stringent platelet transfusion policy can be used also after blood stem cell and bone marrow transplantation. In stable patients with aplastic anemia and myelodysplasia, prophylactic transfusions should be replaced in most patients by a therapeutic transfusion strategy. Such restrictive platelet transfusion strategies decrease the risk of infectious disease transmission, immunization, and febrile transfusion reactions. Besides reduced hospital visits and a shorter hospital stay for the patients, the costs for platelet transfusions are lowered by 20%-30% compared with traditional transfusion strategies. The decision to administer platelet transfusions should incorporate individual clinical characteristics of the patients and not simply be a reflexive reaction to the platelet count. Further clinical studies are needed to answer the still open question of whether patients with acute leukemia should also be transfused therapeutically rather than prophylactically when they are in stable condition without signs of active bleeding.

Leukaemia at Queen Elizabeth Central Hospital in Blantyre, Malawi

OBJECTIVES

To determine the patterns of leukaemias seen in Malawians at Queen Elizabeth Central Hospital (QECH) and to compare the findings with those from elsewhere. An overview of the problems encountered in the management of leukaemia in developing countries especially those in sub-Saharan Africa are highlighted.

DESIGN

Retrospective descriptive analysis of consecutive leukaemia cases seen from January 1994 through December 1998.

RESULTS

Of the 95 leukaemia patients diagnosed during the study period, childhood (0-15 years) leukaemia occurred in 27 (28.4%) patients while adulthood (above 15 years) leukaemia accounted for 68 (71.6%) patients. The main leukaemia types were: acute lymphoblastic leukaemia (ALL) 14 (14.7%), acute myeloblastic leukaemia (AML) 25 (26.3%), chronic myeloid (granulocytic) leukaemia (CML) 32 (33.7%), chronic lymphocytic (lymphatic) leukaemia (CLL) 22 (23.2%) and hairy cell leukaemia (HCL) two (2.1%) patients. Most of the acute leukaemia (AL) cases occurred in the six to 15 year age bracket with a male preponderance. In ALL, lymphadenopathy was the commonest presenting feature followed by pallor (92.9%) while in the AML group, pallor occurred in 80% of cases. Abdominal swelling (87.5%) due to splenomegaly (81.3%) were the main clinical features in the CML group whereas lymphadenopathy (63.6%) followed by splenomegaly (59.1%) were the dominant presenting features in CLL. Haematologically, although leucocytosis characterised both acute and chronic leukaemias, most cases of acute leukaemia presented with more severe anaemia (Hb < 7 g/dl) and marked thrombocytopenia (Platelet count < 50 x 10(9)/l) than the chronic leukaemias.

CONCLUSIONS AND RECOMMENDATIONS

The study shows that leukaemias are not rare in Malawi and cases which were diagnosed in this series probably only represent the tip of the iceberg. While there is need to increase diagnostic awareness among clinicians and laboratory staff, the severe chronic shortage of cytotoxic drugs and lack of supportive care facilities commonly encountered in developing countries should be realistically addressed through cost-sharing, cost recovery, adequate government subvention and donations from charitable organisations.

Asian Pacific cooperative study of allogeneic bone marrow transplantation

The first cooperative study of the Asian Pacific bone marrow transplantation group included 75 patients with early leukemia who received human leukocyte antigen-matched sibling bone marrow transplants and were randomized into granulocyte colony-stimulating factor and control groups. The selected patients were registered from 10 centers in six countries and areas within Asia (Beijing, Taipei, Hong Kong, Japan, Korea, and Malaysia). The incidence of grades II-IV acute graft-vs.-host disease was 22.2%, and the 2-year survival rate was 62.7%. The period of protective isolation (27.1-66.7 days), period of hospitalization (38.6-130.5 days), and medical costs for 4 months (US $10,300-US $80,803) varied considerably. Good cooperation, i.e., low rate of protocol violation or rapid and precise presentation of case reports, was obtained.

Retrospective survival analysis and cost-effectiveness evaluation of second allogeneic bone marrow transplantation in patients with acute leukemia. Gruppo Italiano Trapianto di Midollo Osseo

The therapeutic options for patients with acute leukemia who relapse after the initial transplant include second bone marrow transplantation (2BMT) and conventional chemotherapy (CC). In this work, we conducted an analysis of published survival data and we evaluated the cost-effectiveness of 2BMT in comparison with CC. We retrieved survival information on 167 patients treated with 2BMT and 299 patients treated with CC. Survival figures were derived from individual patient data and were compared between 2BMT and CC. The mean lifetime survival (MLS) was estimated for each of the two patient cohorts using standard techniques of survival-curve extrapolation. The cost data of patients given 2BMT or CC were estimated from published data. Our analysis of individual survival data showed that 2BMT improved survival at levels of statistical significance (survival gain = 19.6 months per patient). Using an incremental cost of $90000 per patient, the cost-effectiveness ratio of 2BMT in comparison with CC was calculated as $52215 discounted dollars per discounted life year gained. Our results indicate that, in patients with acute leukemia who relapse after their first transplant, 2BMT significantly prolongs survival in comparison with CC and seems to have an acceptable cost-effectiveness profile.

Pharmacoeconomic considerations in treating patients with acute leukaemia

Whereas individual cost-effectiveness analyses of new agents for acute leukaemia should be performed in target populations, any meaningful pharmacoeconomic evaluation of treatment options for this condition should include the many types of costs and outcomes in unselected, representative groups of patients. Both direct costs (e.g. costs for medication and hospitalisation) and indirect costs (e.g. lost productivity costs and reduced quality of life) are important parameters to assess, as are the costs of chronic adverse effects, research and development costs for new agents, and costs of procedure-related deaths. Complete remission, cure and survival are the 'success' response criteria for acute leukaemia treatments, in addition to prolonged life with acceptable quality of life for patients with incurable acute leukaemia. Death is 'failure', caused either by resistant disease (relapse and progressive disease) inspite of optimal chemotherapy or, sometimes, by insufficient treatment. All of these parameters should be taken into account when a pharmacoeconomic evaluation is performed (either for administrative or scientific purposes) in order to ensure a comprehensive and reliable background for the evaluation in question. Treatment of acute leukaemia is expensive with a total cost of about $US3000 per patient per day during the induction. Although 80% of children with acute leukaemia are cured, only less than 50% of adults are cured. Thus, a great cost is associated with death during treatment and only optimal medical treatment with full-scale combination chemotherapy and full supportive treatment can keep the number of deaths to a minimum.

Cost analysis of 2 empiric antibacterial regimens containing glycopeptides for the treatment of febrile neutropenia in patients with acute leukaemia

OBJECTIVE

Patients with cancer-associated neutropenia are at high risk of developing severe infections which can be fatal if treatment is not promptly administered. For this reason, fever is treated as soon as possible with broad spectrum antibacterial therapy. The objective of this study was to conduct a cost analysis in Italy comparing 2 empiric glycoprotein-containing antibacterial regimens for the treatment of febrile neutropenia in patients with acute leukaemia.

DESIGN AND SETTING

A retrospective cost analysis was conducted, using the records of 527 febrile neutropenic patients with acute leukaemia who participated in an 18-month multicentre (29 Italian haematological units) randomised trial during 1991. All patients received either of the following 2 empiric intravenous regimens, each containing 3 antibacterial agents: ceftazidime (2 g, 3 times daily) and amikacin (15 mg/kg/day, in 3 separate doses) plus teicoplanin (6 mg/kg, in a single dose) or vancomycin (30 mg/kg/day, in 2 separate doses). Economic analyses were carried out from a hospital perspective. Only the direct costs per patient, i.e. mean antibacterial treatment and management cost, mean overall treatment failure cost and mean cost of adverse effects, were included.

MAIN OUTCOME MEASURES AND RESULTS

No differences were found in the clinical response, defined as the improvement in the rate of fever or infection (if documented), between the 2 regimens. However, tolerability, defined as the incidence of adverse effects probably or definitely related to the assigned treatment, was reported to be better with the teicoplanin-rather than the vancomycin-containing regimen.

CONCLUSIONS

Thus retrospective cost analysis showed that despite the higher acquisition cost of teicoplanin relative to vancomycin, the lower incidence of adverse effects associated with teicoplanin and its ease of administration (single daily dose) resulted in equivalent overall treatment costs between teicoplanin- and vancomycin containing regimens.

High cost factors for leukaemia and lymphoma patients: a new analysis of costs within these diagnosis related groups

STUDY OBJECTIVE

To determine high cost factors to help managers and clinicians to analyse the reasons of adverse costs and provide indications for financial negotiation.

DESIGN

To locate high cost or long stay patients, the analysis was designed on the basis of a mixture of Weibull distributions. In this new model, the proportion of high cost patients was expressed according to the multinomial logistic regression, permitting the determination of high cost factors.

SETTING

The 1993 French reference database, constituted in the framework of the national study of DRG costs, conducted by the French Ministry of Health. The database of discharge abstracts recorded in 1993 in the Dijon public teaching hospital.

PARTICIPANTS

The analyses were based on 1352 abstracts from the French reference database and 368 from the Dijon database concerning patients, aged 18 and over, suffering from leukaemia and lymphoma.

MAIN RESULTS

High cost and long stay factors were the same: number of stays, death, transfer, acute leukaemia, neutropenia, septicaemia, high dose aplastic chemotherapy, central venous catheterisation, parenteral nutrition, protected or laminar airflow room, blood transfusion, and intravenous antibiotherapy.

CONCLUSIONS

Taking into account high cost predictive factors, as shown in the case of leukaemia and lymphoma patients, would help to reduce the adverse effects of a prospective payment system.

Safety and cost-effectiveness of outpatient total body irradiation in pediatric patients undergoing stem cell transplantation

PURPOSE

To determine the feasibility, safety, and cost of delivering total body irradiation (TBI) in an outpatient setting.

PATIENTS AND METHODS

The records of 33 pediatric patients with hematopoietic malignancies undergoing TBI in preparation for bone marrow transplantation (BMT) at the Children's Medical Center of Dallas between February 1992 and June 1997 were retrospectively reviewed. Seventeen children received TBI in an outpatient setting, including 7 patients younger than 8 years of age. All patients had a good performance status (Karnofsky index > 90%) and lived or were housed within a 50-mile radius of the hospital. Patients received 1200 cGy or 1350 cGy in 8 or 9 fractions twice daily over 4 to 5 days and were admitted for high-dose chemotherapy after the last TBI fraction. Mean age was 9 years (range 13 months to 16 years). Close contact was maintained with the BMT staff during outpatient TBI.

RESULTS

Eleven patients (65%) received oral ondansetron for nausea and vomiting, 6 received promethazine and ondansetron, and 3 required dexamethasone. Only 2 of the 17 children (12%) required admission during TBI for persistent vomiting and poor oral intake. Two other children (12%) required outpatient administration of intravenous fluids. The other 13 patients (76%) tolerated the outpatient TBI regimen well. Taking into account hospitalization and ambulance transport charges, outpatient TBI represented a savings of approximately $3250 per patient compared with inpatient TBI.

CONCLUSIONS

Fractionated TBI delivered in an outpatient setting to selected children of all ages is a safe and cost-effective practice.

[Modelling of length of stay and costs in 2 homogeneous groups of hematological and pneumological patients: clinical characterization of patients with long-stay and high costs]

After the implementation of the Medicare Prospective Payment System (PPS) in the USA, many European countries like France have introduced DRGs to curb hospital overspending. However, there has been some reluctance from hospital actors, especially because of the heterogeneous nature of DRG's. To analyse this situation, we propose a method based on distribution modelization of length of stays and costs within DRGs. For each DRG, the model is based on a mixture of Poisson and Weibull distributions identified as subgroups. The subgroups are characterized by their means and their proportions which are estimated by maximization of data likelihood. For a particular DRG, the proportion of long stay or high-cost patients can be explained by the introduction of clinical variables in the model. First the model was applied to the DRG "leukemia and lymphoma" (HCFA V.3), using 133 discharge abstract files from the Dijon public teaching hospital which were classified into this DRG in 1993. Among the studies parameters only acute leukemia, neutropenia < 500 PNN/mm3, high dose aplastic chemotherapy, central venous catheterization, parenteral nutrition, use of protected or laminar air flow room, septicemia, large spectrum intravenous antibiotherapy, and blood transfusion had a significant influence on the distribution of the patients in the long stay or costly subgroup. Second, for DRG "chronic bronchopneumopathies" (n = 220) the significant parameters were mechanical ventilation, antibiotherapy, post hospitalization medicalized care.

Oncology case management linking structure and process with clinical and financial outcomes

Case management programs have emerged in a variety of models. Current literature about the structure and process of case management programs has not always clearly described linkages with outcomes. Therefore, the purpose of this article is to describe a case management program, apply the model with oncology patients, and then to clarify the structure and process that the authors believe are correlated strongly with both clinical and financial indicators of quality. Planning for the case management program involved interdisciplinary inpatient staff and personnel from the ambulatory oncology clinics. After program implementation, data on patients with a diagnosis of chemotherapy without acute leukemia (DRG 410) were collected throughout 1 year (March 1995-February 1996). Results indicated a reduction in length of stay and side effects of chemotherapy linked to the improvement in process. The primary recommendation to nurse managers who are considering a case management program is to carefully decide on a structure and process that can be formalized before the program is implemented.

Infection in immunocompromised patients with malignant blood disorders in a district general hospital

The pattern and management of infection in immunocompromised patients over a period of 3 years in a district general hospital has been studied. A total of 222 positive cultures was obtained in 607 episodes of suspected infection all involving patients with malignant blood disorders. Febrile episodes requiring intravenous antibiotics occurred in 248 instances involving 107 patients. The pattern of organisms cultured and the responses to various antibiotic regimes are reported. The costs of antibiotic therapy are considered in the light of the overall response. Of the patients studied, 54 died, infection having a likely causative or contributory part in 21 of them (less than 10% of infective episodes). We conclude that the infective complications of these disorders, particularly in older patients, can be efficiently managed in a district general hospital when full supportive facilities are available.

Cost-effective use of autologous bone marrow transplantation: few answers, many questions, and suggestions for future assessments

High dose chemotherapy with the support of autologous bone marrow transplantation (ABMT) or peripheral blood progenitor cells (PBPC) has been increasingly used in a variety of haematological and epithelial cancers over the last decade. The rationale of this approach is to overcome the chemotherapy resistance of tumour cells by increasing the dose of cytotoxic drugs. However, the clinical benefit of dose-intensification has been difficult to prove. Almost all studies of ABMT have been done without randomised comparisons with the standard form of therapy for a specific condition. From an economic perspective, the cost of ABMT has been steadily decreasing with improvements in supportive care primarily. Still, current ABMT cost estimates range from $US70 000 to $US150 000 for each uncomplicated procedure. Despite the lack of compelling evidence in support of dose-intensification, ABMT has become a default standard of care after relapse for many patients with lymphoma or leukaemia. We used a decision analysis model to estimate the cost effectiveness of the timing of ABMT in relapsed Hodgkin's disease. The model illustrates the difficulty of using available clinical trial data when follow-up of promising early reports is not available. The model showed that in most situations the optimal strategy is ABMT in second relapse despite growing consensus that immediate ABMT is the treatment of choice. ABMT for women with high-risk or early metastatic breast cancer is one of the most controversial areas in clinical oncology. In the US, several ongoing major randomised trials are addressing the role of ABMT in breast cancer. Using a Markov process we found that ABMT is the preferred strategy under almost all assumptions. The size of the benefit and cost effectiveness of ABMT varied markedly depending on the assumptions made. The model does not supplant the need for randomised trials that concurrently measure efficacy, quality of life, and resource utilisation. However, such analyses point out the critical areas where costs could be cut substantially without effecting efficacy. Drawing conclusions about the cost effectiveness of ABMT for all conditions is hampered by the lack of randomised comparisons of efficacy. Concurrent economic appraisals of selected phase III comparative trials should be considered since the supportive care costs associated with ABMT appear to be stabilising. However, the most important point is that randomised trials are the only mechanism for estimating the therapeutic effect of high dose chemotherapy.

[Chemotherapy and bone marrow transplantation for acute leukemia]

Chemotherapy (CT) and bone marrow transplantation (BMT) have made remarkable progress in recent years. The comparison of both treatment modalities has become an important issue. The methods of comparison, however, should be varied according to the subjects and purposes of comparison. For a general comparison of both CT and BMT, the registry data of both treatments, seems adequate. For the comparison of a CT regimen with a BMT regimen, a randomized control study seems most adequate. in order to get an overview. For the selection of treatment for a certain patient, comparison of CT and BMT data from the center in which the patient will be treated seems most important. As the latter comparison we have studied the rate of early death, the rate of long-term survival and medical costs in leukemia patients diagnosed and followed for 5 years, at the Center for Adult Diseases Osaka. The early death rate was similar in both groups of patients. The long-term survival rate was 78% in BMT and 28% in CT patients. Cost effectiveness was also favorable in BMT patients. Data on CT and BMT in each center should be prepared for the selection of treatment for patients at each center.

[High-cost therapy. Ethical principles of allocation of scarce resources]

This article raises some ethical problems concerning high-cost therapy for malignant haematological diseases. The problem of setting priorities is discussed within the framework of utilitarianism, right-based theories and the contractarian theory of John Rawls. It is argued that utilitarianism can provide precise answers, based on the principle of allocative efficiency. However, this is not the only objective of a public health care system. The right-based approach is discussed, but sufficiently precise definitions seem hard to formulate. The contractarian approach is regarded as interesting, since it tries to address the question of trade-offs between objectives of allocative efficiency and distributive fairness.

[Cost of leukemia treatment]

Medical cost has increasingly become an important problem in the medical practice. As one of the useful fields of computer in the hospital, we have analyzed the costs of chemotherapy and bone marrow transplantation in patients with leukemia who were diagnosed between 1983 and 1986 and followed up till Dec. 1989. For CML the difference in the cost was 5 million yen and a survival rate was 75% and was higher in BMT than in chemotherapy. For Acute leukemia the difference of the costs was 8 million yen and survival rates were 89% and 30%. These data may show that BMT is a very effective and economical treatment for leukemia. In this study we have analyzed only the direct medical cost paid by the governmental insurance, however there seems necessary many other costs which are not covered by the insurance such as the cost for the family members, the cost for cryopreservation of cells and sterilization tentatively covered by the hospital or the cost of blood or marrow bank which are covered or should be covered by the government. Evaluation of the treatment outcome by the parameters such as length and quality of life, productivity of the patient, prevention of the loss of social investment including education on the patient, seemed also necessary for justification of the medical cost.

Costs of bone marrow transplants using unrelated donors

Bone marrow transplantation is an expensive treatment, rationed primarily by the availability of donors. Recruiting potential unrelated bone marrow donors to a register would add not only to the cost, but also to the volume, of transplantation. Proposals to establish such registries have thus been subject to rigorous financial scrutiny. In Australia, 3 alternative estimates suggest that approximately 200 patients, otherwise suitable for bone marrow transplantation, do not receive transplants because they have no suitable related donor. The population of Australia is approximately 16 million. The alternatives for these patients are thus chemotherapy or unrelated bone marrow transplantation. The costs of chemotherapy and transplantation have been directly compared in 1 trial of treatment for acute nonlymphoblastic leukaemia. The cost per year of life saved was approximately the same for the 2 treatments, with better patient survival from transplantation. The estimated cost difference in both the United States and Australia, between the policy extremes of no patients transplanted, and all transplanted, was between 1.3-2.4% of the total costs of managing these patients. The cost of searching existing registers for unrelated donors for Australian patients, averages A$24,000-28,000 to the point of a successful donor procedure. The cost of establishing and maintaining an Australian Register of a size predicted to find donors for half of the potential recipients, has been estimated at A$ 10,000 per donor procedure. The decision to proceed with unrelated bone marrow transplantation commits resources that are currently used by the alternative therapies. It is thus important to monitor both the costs and effects of the new approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylaxis, cost and effectiveness of therapy of infections caused by gram-positive organisms in neutropenic children

Gram-positive infections are being reported with increasing frequency in children with haematological malignancies. Staphylococcus epidermidis, once considered a non-pathogenic skin contaminant, is emerging as a major cause of severe infection. However, in infants Gram-negative septicaemias are more frequent than in older children. A teicoplanin and ceftriaxone combination was assessed for use as empirical therapy of febrile episodes in neutropenic children with acute leukaemias. Of 47 patients, fever was of unknown origin in 21, and documented in 26 with 28 strains isolated; 19 Gram-positive (all sensitive to teicoplanin) and nine Gram-negative. Within 48 h, 41 patients became afebrile and the pathogen was cleared if initially present. Mean duration of treatment was 16 days. Febrile relapse occurred in 24 patients with eight documented superinfections. The need for prophylactic cover against Gram-positive organisms at the time of intravenous catheter insertion is questionable. We studied 71 patients who were randomly allocated to receive teicoplanin when the central line was inserted and if febrile, with added ceftriaxone and amikacin (arm A) or the tri-antibiotic regimen when fever occurred (arm B). In arm A a febrile episode occurred after ten days in 34/35 patients with only one Gram-positive organism isolated. In arm B a febrile episode occurred in all 36 patients after five days and ten Gram-positive strains were isolated. Those patients in arm A also received fluconazole. Amphotericin B was administered in cases of failure or relapses in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effectiveness analysis of paramedic emergency medical services in the treatment of prehospital cardiopulmonary arrest

STUDY OBJECTIVES

1) Identification of marginal costs associated with prehospital resuscitation of cardiopulmonary arrest; 2) Determination of cost effectiveness for such resuscitation; and 3) Comparison of cost effectiveness of paramedic care with selected other medical interventions.

DESIGN

Retrospective review of 190 cases of out-of-hospital cardiac arrest.

SETTING

City limits of a midsized southwestern city. The events studied took place outside of medical facilities.

TYPE OF PARTICIPANTS

Victims of out-of-hospital cardiac arrest for whom the EMS system was activated by a 911 telephone request for emergency medical assistance.

MEASUREMENTS AND MAIN RESULTS

The cost, including training, personnel, equipment, and response time maintenance, per year of life saved was found to be $8,886.00 for paramedic care. This result was compared with published cost-effectiveness figures for heart transplantation, liver transplantation, bone marrow transplantation, and chemotherapy for acute leukemia. Paramedic care was more cost effective, as measured by cost per year of life saved, than organ transplantation and chemotherapy for acute leukemia.

CONCLUSION

Out-of-hospital treatment by paramedics of cardiopulmonary arrest is more cost effective than heart, liver, bone marrow transplantation, or curative chemotherapy for acute leukemia.

Cost-benefit analysis of a plateletapheresis program

We determined costs and benefits of a community donor plateletapheresis program (CDPP) designed to provide HLA-matched platelet transfusions for patients who were refractory to random-donor platelets (RDPs). Costs of establishing and maintaining the CDPP were $127,520 for the first year (1982). Benefits were expressed as cost savings attributed to the CDPP. After the program began, the use of RDP in the community was 17,458 units less than projected. Estimates of net cost savings during the first year ranged from $177,570 to $272,253 (1982 dollars; cost-to-benefit ratios were 1:1.39 to 1:2.14.) In a matched cohort study of marrow transplant patients, CDPP platelet transfusions were as effective as those from family donors while total platelet and red cell use was unchanged. In patients with acute leukemia treated with chemotherapy, significant reduction in both platelet and red cell use was seen after institution of CDPP support. We conclude that the CDPP is a cost-effective approach to platelet support.

The use of Grade of Membership analysis to evaluate and modify diagnosis-related groups

A classification methodology is presented that can be used to evaluate the heterogeneity of reimbursement categories and service groups in multivariate terms. This methodology, called Grade of Membership analysis, has several properties that are particularly important in such assessments. First, simultaneously with the determination of the multivariate profile of characteristics that describe a group, the methodology determines the degree to which each case is described by that profile, which means that the model can explicitly represent the heterogeneity of individual cases in any derived classification scheme. Second, the estimates of the model's parameters are produced by maximum likelihood procedures; hence, the classification and group descriptions generated by the model can be statistically evaluated. Third, because of the way the group profiles are constructed, the results of the analysis will be reasonably robust to the selection of new samples. The analysis is illustrated using data on hospital discharges for the state of Maryland in 1981. The purpose of the analysis is to examine the association between the patterns of clinical and service attributes identified by the procedures with DRG category assignments.