The health and cost effects of substituting home care for inpatient acute care: a review of the evidence

BACKGROUND: There is much interest in reducing hospital stays by providing some health care services in patients'' homes. The authors review the evidence regarding the effects of this acute care at home (acute home care) on the health of patients and caregivers and on the social costs (public and private costs) of managing the patients'' health conditions. METHODS: MEDLINE and HEALTHSTAR databases were searched for articles using the key term "home care." Bibliographies of articles read were checked for additional references. Fourteen studies met the selection criteria (publication between 1975 and early 1998, evaluation of an acute home care program for adults, and use of a control group to evaluate the program). Of the 14, only 4 also satisfied 6 internal validity criteria (patients were eligible for home care, comparable patients in home care group and hospital care group, adequate patient sample size, appropriate analytical techniques, appropriate health measures and appropriate costing methods). RESULTS: The 4 studies with internal validity evaluated home care for 5 specific health conditions (hip fracture, hip replacement, chronic obstructive pulmonary disease [COPD], hysterectomy and knee replacement); 2 of the studies also evaluated home care for various medical and surgical conditions combined. Compared with hospital care, home care had no notable effects on patients'' or caregivers'' health. Social costs were not reported for hip fracture. They were unaffected for hip and knee replacement, and higher for COPD and hysterectomy; in the 2 studies of various conditions combined, social costs were higher in one and lower in the other. Effects on health system costs were mixed, with overall cost savings for hip fracture and higher costs for hip and knee replacement. INTERPRETATION: The limited existing evidence indicates that, compared with hospital care, acute home care produces no notable difference in health outcomes. The effects on social and health system costs appear to vary with condition. More well-designed evaluations are needed to determine the appropriate use of acute home care.     

Economic Impact of Dementia by Disease Severity: Exploring the Relationship between Stage of Dementia and Cost of Care in Taiwan

Objective

Given the shortage of cost-of-illness studies in dementia outside of the Western population, the current study estimated the annual cost of dementia in Taiwan and assessed whether different categories of care costs vary by severity using multiple disease-severity measures.

Methods

This study included 231 dementia patient–caregiver dyads in a dementia clinic at a national university hospital in southern Taiwan. Three disease measures including cognitive, functional, and behavioral disturbances were obtained from patients based on medical history. A societal perspective was used to estimate the total costs of dementia according to three cost sub-categories. The association between dementia severity and cost of care was examined through bivariate and multivariate analyses.

Results

Total costs of care for moderate dementia patient were 1.4 times the costs for mild dementia and doubled from mild to severe dementia among our community-dwelling dementia sample. Multivariate analysis indicated that functional declines had a greater impact on all cost outcomes as compared to behavioral disturbance, which showed no impact on any costs. Informal care costs accounted for the greatest share in total cost of care for both mild (42%) and severe (43%) dementia patients.

Conclusions

Since the total costs of dementia increased with severity, providing care to delay disease progression, with a focus on maintaining patient physical function, may reduce the overall cost of dementia. The greater contribution of informal care to total costs as opposed to social care also suggests a need for more publicly-funded long-term care services to assist family caregivers of dementia patients in Taiwan.     

The economic costs of progressive supranuclear palsy and multiple system atrophy in France, Germany and the United Kingdom

Progressive supranuclear palsy (PSP) and multiple system atrophy (MSA) are progressive disabling neurological conditions usually fatal within 10 years of onset. Little is known about the economic costs of these conditions. This paper reports service use and costs from France, Germany and the UK and identifies patient characteristics that are associated with cost. 767 patients were recruited, and 760 included in the study, from 44 centres as part of the NNIPPS trial. Service use during the previous six months was measured at entry to the study and costs calculated. Mean six-month costs were calculated for 742 patients. Data on patient sociodemographic and clinical characteristics were recorded and used in regression models to identify predictors of service costs and unpaid care costs (i.e., care from family and friends). The mean six-month service costs of PSP were €24,491 in France, €30,643 in Germany and €25,655 in the UK. The costs for MSA were €28,924, €25,645 and €19,103 respectively. Unpaid care accounted for 68-76%. Formal and unpaid costs were significantly higher the more severe the illness, as indicated by the Parkinson's Plus Symptom scale. There was a significant inverse relationship between service and unpaid care costs.     

Waist circumference and body mass index as predictors of health care costs

BACKGROUND: In the present study we analyze the relationship between body mass index (BMI) and waist circumference (WC) and future health care costs. On the basis of the relation between these anthropometric measures and mortality, we hypothesized that for all levels of BMI increased WC implies added future health care costs (Hypothesis 1) and for given levels of WC increased BMI entails reduced future health care costs (Hypothesis 2). We furthermore assessed whether a combination of the two measures predicts health care costs better than either individual measure. RESEARCH METHODOLOGY/PRINCIPAL FINDINGS: Data were obtained from the Danish prospective cohort study Diet, Cancer and Health. The population includes 15,334 men and 16,506 women 50 to 64 years old recruited in 1996 to 1997. The relationship between future health care costs and BMI and WC in combination was analyzed by use of categorized and continuous analyses. The analysis confirms Hypothesis 1, reflecting that an increased level of abdominal fat for a given BMI gives higher health care costs. Hypothesis 2, that BMI had a protective effect for a given WC, was only confirmed in the continuous analysis and for a subgroup of women (BMI<30 kg/m(2) and WC <88 cm). The relative magnitude of the estimates supports that the regressions including WC as an explanatory factor provide the best fit to the data. CONCLUSION: The study showed that WC for given levels of BMI predicts increased health costs, whereas BMI for given WC did not predict health costs except for a lower cost in non-obese women with normal WC. Combining WC and BMI does not give a better prediction of costs than WC alone.     

Costs of paediatric diabetes care in Germany: current situation and comparison with the year 2000

Diabet. Med. 29, 1327-1334 (2012) ABSTRACT: Aims To estimate direct costs of paediatric Type 1 diabetes care and associated factors in Germany for the year 2007 and to compare results with the costs for the year 2000. Methods Our study includes clinical data and charges for any diabetes-related health care service of 14?185 continually treated subjects with paediatric diabetes aged 相似文献   

Costs and coverage. Pressures toward health care reform.

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.     

Energetics of parental care in six syntopic centrarchid fishes

We studied parental behavior in six syntopically breeding species of centrarchid fishes to determine whether energetic costs could contribute to our understanding of the diversity of parental care. We used a combination of underwater videography, radio telemetry and direct observation to examine how the cost of parental care varied with both its duration and intensity. Duration of parental care, activity patterns, and energetic costs varied widely among species. Overall, the duration of care increased with parental size between species. When energetic costs were adjusted for species-specific differences in the duration of parental care, the cost of parental care also increased with mean size of the species. Species with extended parental care exhibited stage-specific patterns of activity and energy expenditure consistent with parental investment theory, whereas fish with short duration parental care tended to maintain high levels of activity throughout the entire period of parental care. The only apparent exception (a species with brief parental care but stage-specific behavior) was a species with multiple breeding bouts, and thus effectively having protracted parental care. These data suggest that some species with short duration parental care can afford not to adjust parental investment over stages of offspring development. Using our empirical data on parental care duration and costs, we reevaluated the relationship between egg size and quality of parental care. Variation in egg size explained almost all of the observed variation in total energetic cost of parental care, and to a lesser degree, duration—the larger the eggs, the more costly the parental care. This research highlights the value of incorporating energetic information into the study of parental care behavior and testing of ecological theory.     

Predictors of Costs in Dementia in a Longitudinal Perspective

Objective

To analyse predictors of costs in dementia from a societal perspective in a longitudinal setting.

Method

Healthcare resource use and costs were assessed retrospectively using a questionnaire in four waves at 6-month intervals in a sample of dementia patients (N = 175). Sociodemographic data, dementia severity and comorbidity at baseline, cognitive impairment and impairment in basic and instrumental activities of daily living were also recorded. Linear mixed regression models with random intercepts for individuals were used to analyse predictors of total and sector-specific costs.

Results

Impairment in activities of daily living significantly predicted total costs in dementia patients, with associations between basic activities of daily living and formal care costs on the one and instrumental activities of daily living and informal care costs on the other hand. Nursing home residence was associated with lower total costs than residence in the community. There was no effect of cognition on total or sector-specific costs.

Conclusion

Cognitive deficits in dementia are associated with costs only via their effect on the patients'' capacity for activities of daily living. Transition into a nursing home may reduce total costs from a societal perspective, owing to the fact that a high amount of informal care required by severely demented patients prior to transition into a nursing home may cause higher costs than inpatient nursing care.     

The evolution of parental care in stochastic environments

Parental care is of fundamental importance to understanding reproductive strategies and allocation decisions. Here, we explore how parental care strategies evolve in variable environments. Using a set of life-history trait trade-offs, we explore the relative costs and benefits of parental care in stochastic environments. Specifically, we consider the cases in which environmental variability results in varying adult death rates, egg death rates, reproductive rate and carrying capacity. Using a measure of fitness appropriate for stochastic environments, we find that parental care has the potential to evolve over a wide range of life-history characteristics when the environment is variable. A variable environment that affects adult or egg death rates can either increase or decrease the fitness of care relative to that in a constant environment, depending on the specific costs of care. Variability that affects carrying capacity or adult reproductive rate has negligible effects on the fitness associated with care. Increasing parental care across different life-history stages can increase fitness gains in variable environments. Costly investment in care is expected to affect the overall fitness benefits, the fitness optimum and rate of evolution of parental care. In general, we find that environmental variability, the life-history traits affected by such variability and the specific costs of care interact to determine whether care will be favoured in a variable environment and what levels of care will be selected.     

The effects of lactation and infant care on adult energy budgets in wild siamangs (Symphalangus syndactylus)

In mammals with biparental care of offspring, males and females may bear substantial energetic costs of reproduction. Adult strategies to reduce energetic stress include changes in activity patterns, reduced basal metabolic rates, and storage of energy prior to a reproductive attempt. I quantified patterns of behavior in five groups of wild siamangs (Symphalangus syndactylus) to detect periods of high energetic investment by adults and to examine the relationships between infant care and adult activity patterns. For females, the estimated costs of lactation peaked at around infant age 4–6 months and were low by infant age 1 year, whereas the estimated costs of infant‐carrying peaked between ages 7 and 12 months, and approached zero by age 16 months. There was a transition from primarily female to male care in the second year of life in some groups. Females spent significantly less time feeding during lactation than during the later stages of infant care, suggesting that female siamangs do not use increased food intake to offset the costs of lactation. Female feeding time was highest between infant ages 16 and 21 months, a period of relatively low female investment in the current offspring that coincided with the period of highest male investment in infant care. This suggests that male care may reduce the costs of infant care for females in the later stages of a reproductive attempt. The female energy gain resulting from male care was likely invested in somatic maintenance and future reproduction, rather than the current offspring. Am J Phys Anthropol, 2009. © 2009 Wiley‐Liss, Inc.     

Cost Trend Analysis of Initial Cancer Treatment in Taiwan

Background

Despite the high cost of initial cancer care, that is, care in the first year after diagnosis, limited information is available for specific categories of cancer-related costs, especially costs for specific services. This study purposed to identify causes of change in cancer treatment costs over time and to perform trend analyses of the percentage of cancer patients who had received a specific treatment type and the mean cost of care for patients who had received that treatment.

Methodology/Principal Findings

The analysis of trends in initial treatment costs focused on cancer-related surgery, chemotherapy, radiation therapy, and treatments other than active treatments. For each cancer-specific trend, slopes were calculated for regression models with 95% confidence intervals. Analyses of patients diagnosed in 2007 showed that the National Health Insurance (NHI) system paid, on average, $10,780 for initial care of a gastric cancer patient and $10,681 for initial care of a lung cancer patient, which were inflation-adjusted increases of $6,234 and $5,522, respectively, over the 1996 care costs. During the same interval, the mean NHI payment for initial care for the five specific cancers increased significantly (p<0.05). Hospitalization costs comprised the largest portion of payments for all cancers. During 1996–2007, the use of chemotherapy and radiation therapy significantly increased in all cancer types (p<0.05). In 2007, NHI payments for initial care for these five cancers exceeded $12 billion, and gastric and lung cancers accounted for the largest share.

Conclusions/Significance

In addition to the growing number of NHI beneficiaries with cancer, treatment costs and the percentage of patients who undergo treatment are growing. Therefore, the NHI must accurately predict the economic burden of new chemotherapy agents and radiation therapies and may need to develop programs for stratifying patients according to their potential benefit from these expensive treatments.     

The Evolution of Male and Female Parental Care in Fishes

In this paper we propose an explanation for (a) the predominanceof male care in fishes, and (b) the phylogenies and transitionsthat occur among care states. We also provide a general evolutionarymodel for studying the conditions under which parental careevolves. Our conclusions are as follows: (i) Parental care hasonly one benefit, the increased survivorship of young. It may,however, have three costs: a "mating cost," an "adult survivorshipcost," and a "future fertility cost." (ii) On average, malesand females will derive the same benefit from care. They probablyalso pay the same adult survivorship cost. However, their matingcost and future fertility costs may differ, (iii) A mating costusually applies only to males. However, this cost may be reducedby male territoriality and, in some situations, be entirelyremoved. Under this condition, natural selection on presentreproductive success is equivalent for males and females, (iv)When fecundity accelerates with body size in females, whilemale mating success follows a linear relationship with bodysize, future fertility costs of parental care are greater forfemales than males. Although further tests are needed, a preliminaryanalysis suggests this often may be the case in fishes. Thus,the predominance of male parental care in fishes is not explainedby males deriving greater benefits from care, but by males payingsmaller future costs. Males thus accrue a greater net fitnessadvantage from parental care (see expressions [6] and [12]).(v) The evolution of biparental care from uniparental male caremay occur because male care selects for larger egg sizes andincreased embryo investment by females. This increases the benefitto the female of parental care, (vi) By contrast, uniparentalfemale care may originate from biparental care when males areselected to desert. This occurs when female care creates a matingcost to males. In some cases male desertion may "lock" femalesinto uniparental care. However, in many other cases femalesmay be selected to desert, giving rise to "no care." (vii) Theorigin of uniparental female care from no care is rare in externallyfertilizing fishes. This is because the benefits of care rarelyoutweigh a female's future fertility costs (expression [9]).For internally fertilizing species, however, the benefit ofcare is high whereas the cost is probably low. Most of thesespecies have evolved embryo retention, (viii) When parentalcare begins with male care and moves to biparental care, ouranalysis suggests that care evolution will include cyclicaldynamics. Parental care in some fishes may thus be seen as transitionaland changing through evolutionary time rather than as an evolutionarilystable state. In theory, "no care" may be a phylogeneticallyadvanced state.     

Disease Prevention: Saving Lives or Reducing Health Care Costs?

Background

Disease prevention has been claimed to reduce health care costs. However, preventing lethal diseases increases life expectancy and, thereby, indirectly increases the demand for health care. Previous studies have argued that on balance preventing diseases that reduce longevity increases health care costs while preventing non-fatal diseases could lead to health care savings. The objective of this research is to investigate if disease prevention could result in both increased longevity and lower lifetime health care costs.

Methods

Mortality rates for Netherlands in 2009 were used to construct cause-deleted life tables. Data originating from the Dutch Costs of Illness study was incorporated in order to estimate lifetime health care costs in the absence of selected disease categories. We took into account that for most diseases health care expenditures are concentrated in the last year of life.

Results

Elimination of diseases that reduce life expectancy considerably increase lifetime health care costs. Exemplary are neoplasms that, when eliminated would increase both life expectancy and lifetime health care spending with roughly 5% for men and women. Costs savings are incurred when prevention has only a small effect on longevity such as in the case of mental and behavioural disorders. Diseases of the circulatory system stand out as their elimination would increase life expectancy while reducing health care spending.

Conclusion

The stronger the negative impact of a disease on longevity, the higher health care costs would be after elimination. Successful treatment of fatal diseases leaves less room for longevity gains due to effective prevention but more room for health care savings.     

Increased Medical Costs in Elders With the Metabolic Syndrome are Most Evident With Hospitalization of Men

BackgroundLittle is known about health care costs associated with the metabolic syndrome (MetS).ObjectiveWe assessed annualized health care costs and health outcomes for both genders in different health care settings among representative Taiwanese elders.MethodsThe Nutrition and Health Survey in Taiwan (1999–2000) provided 1378 individuals aged 65 years or older with known MetS status. Nutrition and Health Survey in Taiwan files were linked to National Health Insurance records (1999–2006). Student t tests and multiple regression models were used to assess expenditures in total and in 6 services: inpatient, ambulatory care, dental care, traditional Chinese medicine, emergency care, and contracted pharmacy. The Cox model was used to assess gender effect on all-cause mortality and cardiovascular disease mortality, whereas logistic regression was used for that on cardiovascular disease hospitalization. The 5 MetS component costs were evaluated by multiple regressions.ResultsMetS affected 29% of men and 48% of women. After full adjustment, those with MetS had 1.30 (95% CI, 1.11–1.52), men had 1.43 (95% CI, 1.20–1.70), and women had 1.19 (95% CI, 0.93–1.52) times higher costs than those without MetS. Compared with no MetS, MetS costs were increased 2.94-fold for inpatient care (95% CI, 1.23–7.10) and 1.30-fold for ambulatory care for men (95% CI, 1.12–1.52), whereas ambulatory MetS costs were increased 1.28-fold for women (95% CI, 1.05–1.57). MetS was associated with higher risk of cardiovascular disease hospitalization in men (adjusted odds ratio, 1.76; 95% CI, 1.20–2.58) but not in women (adjusted odds ratio, 1.08; 95% CI, 0.67–1.75). Among those with MetS, all-cause and cardiovascular mortality were comparable between men and women. Of the MetS components, low HDL cholesterol had the greatest affect on costs, more so in men (2.23-fold) than women (1.58-fold).ConclusionsIn people with MetS, service costs were greater overall, significantly for men, but not women, and these increased costs were evident for men who experienced hospitalization, but not women. At the same time, cardiovascular and all-cause mortalities were not significantly different by gender in regard to MetS in Taiwanese elders.     

Moderate and Severe Obesity Have Large Differences in Health Care Costs

Objective: To analyze health care use and expenditures associated with varying degrees of obesity for a nationally representative sample of individuals 54 to 69 years old. Research Methods and Procedures: Data from the Health and Retirement Study, a nationwide biennial longitudinal survey of Americans in their 50s, were used to estimate multivariate regression models of the effect of weight class on health care use and costs. The main outcomes were total health care expenditures, the number of outpatient visits, the probability of any inpatient stay, and the number of inpatient days. Results: The results indicated that there were large differences in obesity‐related health care costs by degree of obesity. Overall, a BMI of 35 to 40 was associated with twice the increase in health care expenditures above normal weight (about a 50% increase) than a BMI of 30 to 35 (about a 25% increase); a BMI of over 40 doubled health care costs (～100% higher costs above those of normal weight). There was a difference by gender in how health care use and costs changed with obesity class. The primary effect of increasing weight class on health care use appeared to be through elevated use of outpatient health care services. Discussion: Obesity imposes an increasing burden on the health care system, and that burden grows disproportionately large for the most obese segment of the U.S. population. Because the prevalence of severe obesity is increasing much faster than that of moderate obesity, average estimates of obesity effects obscure real consequences for individuals, physician practices, hospitals, and health plans.     

Differences in Patterns of Reproductive Allocation between the Sexes in Nicrophorus orbicollis

Organisms are selected to maximize lifetime reproductive success by balancing the costs of current reproduction with costs to future survival and fecundity. Males and females typically face different reproductive costs, which makes comparisons of their reproductive strategies difficult. Burying beetles provide a unique system that allows us to compare the costs of reproduction between the sexes because males and females are capable of raising offspring together or alone and carcass preparation and offspring care represent the majority of reproductive costs for both sexes. Because both sexes perform the same functions of carcass preparation and offspring care, we predict that they would experience similar costs and have similar life history patterns. In this study we assess the cost of reproduction in male Nicrophorus orbicollis and compare to patterns observed in females. We compare the reproductive strategies of single males and females that provided pre- and post-hatching parental care. There is a cost to reproduction for both males and females, but the sexes respond to these costs differently. Females match brood size with carcass size, and thus maximize the lifetime number of offspring on a given size carcass. Males cull proportionately more offspring on all carcass sizes, and thus have a lower lifetime number of offspring compared to females. Females exhibit an adaptive reproductive strategy based on resource availability, but male reproductive strategies are not adaptive in relation to resource availability.     

Costs of parental care on hunting behaviour of Helobdella papillornata (Euhirudinea: Glossiphoniidae)

Helobdella papillornata, an Australian freshwater leech, feeds primarily on snails and has a high level of parental care involving brooding eggs and young, with direct feeding of young. Parental costs and offspring benefits from these behaviours are poorly understood. A potential cost of parental care may be a change in the time taken to hunt prey. To test this hypothesis, the hunting behaviour of adults without progeny, parents with eggs, and parents with young were compared. We found that parents brooding eggs had a significantly (P = 0.029) longer lag time to begin hunting than parents brooding young, and spent significantly (P = 0.018) less time actively hunting than non-brooding adults. These costs, which may represent lost potential for the parent’s future reproductive success, should be outweighed by the fitness benefits of improved growth and survival of offspring, if parental care is favoured by selection. The hunting costs of care in Helobdella and other benthic, dorsoventrally flattened leeches in the family Glossiphoniidae may be smaller than the costs of brood tending that would be imposed on other freshwater leeches, and this difference may help explain the restriction of care to a single clade of the Euhirudinea.     

The Costs of Preventing and Treating Chagas Disease in Colombia

Background

The objective of this study is to report the costs of Chagas disease in Colombia, in terms of vector disease control programmes and the costs of providing care to chronic Chagas disease patients with cardiomyopathy.

Methods

Data were collected from Colombia in 2004. A retrospective review of costs for vector control programmes carried out in rural areas included 3,084 houses surveyed for infestation with triatomine bugs and 3,305 houses sprayed with insecticide. A total of 63 patient records from 3 different hospitals were selected for a retrospective review of resource use. Consensus methodology with local experts was used to estimate care seeking behaviour and to complement observed data on utilisation.

Findings

The mean cost per house per entomological survey was $4.4 (in US$ of 2004), whereas the mean cost of spraying a house with insecticide was $27. The main cost driver of spraying was the price of the insecticide, which varied greatly. Treatment of a chronic Chagas disease patient costs between $46.4 and $7,981 per year in Colombia, depending on severity and the level of care used. Combining cost and utilisation estimates the expected cost of treatment per patient-year is $1,028, whereas lifetime costs averaged $11,619 per patient. Chronic Chagas disease patients have limited access to healthcare, with an estimated 22% of patients never seeking care.

Conclusion

Chagas disease is a preventable condition that affects mostly poor populations living in rural areas. The mean costs of surveying houses for infestation and spraying infested houses were low in comparison to other studies and in line with treatment costs. Care seeking behaviour and the type of insurance affiliation seem to play a role in the facilities and type of care that patients use, thus raising concerns about equitable access to care. Preventing Chagas disease in Colombia would be cost-effective and could contribute to prevent inequalities in health and healthcare.