Cost-of-illness studies: fact or fiction?
there are direct costs (for which payments are made)
Cost-of-illness studies have been proliferating and doctors
and policymakers often ask what the very large financial
estimates mean and how useful and reliable they are.
Different aspects of costs are measured, including losses
to industry and business due to staff illness,’ lifetime
costs,2 economic costs,3 and direct and indirect costs.4
One important issue is whether the estimates are based on
prevalence or on incidence. Prevalence-based costs
estimate the direct and indirect economic burden to
society incurred during a period of time (the base period)
as a result of the prevalence of the disease; the period is
usually a year. This approach measures the value of
resources used or lost during a specified period of time,
irrespective of the time of disease onset. Incidence-based
costs represent the lifetime costs resulting from a disease
or illness, based on all cases with onset of disease in a
given base year.
The approach adopted depends on the purpose of the
analysis. If the results are to be used for cost control,
prevalence-based costing is appropriate; this method
identifies the main components of current expenditures
and foregone resources and identifies possible targets for
economy. If the analysis is aimed at making decisions
about which treatment or research strategy to implement,
the incidence-based approach is more appropriate
because it provides the basis for predictions about the
likely savings from programmes that reduce incidence or
improve outcomes.
Valuation of life is an important component of cost-of-
illness studies. Economists generally adopt two
approaches for this purpose: (a) the human capital
approach, refined by me and my colleagues;4,5 and (b) the
willingness-to-pay approach, first proposed by Schelling6
and Mishan.’ In the human capital approach, a person is
regarded as producing a stream of output that is valued at
market earnings, and the value of life is the discounted
future earnings stream. Morbidity and mortality destroy
labour, a valuable economic resource, by causing persons
to lose time from work and other productive activities, or
by bringing about premature death.8 This method has
some disadvantages. Because life is valued in terms of
market earnings, the technique yields very low values for
children and the retired elderly. In addition, psychosocial
costs-eg, pain and suffering-are components of the ’
burden of illness that are omitted from the human capital
approach.
The willingness-to-pay approach values life according
to what individuals are willing to pay for a change that
reduces the probability of illness or death. This method
could be helpful in indicating how individuals value
health and life, in deriving social preferences regarding
public policy, and in assessing the burden of pain and
suffering. This technique is influenced by the wealth (thus
ability to pay) of the individual involved and it suffers
from circularity because the values. placed by individuals
on government health programmes are clearly influenced
by those policies.9 Willingness-to-pay measures in the
USA approach$2 million per life, a much larger sum
than that generated by human capital measures.
Cost-of-illness studies are typically divided into two
main categories: (a) core costs, those resulting directly
from the illness; and (b) other related costs, including
non-health costs of the illness. Within each category,
and indirect costs (for which resources are lost). Direct
costs (expenditures for hospital and nursing home
care, physician and other professional services, drugs,
spectacles, and appliances) are generally estimated as the
product of two components-number of services and unit
prices or charges. For example, short-stay hospital days of
care, by diagnosis, can be obtained in the USA from the
National Hospital Discharge Survey conducted by the
National Center for Health Statistics (NCHS), and
expenses per patient day from the annual survey of the
American Hospital Association. Nursing home costs are
estimated by multiplying the numbers of residents with
the diagnosis by the annual charge for all residents as
reported by the National Nursing Home Survey
conducted periodically by NCHS. Costs of outpatient
care by office-based physicians can be based on visit data
from the National Ambulatory Care Survey, also
conducted periodically by NCHS, and charge data for
physicians can be obtained from the American Medical
Association annual report on physician practice. Other
direct medical and related costs are calculated similarly
from other data sources.
Indirect costs include morbidity and mortality costs.
Morbidity costs are the value of reduced or lost
productivity due to the disease in question and are
estimated as the product of (a) mean earnings an
individual would have accrued had he or she not been
affected by the disease, disaggregated by age and gender;
and (b) the number of days lost from work for the
employed population or days lost in performing their
main activity for those keeping house. If an individual had
not died prematurely from the disease, he or she would
have continued to be productive in future years. Mortality
costs are the product of the number of deaths from the
disease and the expected value of an individual’s future
earnings with gender and age taken into account. This
method of derivation considers life expectancy for
different age and gender groups, the changing pattern of
earnings at successive ages, the varying labour force
participation rates, an imputed value for house-keeping
services, and the appropriate discount rate to convert a
stream of earnings into its present worth.
National surveys provide reasonably good information
on the use of services for estimation of direct costs, but
charge and cost data are less readily available and
probably less reliable. Indirect costs depend on the
discount rate used; the higher the discount rate, the lower
the final costs. If the results of different cost-of-illness
studies are compared, special attention should be paid to
the techniques used, the discount rate, the reference
years, and the scope and recency of the data. Cost-of-
illness studies are used by policymakers to justify budgets,
to set priorities for funding in biomedical research, and to
develop intervention programmes to ameliorate or prevent
a disease. Researchers in this area have an obligation to
present the methods in considerable detail so that users
will be better able to assess their accuracy and to evaluate
whether the results are facts or fiction.
Dorothy P Rice
Institute for Health and Aging, University of California, San Francisco,
California, USA
1 Farnharn PG. Defining and measuring the costs of the HIV epidemic
tobusiness firms. Public Health Rep 1994; 109: 311-18.
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2 Rice DP, MacKenzie E, and associates. Cost of injury in the United
States: a report to Congress. 1989. Produced by Institute for Health &
Aging, University of California, San Francisco; Injury Prevention
Center, School of Hygiene and Public Health, Johns Hopkins
University; National Highway Traffic Safety Administration, US
Department of Transportation; and Centers for Disease Control.
3 Rice DP, Kelman S, Miller LS, Dunmeyer S. The economic costs of
alcohol and drug abuse and mental illness. Rockville, MD: US
Alcohol, Drug Abuse, and Mental Health Administration, 1990,
publication no (ADM) 90-1694.
4 Scitovsky AA, Rice DP. Estimates of the direct and indirect costs of
acquired immunodeficiency syndrome in the United States: 1985,
1986, and 1991. Public Health Rep 1987; 102: 5-17.
5 Rice DP. Estimating the cost of illness. Rockville, MD: US
Department of Health, Education and Welfare, 1966, Health
Economics Series, no 6. DHEW pub no (PHS) 947-6.
6 Schelling TC. The life you save may be your own. In: Chase SB, ed.
Problems in public expenditure analysis. Washington, DC: Brookings
Institution, 1968.
7 Mishan EJ. Evaluation of life and limb; a theoretical approach. J Polit
Econ 1971; 79: 687-705.
8 Hodgson TA, Meiners M. Cost of illness methodology: a guide to
current practices and procedures. Milbank Memorial Fund Quart 1982;
60: 429-62.
9 Robinson JC. Philosophical origins of the economic value of life.
Milbank Memorial Fund Quart 1986; 64: 133-35.
Single-dose antibiotic treatment for
travellers’ diarrhoea
See page 1537
Diarrhoea is by far the most common ailment experienced
by international travellers.’ 20-50% of those who travel to
the tropics, whether for sun, sand, sex, or solitude, will be
so afflicted. Although the illness is usually mild and self-
limited, 30% of affected individuals will be bed-ridden
and another 40% will have to curtail their activities.2
The overwhelming majority of those with travellers’
diarrhoea (at least 80%) are infected with bacterial
enteropathogens-notably, enterotoxigenic Escherichia
coli, Campylobacter jejuni, and species of salmonella and
shigella. The bacterial aetiology of travellers’ diarrhoea
accounts for the well-documented efficacy of antibiotics
used for prophylaxis and therapy of this condition.
However, antibiotic resistance has recently increased so
strikingly in most areas of the world that only quinolones
remain reliably effective. In several recent studies
tetracycline resistance to shigella, salmonella, and E coli
ranged from 59 to 91% of strains whereas co-trimoxazole
resistance ranged from 35 to 76%/ Quinolone resistance
has been increasing as well: in Thailand 50% of
campylobacter strains were resistant to ciprofloxacin.5
Empirical self-treatment of travellers’ diarrhoea was
pioneered by DuPont and his colleagues in the early
1980s.6 Numerous studies have subsequently shown that
antibiotic therapy reduces the duration of diarrhoea from
50-93 h (untreated) to 16-30 h when treatment is given
within 24 h of the onset of symptoms. Most regimens now
consist of two antibiotic doses daily for 3-5 days, with or
without an antimotility agent such as loperamide. The
combination of loperamide with an antibiotic seems to be
the most effective therapy for the majority of those with
travellers’ diarrhoea, although not all controlled trials have
shown increased benefit with the addition of the
antimotility agent. A study of combination therapy for
shigella dysentery in Thailand did not confirm the notion
that loperamide is contraindicated in those with high fever
and bloody diarrhoea, since no adverse effects-notably
toxic megacolon-were detected in the loperamide group.’
However, this was a small study, so it is too early to
1520
remove the caution concerning the use of antimotility
drugs patients with severe dysentery.
in
To reduce costs and improve compliance and
convenience, several investigators have focused on single-
dose antibiotic therapy for the treatment of infectious
diarrhoea. Single-dose therapy with norfloxacin 800 mg
for the treatment of shigellosis was as effective as a 3-day
course in Mexico and Thailand.8,9 However, the latter
study showed that short-course quinolone therapy (1 dose
or 3 days) did not consistently eliminate salmonella
infection or lead to rapid resolution of symptoms. When a
750 mg dose of ciprofloxacin was compared with a 3-day
course of therapy plus loperamide for travellers’ diarrhoea,
those who took the combination had fewer liquid bowel
movements. In a similar study of ciprofloxacin for
shigellosis, a single 1 g dose was effective therapy for
patients infected with species of shigella other than
S dysenteriae type 1, but single-dose therapy was inferior
to 5 days’ treatment for patients infected with S dysenteriae
type 1.10
In this issue, Salam and colleagues report a study of
single-dose 500 mg ciprofloxacin compared with placebo
for the treatment of acute travellers’ diarrhoea in British
soldiers in Belize. Mean duration of diarrhoea as assessed
by the time to the last unformed stool was reduced from
about 50 h to 24-8 h. Mean number of stools was reduced
by more than 50% as well. These results confirm earlier
work that single-dose therapy for travellers’ diarrhoea is in
most cases an effective way to shorten the course of the
illness.
Discussion of the use of antibiotics for prevention
of travellers’ diarrhoea is outside the scope of this
commentary. However, a small international study group
recently concluded that prophylaxis has a role in certain
high-risk travellers." The advantages and disadvantages of
prophylaxis were weighed against empirical therapy in
three recent reviews.5,12,13 The issue of antibiotic
prophylaxis aside, all travellers from the developed to the
developing world, especially those taking short trips, are
advised to carry a quinolone antibiotic and an antimotility
agent; one or both should be taken at the first sign of
diarrhoea.
JS Keystone
Tropical Disease Unit, Department of Medicine,
The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada
1 Steffen R, Rickenbach M, Wilhelm U, Helminger A, Schar M. Health
problems after travel to developing countries. J Infect Dis 1987; 156:
84-91.
2 Gorbach SL. Travelers’ diarrhea. N Engl J Med 1982; 307: 881-83.
3 Steffen R. Epidemiologic studies of travelers’ diarrhea, severe
gastrointestinal infections and cholera. Rev Infect Dis 1986; 8 (suppl 2):
S122-30.
4 Tellier R, Keystone JS. Prevention of travelers’ diarrhea. Infect Dis Clin
N Am 1992; 6: 333-54.
5 Taylor DN. Quinolones as chemoprophylactic agents for travellers’
diarrhea. J Trav Med 1994; 1: 119-21.
6 DuPont HI, Ericcson CD, Johnson PC. Chemotherapy and
chemoprophylaxis of travelers’ diarrhea. Ann Intern Med 1985; 102:
260-61.
7 Murphy GS, Bedhidatta L, Echeverria P, et al. Ciprofloxacin and
loperamide in the treatment of bacillary dysentery. Ann Intern Med
1985; 102: 582-86.
8 Gotuzzo E, Oberhelman RA, Maguina C, et al. Comparison of single-
dose treatment with norfloxacin and standard 5-day treatment with
trimethoprim-sulfamethoxazole for acute shigellosis in adults.
Antimicrob Agents Chemother 1989; 33: 1101-04.
9 Petrucelli BP, Murphy GS, Sanchez JL, et al. Treatment of travelers’
diarrhea with ciprofloxacin and loperamide. J Infect Dis 1992; 165:
557-60.