David R. Lairson

Cost of Epilepsy in the United States: A Model Based on Incidence and Prognosis

Summary: A model of the clinical course of epilepsy from onset until remission or death has been developed for six prognostic groups, including survival, use and cost of medical care, and time lost from work and housekeeping. The model has been used to generate preliminary estimates of the lifetime cost of epilepsy for a cohort of persons diagnosed in 1990 in the United States. The distribution of incident cases among prognostic groups is derived from epidemiologic studies of prognosis in epilepsy. Direct cost is estimated by multiplying nationally representative unit costs by the expected type and frequency of medical care use. The latter were derived by an expert panel, based on inferences from existing literature and on their own clinical experiences. Indirect cost is estimated based on lost earnings associated with projections of restricted activity days, excess unemployment, and excess mortality. Total lifetime cost in 1990 dollars of all persons with epilepsy onset in 1990 was estimated at

Screening for Diabetic Retinopathy: The wide-angle retinal camera

3.0 billion, with indirect cost accounting for 62% of the total. Cost per patient ranged from

Cost-effectiveness of alternative methods for diabetic retinopathy screening

4,272 for persons with remission after initial diagnosis and treatment to

Methodological issues in estimating the cost of epilepsy.

138,602 for persons with intractable and frequent seizures. Antiepileptic drug (AED) treatment is the most costly category of service. Different assumptions about the amount and type of drug administration cause major changes in overall cost estimates.

Equity of health care in Australia

OBJECTIVE— To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS— Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physicians assistant through dilated pupils using direct ophthalmoscopy, a single 45° retinal photograph without pharmacological dilation, and a set of three dilated 45° retinal photographs) were compared with a reference standard of stereoscopic 30° retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identified from a laboratory list of elevated serum glucose values were recruited from a DOD medical center. RESULTS— The subjects (352) had complete exams excluding the exam by the physicians assistant that was added later. The sensitivities, specificities, and positive and negative likelihood ratios are as follows: ophthalmologist 0.33, 0.99, 72, 0.67; photographs without pharmacological dilation 0.61, 0.85, 4.1, 0.46; dilated photographs 0.81, 0.97, 24, 0.19; and physicians assistant 0.14, 0.99, 12, 0.87. CONCLUSIONS— Fundus photographs taken by the 45° camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy. Physician extenders can effectively perform the photography with minimal training but would require more training to perform adequate eye exams. In this older population, many patients did not obtain adequate nonpharmacological dilation for use of the 45° camera.

The independent contributions of socioeconomic status and health practices to health status.

OBJECTIVE To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologists exam and an ophthalmic exam by a physicians assistant or nurse practitioner technician, for detecting nonproliferative and proliferative diabetic retinopathy. RESEARCH DESIGN AND METHODS Comparison of 45-degrees fundus photographs with and without pharmacological pupil dilation taken by technicians and interpreted by experts, direct and indirect ophthalmoscopy by ophthalmologists, and direct ophthalmoscopy by technicians with seven-field stereoscopic fundus photography (reference standard). Costs were estimated from market prices and actual resource use. The study included 352 patients attending outpatient diabetes and general-medicine clinics at VA and DOD facilities. RESULTS Medical system costs per true positive were: 45-degrees photos with dilation,

Estimating the Cost of Epilepsy

295; 45-degrees photos without dilation,

Screening for Patients with Alcohol Problems: Severity of Patients Identified by the Cage

378; ophthalmologist,

Stage at diagnosis of breast cancer. Comparison in a fee-for-service and health maintenance organization practice.

390; and technician,

Agreement of self-reported and physiologically estimated fitness status in a symptom-free population

794. Patient costs per true positive were: 45-degrees photos with dilation,