The Cost Effectiveness of Bone Marrow

Transplant Therapy and Its Policy

Implications

May 1981

NTIS order #PB81-221798
CASE STUDY #6

THE IMPLICATIONS OF

COST-EFFECTIVENESS

ANALYSIS OF

MEDICAL TECHNOLOGY

MAY 1981

BACKGROUND PAPER #2: CASE STUDIES OF

MEDICAL TECHNOLOGIES

CASE STUDY #6: THE COST EFFECTIVENESS OF BONE MARROW

TRANSPLANT THERAPY AND ITS POLICY IMPLICATIONS

S. O. Schweitzer, Ph. D.

and

C. C. Scalzi, R. N., M.N.

School of Public Health, University of California at Los Angeles

Los Angeles, Calif.

OTA Background Papers are documents that contain information believed to be

useful to various parties. The information undergirds formal OTA assessments or is

an outcome of internal exploratory planning and evaluation. The material is usually

not of immediate policy interest such as is contained in an OTA Report or Technical

Memorandum, nor does it present options for Congress to consider.

CONGRESS OF THE UNITED STATES

Office of Technology Assessment

Washington D C 20510

●
Library of Congress Catalog Card Number 80-600161

For sale by the Superintendent of Documents,

U.S. Government Printing Office, Washington, D.C. 20402
Foreword

This case study is one of 17 studies comprising Background Paper #2 for OTA’s

assessment, The lmplications of- Cost-Effectiveness Analysis of Medical Technology.

That assessment analyzes the feasibility, implications, and value of using cost-effectiveness and cost-benefit analysis (CEA/CBA) in health care decisionmaking. The major, policy-oriented report of the assessment was published in August 1980. In addition

to Background Paper #z, there are four other background papers being published in

conjunction with the assessment: 1) a document which addresses methodological

issues and reviews the CEA/CBA literature, published in September 1980; 2) a case

study of the efficacy and cost-effectiveness of psychotherapy, published in October

1980; 3) a case study of four common diagnostic X-ray procedures, to be published in

summer 1981; and 4) a review of international experience in managing medical technology, published in October 1980. Another related report was published in

September of 1979: A Review of Selected Federal Vaccine and Immunization Policies.

The case studies in Background Paper #2: Case Studies of Medical Technologies

are being published individually. They were commissioned by OTA both to provide

information on the specific technologies and to gain lessons that could be applied to

the broader policy aspects of the use of CEA/CBA. Several of the studies were specifically requested by the Senate Committee on Finance.

Drafts of each case study were reviewed by OTA staff; by members of the advisory panel to the overall assessment, chaired by Dr. John Hogness; by members of

the Health Program Advisory Committee, chaired by Dr. Frederick Robbins; and by

numerous other experts in clinical medicine, health policy, Government, and economics. We are grateful for their assistance. However, responsibility for the case studies remains with the authors.

Director

111
Advisory Panel on The Implications of

Cost-Effectiveness Analysis of Medical Technology

John R. Hogness, Panel Chairman

President, Association of Academic Health Centers

Stuart H. Altman Sheldon Leonard

Dean Ma)lager

Florence Heller School Regulatory Affairs

Brandeis University General Electric Co.

James L. Bennington

Chairman

Department of Anatomic Pathology and

Clinic a/ Laboratories

Childrens Hospital of San Francisco

John D. Chase

Associate Dean for Clinical Affairs

University of Washington School of Medicine

Joseph Fletcher

Visiting Scholar

Medical Ethics

School of Medicine

University of Virginia

Clark C. Havighurst

Professor of Law

School of Law

Duke University

Barbara J. McNeil

Department of Radiology

Peter Bent Brigham Hospital

Robert H. Moser

Executive Vice President

American College of Physicians

Frederick Mosteller

Chairman

Departmwent of Biotiostatistics

Harvard University

Robert M. Sigmond

Advisor on Hospital Affairs

Blue Cross and Blue Shield Associations

Jane Sisk Willems

VA Scholar

Veterans Administration

11’
OTA Staff for Background Paper #2

Joyce C. Lashof, Assistant Director, OTA

Health and life Sciences Division

H. David Banta, Health Program Manager

Clyde J. Behney, Project Director

Kerry Britten Kemp, * Editor

Virginia Cwalina, Research Assistant

Shirley Ann Gayheart, Secretary

Nancy L, Kenney, Secretary

Martha Finney, * Assistant Editor

Other Contributing Staff

Bryan R. Luce Lawrence Miike Michael A. Riddiough

Leonard Saxe Chester Strobel*

OTA Publishing Staff

John C. Holmes, Publishing Officer

John Bergling* Kathie S. Boss Debra M. Datcher

Patricia A. Dyson* Mary Harvey* Joe Henson

*OTA contract personnel.
Preface

This case study is one of 17 that comprise

Background Paper #2 to the OTA project on the

Implications of Cost-Effectiveness Analysis of

Medical Technology. * The overall project was

requested by the Senate Committee on Labor

and Human Resources. In all, 19 case studies of

technological applications were commissioned

as part of that project. Three of the 19 were specifically requested by the Senate Committee on

Finance: psychotherapy, which was issued separately as Background Paper #3; diagnostic Xray, which will be issued as Background Paper

#5; and respiratory therapies, which will be included as part of this series. The other 16 case

studies were selected by OTA staff.

In order to select those 16 case studies, OTA,

in consultation with the advisory panel to the

overall project, developed a set of selection

criteria. Those criteria were designed to ensure

that

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as a group the case studies would provide:

examples of types of technologies by function (preventive, diagnostic, therapeutic,

and rehabilitative);

examples of types of technologies by physical nature (drugs, devices, and procedures);

examples of technologies in different stages

of development and diffusion (new, emerging, and established);

examples from different areas of medicine

(such as general medical practice, pediatrics, radiology, and surgery);

examples addressing medical problems that

are important because of their high frequency or significant impacts (such as

cost);

examples of technologies with associated

high costs either because of high volume

(for low-cost technologies) or high individual costs;

examples that could provide informative

material relating to the broader policy and

methodological issues of cost-effectiveness

or cost-benefit analysis (CEA/CBA); and

● Office of Technology Assessment, U.S. Congress, The Implications of Cost-Effectiveness Analysis of Medical Technology, GPO

stock No. 052-003 -00765-7 (Washington, D. C.: U. S, Government

printing Office, August 1980),

. examples with sufficient evaluable literature.

On the basis of these criteria and recommendations by panel members and other experts,

OTA staff selected the other case studies. These

16 plus the respiratory therapy case study requested by the Finance Committee make up the

17 studies in this background paper.

AII case studies were commissioned by OTA

and performed under contract by experts in academia. They are authored studies. OTA subjected each case study to an extensive review

process. Initial drafts of cases were reviewed by

OTA staff and by members of the advisory

panel to the project. Comments were provided

to authors, along with OTA’s suggestions for

revisions. Subsequent drafts were sent by OTA

to numerous experts for review and comment.

Each case was seen by at least 20, and some by

40 or more, outside reviewers. These reviewers

were from relevant Government agencies, professional societies, consumer and public interest

groups, medical practice, and academic medicine. Academicians such as economists and decision analysts also reviewed the cases. In all,

over 400 separate individuals or organizations

reviewed one or more case studies. Although all

these reviewers cannot be acknowledged individually, OTA is very grateful for their comments and advice. In addition, the authors of

the case studies themselves often sent drafts to

reviewers and incorporated their comments.

er to more fully

present divergent views on particular technologies a commentary should be added to

the case study. Thus, following the case
The case studies were selected and designed to

fulfill two functions. The first, and primary,

purpose was to provide OTA with specific information that could be used in formulating

general conclusions regarding the feasibility and

implications of applying CEA/CBA in health

care. By examining the 19 cases as a group and

looking for common problems or strengths in

the techniques of CEA/CBA, OTA was able to

better analyze the potential contribution that

these techniques might make to the management

of medical technologies and health care costs

and quality. The second function of the cases

was to provide useful information on the speSome of the case studies are formal CEAS or

CBAS; most are not. Some are primarily concerned with analysis of costs; others are more

concerned with analysis of efficacy or effectiveness. Some, such as the study on end-stage

renal disease, examine the role that formal

analysis of costs and benefits can play in policy

formulation. Others, such as the one on breast

cancer surgery, illustrate how influences other

than costs can determine the patterns of use of a

technology. In other words, each looks at evaluation of the costs and the benefits of medical

technologies from a slightly different perspective. The reader is encouraged to read this study

in the context of the overall assessment’s objectives in order to gain a feeling for the potential

role that CEA/CBA can or cannot play in health

care and to better understand the difficulties and

complexities involved in applying CEA/CBA to

specific medical technologies.

The 17 case studies comprising Background

Paper #2 (short titles) and their authors are:

Artificial Heart: Deborah P. Lubeck and John P.

Bunker

Automated Multichannel Chemistry Analyzers:

Milton C. Weinstein and Laurie A. Pearlman

Breast Cancer Surgery: Karen Schachter and

Duncan Neuhauser

Cardiac Radionuclide Imaging: William B.

Stason and Eric Fortess

Cervical Cancer Screening: Bryan R. Luce

Cimetidine and Peptic Ulcer Disease: Harvey V.

Fineberg and Laurie A. Pearlman

Colon Cancer Screening: David M. Eddy

CT Scanning: Judith L. Wagner

Elective Hysterectomy: Carol Korenbrot, Ann

B. Flood, Michael Higgins, Noralou Roos,

and John P. Bunker

End-Stage Renal Disease: Richard A. Rettig

Gastrointestinal Endoscopy: Jonathan A. Showstack and Steven A. Schroeder

Neonatal Intensive Care: Peter Budetti, Peggy

McManus, Nancy Barrand, and Lu Ann

Heinen

Nurse Practitioners: Lauren LeRoy and Sharon

Solkowitz

Orthopedic Joint Prosthetic Implants: Judith D.

Bentkover and Philip G. Drew

Periodontal Disease Interventions: Richard M.

Scheffler and Sheldon Rovin

Selected Respiratory Therapies: Richard M.

Scheffler and Morgan Delaney

These studies will be available for sale by the

Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.

Call OTA’s Publishing Office (224-8996) for

availability and ordering information.
Case Study #6

The Cost Effectiveness of

Bone Marrow Transplant Therapy and

Its Policy Implications

S. O. Schweitzer, Ph.D.

and

C. C. Scalzi, R. N., M.N.

School of Public Health

University of California at Los Angeles

Los Angeles, Calif.

AUTHORS’ ACKNOWLEDGMENTS

We are grateful for the invaluable assistance and cooperation of Robert Peter

Gale, M. D., Director, University of California at Los Angeles (UCLA) Bone Marrow

Transplantation Program, for the encouragement and criticism given by Devra Bres10W, M. A., and Charles Lewis, M. D., and for the capable research assistance of Mark

Keating and Dennis Strum. Financial support for this study was provided by the

UCLA Health Services Research Center and by the Office of Technology Assessment

(OTA). Responsibility for any errors rests with the authors, who also retain responsibility for the opinions presented. The conclusions do not necessarily reflect the position of OTA.
Contents

Page

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Diffusion of New Technology . . . . . . . . . . . . . .

Description of BMT Therapy . . . . . . . . . . . . . . . . . .

Description of Conventional Therapy and Outcomes

. . . ... .’ ..* .* .* .. .. .. .. .. .. .. .. .. .. .. ..

3

5

5

6

6

7

8

9

m

11

13

13

14

15

. . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .. .. .. .. .. .. .. .. .. .. .. ..

.. .. .. .. .. .. .. .. .. .. . . . . . . . . . . . . .

Cost-Effectiveness Analysis . . . . . . . . . . . . . . . . . . .

Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cost of BMT Therapy. . . . . . . . . . . . . . . . . . . .

Cost of Conventional Therapy . . . . . . . . . . . . .

Cost-Effectiveness Calculations. . . . . . . . . . . . .

Cost-Effectiveness Ratios . . . . . . . . . . . . . . . . .

Adjustments for Quality of Life of Survivors. . .

● ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎

✎ ✎ ☛ ✎ ☛✌ ☛ ✎ ☛ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎

✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎

✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎

● ✎ ☛ ☛✌ ☛ ☛ ✎ ✎ ✎ ✎ ☛ ☛ ✎ ✎✎☛☛✌✎✎✎✎

● ☛✎✎✎☛☛☛✎✎✎☛✎✎✎✎✎✎✎✎☛☛ ✎

✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎ ✎

BMT Cost in Perspective . . . . .

Policy Implications. . . . . . . . . .

References . . . . . . . . . . . . . . . .

Appendix: Mean Hospital Costs

. . .. .. . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .

and Professional Fees for Patients and Donors

in UCLA’s Bone Marrow Transplantation Program. . . . . . . . . . . . . . . . . . . . .

LIST OF TABLES

Table No. Page

1. Mean Total Cost of BMT Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

10

10

12

15

15

2. Present Value of Years of Life Extended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. BMT Cost per Year of Life Extended. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. BMT Cost-Effectiveness Ratios With Quality-of-Life Adjustment. . . . . . . . . . . .

Mean Expected Charges for Hospital Costs for a Hospital Stay of a

UCLA BMT Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mean Expected Charges for Professional Fees for a Hospital Stay of a

UCLA BMT Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mean Expected Charges for Hospital Costs and Professional Fees for a

A-1.

A-2.

A-3.

UCLA BMT Donor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LIST OF FIGURES

15

Figure No. Page

1. Actuarial Survival of Aplastic Anemia Patients Given Conventional Therapy. .

2.

3.

4.

5.

6

6

7

12

12

Actuarial Survival of Acute Leukemia Patients Given Conventional Therapy . .

Actuarial Survival of Aplastic Anemia and Acute Leukemia Patients

Given Bone Marrow Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Quality of Life for Aplastic Anemia Patients Given Bone Marrow Transplant . .

Quality of Life for Acute Leukemia Patients Given Bone Marrow Transplant. . .
Case Study #6:

The Cost Effectiveness of

Bone Marrow Transplant Therapy

and Its Policy Implications

S. O. Schweitzer, Ph. D.

and

C. C. Scalzi, R. N., M.N.

School of Public Health

University of California at Los Angeles

Los Angeles, Calif.

INTRODUCTION

The diffusion of biomedical technology in the

United States has had a striking impact on

health care personnel, institutions, and costs.

The rate at which biomedical innovations are

diffused within the health care system, although

an important characteristic of that system, is

also one about which relatively little is known.

The diffusion of some innovations (e. g., certain

anticancer drugs) is allegedly too slow, while

the diffusion of others (e.g., coronary bypass

surgery and total body scanners) is allegedly too

rapid, We have little knowledge about determining how and why technological innovations

actually diffuse and little experience in specifying socially optimal rates of diffusion for

various types of innovations. Focusing on one

new technology—bone marrow transplantation

(BMT)–this study presents both a critica] analysis of the technology itself and policy options

that would strengthen control over the rate of

technological diffusion.

THE DIFFUSION OF NEW TECHNOLOGY

The increasing allocation of resources to the

health care sector of the economy and health

care cost inflation resulting from the rapid diffusion of certain biomedical technologies have

become issues of urgent public policy debate at

all levels of government: Federal, State, and

even local. Clearly, the widespread—and possibly excessive—diffusion of some medical technologies has been encouraged by the current

public and private methods of financing medical

care. Financial reimbursement of new technologies by third-party payers (including medicaid

and medicare) is crucial for the providers of

health care services. One would expect that,

given their importance in influencing the health

care system, decisions to reimburse for a new

technology would be complex, based on a number of evaluative criteria, In fact, however, they

have not been. No formal process, public or private, to ensure that studies of cost and effec3
4 ● Backround Paper #.?: Case Studies of Medical Technologies

tiveness of new technologies are conducted and

that prospective data are collected and analyzed

has existed.

If the consumption and production of health

services were subject to the same forces present

in competitive markets, the problem of widespread diffusion of medical technology and its

impact on the quality and cost of health care

services would not be an issue. In a perfectly

competitive market, the price of a service falls

to a point where supply recedes to meet demand

at a market-clearing price. However, the market

for health care services does not function in this

manner. Third-party financing has expanded

the demand for health services and has made

both consumers and providers decreasingly sensitive to price. In addition, factors such as the

importance of Government research in creating

biomedical innovations, as well as the frequent

inability of consumers to evaluate the need for

or relative success of a new biomedical technology, militate against the application of classical

market constraints to the adoption of technology in the health care sector.

The effects of widespread diffusions of new

medical technologies have surfaced as causal

factors in the escalation of health care costs. Excessive supply of new technologies in the health

care sector may result in the underutilization of

existing technologies and personnel. With a

rapid rate of technological innovation, the rate

of technological obsolescence becomes a significant concern. To make matters worse, an extrapolation of a common law of technological

diffusion and use (Roemer’s Law) would propose that the availability of new medical technologies creates demand for, and hence generates use of, these technologies. If mere availability defines the use of new technologies, then, in

addition to the problem of underutilization of

existing technologies, there may be overutilization of new technologies.

A number of new biomedical technologies

now being used on a small scale may shortly

present themselves as widely useful modes of

medical treatment. One such technology is BMT

for the treatment of aplastic anemia and acute

leukemia. It would appear useful to conduct a

social cost-effectiveness analysis (CEA) of BMT

therapy now, while the technology is still in an

early stage. Control and restriction of the service to a limited number of institutions are still

feasible (if desirable) at present, but in a few

years might not be.

Examining BMT therapy is significant for a

variety of reasons:

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The

BMT is an extremely expensive procedure.

The question arises whether BMT therapy

is an effective treatment in terms of patient

survival and quality of such survival.

There is a greater demand for BMT procedures than there are time, resources, and

availability of payment mechanisms. 1

BMT programs require extensive and costly

coordination of a number of different medical care services.

The startup and capital acquisition costs of

new programs are significant.

BMT programs require specialized professional training of health care personnel because of the intensive nature of the technology.

It appears that without information about

the effectiveness of a new procedure such as

BMT, physicians test the technology using

a variety of methods to develop their own

sense of its worth.

process of information gathering by physicians may in itself contribute substantially t o

the inappropriate use and attendant high cost of

the technology (7).
Case Study #6 The Cost Effectiveness of Bone Marrow Transplant Therapy and Its Policy Implications ● 5

DESCRIPTION OF BMT THERAPY

BMT therapy is a relatively new medical technology used in the treatment of aplastic anemia

and acute leukemia. In much the same way as a

kidney transplant can replace a diseased kidney,

transplanted bone marrow can replace a diseased bone marrow. The bone marrow is the

site of production of red blood cells, white

blood cells, and platelets. In the severe form of

aplastic anemia, the bone marrow ceases to

function. The patient becomes severely anemic

and is susceptible to bleeding and infectious

complications. In acute leukemia, a neoplastic

disease, the bone marrow produces immature

(malignant) white blood cells that replace normal marrow elements. Patients with severe

aplastic anemia and patients with leukemia who

are unresponsive to conventional therapy (discussed below) are potential candidates for BMT

therapy.

The BMT procedure involves three phases. In

the first phase, lasting 5 to 14 days, the bone

marrow recipient is prepared for the graft. Immunosuppressive and cytotoxic chemotherapy

are administered and irradiation is used to

enable the recipient to accept the graft, to prevent graft rejection, and in cases of acute

leukemia to eliminate residual leukemia.

In the second phase, bone marrow is procured

from an HL-A* sibling donor and intravenously

administered to the graft recipient. Donors and

recipients of bone marrow transplants must be

matched at the HL–A locus, the complex of

genes that determine the compatibility of tissue

transplants. A second test, important in the

selection of donors for BMT, is the mixed leukocyte culture test in which donor and recipient leukocytes are cultured together to determine their ability to recognize each other as foreign (3).

The third phase is a period of waiting for the

bone marrow to engraft and function normally

in the recipient. During the time required for

engraftment (approximately 2 to 4 weeks), the

graft recipient is vulnerable to infection, bleeding, severe weight loss, rejection of the graft,

and graft-versus-host disease (GvHD). GvHD

occurs in approximately 70 percent of BMT

patients. The transplanted lymphocytes recognize the host (i. e., patient) as foreign and attack

the patient’s skin, liver, and intestine. Thus,

large areas of the patient’s skin maybe damaged

and the patient may develop severe diarrhea.

Severe jaundice with abnormal liver function

tests is also common. GvHD varies from a transient, mild skin rash to a rapid] y progressive

fatal disease. If the marrow engrafts and the patient survives the immediate posttransplant

period (first 3 to 6 weeks), he or she faces

another set of complications, including GvHD

and interstitial pneumonia. Interstitial pneumonia occurs in 60 percent of BMT patients,

typically 4 to 6 weeks post transplant. The disease progresses rapidly and is fatal in approximate] y 50 percent of cases.

DESCRIPTION OF CONVENTIONAL THERAPY AND OUTCOMES

For purposes of analyzing the effectiveness of

BMT therapy, one should compare results obtained in patients treated with BMT therapy

with results obtained in equivalent patients

treated with conventional forms of therapy. In

this case study, we consider only two diagnoses

for which BMT or conventional treatment is administered, aplastic anemia and acute leu-
kemia. 2 Conventional therapy for aplastic anemia involves corticosteroids, androgens, and

red blood cell and platelet transfusions. Conventional therapy for acute leukemia consists of

various combinations of chemotherapy.

The data employed in our analysis to compare the effectiveness of BMT therapy and conventional therapy were abstracted from survival

studies reported in the medical literature (8,9).

Survival data were obtained on retrospective

control groups of aplastic anemia and acute leukemia patients who would have received transFigure 1 .—Actuarial Survival of Aplastic Anemia

Patients Given Conventional Therapy

0 8 16 24 32 40 48

Weeks survived

SOURCE UCLA Bone Marrow Transplant Team, “Bone Marrow Transplantation

in Severe Aplastlc Anemia, ” Lancet 229. October 1978

COST-EFFECTIVENESS ANALYSIS

Data

The source of data for the CEA of BMT therapy which follows is the UCLA Bone Marrow

Transplantation Program. This program is the

second largest of six BMT programs in the

United States and performs about so transplants

a year. It is important to note that a BMT proplants had a suitable bone marrow donor been

available. The patients in the control groups

were reportedly matched for known prognostic

factors with BMT patients and were cared for

by a single group of physicians.

The actuarial survival curves for aplastic

anemia and leukemia patients given conventional therapy are displayed in figures 1 and 2,

respectively. As indicated, the outlook for patients with these diseases is very poor. All nine

aplastic anemia patients represented in figure 1

died within 1 year of diagnosis; the median survival time from diagnosis was 2.5 months. None

of the 37 acute leukemia patients represented in

figure 2 survived more than 13 months postrelapse; the median survival was 4 months.

Figure 2. —Actuarial Survival of Acute Leukemia

Patients Given Conventional Therapy

123456 7 8 9 10 11 12

Months survived

SOURCE UCLA Bone Marrow Transplant Team, “Bone Marrow Transplantation

In Acute Leukemia. ” Lancret 21197, December 1977

gram is an enormous clinical effort which requires the coordination of many different professionals. At UCLA, the transplant team consists of clinicians from the departments of pediatrics, medicine, and surgery, clinical pathologists, geneticists, basic scientists from the

departments of microbiology and immunology,

and experts in tissue-typing and radiation.
Case Study #6 The Cost Effectiveness of Bone Marrow Transplant Therapy and Its Policy implications ● 7

The treatment protocol for BMT varies somewhat from center to center, although patient

characteristics and selection criteria are generally uniform. However, it should be cautioned

that a therapy as new as BMT is constantly being changed (e. g., recent changes have occurred

in the choice of morbidities to be treated with

BMT and the stage at which BMT is employed).

Variation in experience over time within any

one site, as well as variation across sites, is

therefore to be expected. In addition, the

number of patients treated in each individual

center has been small. Evaluating a technology

such as BMT therapy is a bit like taking a snapshot of a moving object—as soon as the picture

is taken, it is different from the way it was.

Nonetheless, evaluations are useful to monitor

progress of technological development, as well

as to indicate the appropriate timing for public

policy intervention, such as third-party financing of care.

For purposes of our analysis, data were collected on 107 patients with aplastic anemia and

leukemia who had been given BMT therapy at

UCLA. The specific sources of the data were patients’ medical records, the patient billing

department at UCLA, and interviews with nursing and medical staff on the BMT team.

The actuarial survival curves for UCLA BMT

patients with aplastic anemia and acute leukemia are shown in figure 3. As can be seen, the

two curves are similar. For both groups of patients, the greatest risk of death occurs within

the first 5 to 8 months after transplant. Patients

who survive this period appear to stand an excellent chance of longer term survival.

Cost of BMT Therapy

The total cost of BMT treatment consists of:

1) direct costs, which are the medical costs; and

2) indirect costs, which are all other costs imposed on the patient and others. BMT patients

and donors incur costs in both categories, because both patients and donors receive medical

treatment and experience lost time. For the purposes of our analysis, patient charges were used

as proxies for direct costs. The substitution of

charges for costs was necessitated by the

a

Patients treated at UCLA’s Bone Marrow Transplantation Program from Mar. 1 

1974, to Aug. 31, 1978.

SOURCE: Based on data from UCLA’s Bone Marrow Transplantation Program,

Los Angeles, Calif , 1978.

availability of data. However, since the policy

implications of our study deal largely with reimbursement, charges are the relevant “cost”

measures.

In the case of the bone marrow donor and

family, lost time is assumed to be valued at an

average national wage rate. A potential longterm indirect benefit of BMT treatment, earnings of those patients who are able to return to

work or other normal activities, would reduce

the total net costs of treatment, especially if the

proportion of patients able to return were large.

However, the experience of the patient group at

UCLA did not seem to warrant an attempt to

estimate this earnings flow.

Charges were obtained from the UCLA

Health Sciences Records System for every third

BMT patient treated at UCLA between 1974 and

1978. The mean charge for BMT treatment (including hospital charges and professional fees),

and indirect costs for patient, donor, and family

are tabulated in table 1. The mean charges by

detailed service category are shown in the tables

in the appendix. These detailed mean charges

for services reflect both the actual charge for a

service and the probability of the service’s use,

so tabulated charges are not necessarily equal to

actual charges. The difference in total cost of

BMT therapy for the two morbidity groups,
Total cost (direct and indirect). . . . . . . . . $67, 772

One explanation is that the length-of-treatment

effect was countered and dominated by the intensity of treatment provided to critically ill patients.

To be conservative, in our analysis we use the

lower costs of survivors rather than mean costs

for all BMT patients. To estimate the mean total

cost of BMT treatment for survivors, we reduce

the mean total cost of $67,772, shown in table 1,

by 2.4 percent ($1,627). Thus, the adjusted total

BMT treatment cost for the analysis is $66,145.

(Note that this cost refers to the total cost of

BMT treatment rather than only the direct treatment costs. )

Cost of Conventional Therapy

A CEA of a policy or procedure must always

be performed with respect to an alternative

policy or procedure. Often the alternative is

stated implicitly, as when a project is compared

to no project (e.g., a new bridge v. none at all,

or use of a new technology where none had existed before). In the case of treatment for

aplastic anemia and leukemia, an interesting

dilemma is evident. Conventional therapy for

patients with these diseases is always undertaken, despite the fact that such treatment does

not significantly improve patient outcome.

If one were to do a CEA of conventional

therapy compared to no treatment, the conclusion would be that the substantial expenditure

of resources on conventional therapy has little

to show in terms of patient outcome. One might

argue, therefore, that conventional treatment

should be abandoned as being of no benefit.

This would then lead one to analyze BMT therapy as an alternative to no treatment at all.

However, the fact is that we do not simply

abandon patients who are afflicted by these

diseases. When BMT therapy is not feasible,

either for lack of a suitable donor or for financial reasons, patients are given conventional

treatment, despite the lack of a significantly improved outcome. This being the case (for whatever reason), BMT therapy is an option that

represents an alternative to conventional therapy. Therefore, the cost of BMT therapy must

be considered not in isolation but as compared
Case Study #6 The Cost Effectiveness of Bone Marrow Transplant Therapy and lts Policy implications ● 9

to the cost of conventional therapy. The net, or

marginal, costs of BMT therapy are reestablished by subtracting the costs of conventional

therapy from those of BMT.

For purposes of our analysis, mean direct

costs for conventional treatment were calculated for patients with acute leukemia and

aplastic anemia who were eligible for BMT but

could not receive this treatment because of an

absence of suitable donors. Costs for patients

with acute leukemia were analyzed from time of

relapse; those for patients with severe aplastic

anemia were analyzed from time of diagnosis.

These time periods were selected because they

coincided with the eligibility requirements for

BMT. Indirect costs (lost wages) to patients

were not calculated for any of the patient/treatment groups, because all patients were assumed

to be too ill to return to work. Conventional

treatment does not generate the indirect costs to

donor and family that BMT therapy generates.

The mean direct costs of conventional treatment for aplastic anemia and for acute leukemia

are shown below.

For aplastic anemia , . . . . . . . , . . . . . . . . . .. $21,729

For acute leukemia . . . . . . . . . . . . . . . . . . . . . 30,105

Cost= Effectiveness Calculations

We calculate the BMT cost-effectiveness

ratios twice, first with “lives saved” as t he

denominator, and then with “years of life extended” as the denominator. Unlike the first

calculation, the latter calculation is not straightforward, because the long-term survival rate of

BMT patients is not known. We estimate longterm BMT survival most optimistically by using

the observed 3-year survival rate to estimate

long-term survival, and we calculate years of

life extended assuming that the longevity of

BMT patients, who survive for 3 years, equals

that of the general population. There is no

evidence by which we can verify our assumption concerning the longevity of BMT survivors; therefore, we must recognize that by

using that assumption we are calculating an upper bound to the benefits of BMT treatment. To

show the effects of alternative assumptions, we

use a sensitivity analysis. An average life extension of 53 years is assumed to be gained by survivors of BMT treatment (the mean age of BMT

patients is 22.2 years) (5). For purposes of a sensitivity analysis, life extensions of 25 and 10

years are assumed.

Discounting of benefits that accrue in the

future–whether they be real benefits (e.g.,

years of life) as in this study, or monetary benefits—is necessary so that benefits in each year

can be made comparable, and hence additive.

The significance of discounting is that benefits

in the future are valued less than those accruing

now. This procedure is entirely consistent with

the rate of time preference experienced generally, with present wealth more highly valued than

deferred wealth.

There is no agreement in the literature as to

the appropriate discount rate, but the prevailing, commonly observed rate of interest on

Ioanable funds is often suggested as appropriate. We use 10 percent as the discount rate in

our analysis, but also show calculations for 8

and 12 percent to test for sensitivity. Our costeffectiveness ratios with “lives saved” as the

denominator do not employ discounting, because all benefits (lives saved) are assumed to result in the current period, when the costs are incurred. The ratios with “years of life extended”

as the denominator do employ discounting,

because these benefits (extended years of life) accrue in the future as well as the present.

Even with discounting, one additional caveat

must be offered concerning the implication of

the results, This concerns the distinction between average and marginal costs. Average

costs measure the average expenditure for a

given set of patients, as reported above. This is

not the appropriate cost estimate, however, if

one considers marginal changes in output levels

of a program. We do not know, for example, if

we were to expand the treatment by, say, 10 patients per year, whether the cost per additional

patient would be higher or lower than the average cost per patient. If there are economies of

scale, one would expect the marginal costs to be

lower than the average. If there are diseconomies of scale, however, the policy-relevant marginal costs would exceed the average.
Cost-Effectiveness Ratios

The net cost of BMT therapy is calculated as

the mean cost for BMT therapy minus the mean

cost for conventional therapy. Thus, the net

cost of BMT therapy for aplastic anemia is

$66,146 minus $21,729, or $44,417; and the net

cost of BMT therapy for acute leukemia is

$66,146 minus $30,105, or $36,041.

Cost-effectiveness ratios for BMT are calculated as follows:

For lives saved:

C/E = Net BMT treatment cost/survival rate

Aplastic anemia,

C/E = $44,417/0.42 = $105,755 per life

Acute leukemia,

C/E = $36,041/0.13 = $277,239 per life

For extended years of life (before discounting):

C/E = Net BMT treatment cost/survival rate x 53 years

Aplastic anemia,

C/E = $44,417/(0.42) (53) = $1,995 per year

Acute leukemia,

C/E = $36,041/(0.13) (53) = $5,231 per year

Discounting extended years of life reduces

present value of these benefits, thus raising

the

the

cost-effectiveness ratios. Table 2 shows the-benefits for three alternative life extensions (53, 25,

and 10 years) and four alternative discount rates

(0, 8, 10, and 12 percent). Discounting extended

years of life dramatically affects the benefits of a

life-extending program. By discounting, 53 extended years of life are valued at only 18 to 25

percent of their undiscounted value. The higher

the discount rate, the greater the reduction in

value of extended years of life. The impact of

discounting is particularly great for the 53-year

life extension assumed in our analysis, but is less

if the life extension is relatively short (e.g., 10

years).

Table 2.—Present Value of Years of Life Extended

(with different discount rates)

Years of Discount rate

life extended – O % 8 % 100/0 – 

—12%

53 . . . . . . . . . . . 53 13.3 10.9 9.4 —

25 . . . . . . . . . . . 25 11.7 10.1 8.9

10 ...., . . . . . . 10 7.7 7.2 6.7

The results of applying these discount factors

to the cost-effectiveness ratios for extended

years of life are presented in table 3. Several

observations can be made about the calculations

of cost per discounted year of life extended. The

first is that the results are more sensitive to

assumptions regarding life expectancy when the

life expectancy is relatively short than when the

life expectancy is relatively long. In other

words, at any of the discount rates used, the

cost per year of life extended is far more sensitive to a difference in the assumed life extension from, say, 10 to 25 years than to a difference between 25 and 53 years, even though

the latter span of 28 years is much greater than

the former span of 15 years. This means that the

results of this analysis are not very sensitive to

the assumed life extension, as long as the figure

is high (e.g., 53 years). However, if the life expectancy figure is low, the results would be sensitive to the exact figure assumed.

Secondly, the choice of discount rate substantially affects the findings. If one alters the

assumptions of a 10-percent discount rate by 2

percentage points either way, the cost-effectiveness ratios for a 53-year life extension will vary

by approximately 10 to 30 percent. If the life extension is less (e.g., 25 or 10 years), the significance of the choice of discount rate is lessened.

Adjustments for Quality of Life

of Survivors

Measures to determine quality of life and

health status are still being developed, and little

agreement has yet been reached concerning appropriate scaling. In the case of BMT therapy,

Table 3.—BMT Cost per Year of Life Extended

(with different discount rates)

—.

Years of

life extended 00/0 8% 100/0 12“/ 0

Aplastic anemia

53 . . . . . . . . . . . $ 2,003 $ 7,982 $ 9,740 $11,295

25 . . . . . . . . . . . 4,246 9,074 10,512 11,929

10 . . . . . . . . . . . 10,616 13,788 14,745 15,846

Acute leukemia

53 . . . . . . . . . . . $ 5,231 $20,845 $25,435 $29,494

25 . . . . . . . . . . . 11,089 23,696 27,450 31,150

10. . . . . . . . . . . 27,724 36,005 38,505 41,379

—
Case Study #6 The Cost Effectiveness of Bone Marrow Transplant Therapy and its Policy Implications 11

some attempt to employ the concept of quality

of life is crucial because of the serious medical

condition of many of the patients who survive

the treatment. To ignore the question of quality

of life because of the seriousness of methodological or measurement difficulties would implicitly assume that all lives saved are equal in

value, regardless of the functional state of the

survivors. If CEA is to be used to compare programs, failure to measure quality of life is a

more serious omission. Therefore, we make a

limited, though inherently reasonable, attempt

to measure this.

Difficulties associated with measuring quality

of life in BMT patients are numerous and significant. Direct interviews with BMT patients

treated at UCLA were impossible, since many

are no longer alive and over 50 percent of the

BMT patients and families do not live in the Los

Angeles area where this study was conducted.

Review of medical charts was tedious, and the

charts proved to be an inadequate source of information regarding the quality of BMT patients’ lives posttransplant.

Through discussion with members of the

UCLA BMT team, one nurse was identified as a

person who had worked closely with all BMT

patients and their families during hospitalization and clinic followup visits. The same nurse

also maintained contact with all patients by

telephone until the patients’ death. We interviewed this nurse and asked her to assess quality

of life (short- and long-term) for each BMT patient. A simple instrument was developed to

provide a subjective measure of quality of life

for BMT patients.

All BMT patients treated at UCLA between

March 1, 1974, to August 31, 1978, were evaluated. Two rankings were given to each BMT

patient who survived more than 1 year following transplantation: 1) a short-term quality

score (3 to 12 months posttransplant), and 2) a

long-term quality score (from 12 months posttransplant until death or until completion of the

data collection on August 31, 1978).

Because of the limitations mentioned previously, it would have been unrealistic to expect

one individual to remember specific details

about 107 BMT patients. For this reason, a simple “degree of dependence v. independence”

measure was used as a proxy measure for quality of life of survivors. The following 4-point

scale was developed and used:

O = Total dependence: Usually a patient who

had developed complications (e.g., GvHD

or interstitial pneumonia) which severely

limited self-care activities, but did not require hospitalization.

1 =Partial dependence: Able to perform selfcare activities, but unable to return to

school or work, or in the case of young

children play with friends.

2 =Semi-independence: Able to return to

school, work, or play on a part-time

basis.

3 =No limitations: Able to engage in normal

activities, returned to work or school fulltime.

Because of the risks associated with the early

phase of convalescence, 3 we decided to measure

quality of life of survivors only after a BMT patient had been discharged and had been at home

for at least 1 month (usually 3 months) subsequent to transplantation.

Short- and long-term quality of life for aplastic anemia patients given BMT therapy are displayed in figure 4; short- and long-term quality

of life for acute leukemia patients given BMT

therapy are shown in figure 5.

It is important to emphasize the obvious limitations of our quality-of-life measure so that the

data can be properly interpreted. The limitations are as follows:

●

●

●

The instrument (4-point ranking scale) was

not tested for either reliability or validity.

Dependence v. independence is only a

proxy measure for quality of life.

The data represent the interpretation and

view of one individual (the nurse—not the

patient or family) and therefore must be

considered very subjective.
12 . Background Paper #2: Case Studies of Medical Technologies

Figure 4.—QuaIity of Life for Aplastic Anemia

Patients Given Bone Marrow Transplanta

Short term Long term

1 month postdischarge to 1 year post-BMT

12 months post-BMT N = 9 Mean = 2.7

N = 24 Mean = 1.6

0

Quality of life

Total dependence.

Partial dependence (unable to return to work

or school).

Partial dependence (able to return to part-time work

or school).

No limitations.

● The sample size was extremely small:

Aplastic anemia: N = 2 4

Acute leukemia: N = 2 3

Analysis of the data with these limitations in

mind shows that the mean short-term quality of

life for 24 patients with aplastic anemia is 1.6

and is slightly lower, 1.3, for 23 patients with

acute leukemia. Less than half the patients in

either group survived 1 year posttransplant, so

the sample for long-term quality of life is very

small. The mean long-term quality of life for 9

patients with aplastic anemia is 2.7 and for 1 0

patients with acute leukemia is 1.9.

Cost-effectiveness ratios are adjusted for

quality of life only for long-term survival. The

quality adjustment factors (Q) are calculated as

follows.

Q = observed quality/potential quality of life

Aplastic anemia, Q = (2.7)/(3.0) = 0.90

Acute leukemia, Q = (1.9)/(3.0)= 0.63

Applying this quality adjustment to the BMT

cost-per-life-saved calculations yields the following ratios.

Figure 5.—Quality of Life for Acute Leukemia

Patients Given Bone Marrow Transplant”

Short term Long term

1 month postdischarge to 1 year post-BMT

12 months post-BMT N = 10 Mean = 1.9

N = 23 Mean = 1.3

127 1

0123

Quality of life

Total dependence.

Partial dependence (unable to return to work

or school).

Partial dependence (able to return to part-time work

or school).

No limitations.

For lives saved:

C/E = Net BMT treatment cost/survival rate x Q

Aplastic anemia,

C/E = $44,417/(0.42) (0.90)= $117,505 per life saved

Acute leukemia,

C/E = $36,041/(0.13) (0.63)= $440,061 per life saved

Applying the quality adjustment to the BMT

cost-effectiveness ratios for extended years

life in table 3 yields the results presented

table 4.

Table 4.—BMT Cost-Effectiveness Ratiosa

With Quality. of-Life Adjustment

Years of

life extended 00/0 80/0 100/0 12%

of

in

Aplastic anemia

53 . . . . . . . . . . . $ 2,327 $ 9,307 $11,308 $13,122

25, . . . . . . . . . . 4,933 10,556 12,233 13,850

10 . . . . . . . . . . 12,331 16,031 17,262 18,496

Acute leukemia

53 . . . . . . . . . . . $ 8,303 $33,213 $40,352 $46,830

25 . . . . . . . . . . 17,603 37,669 43,654 49,463

10 . . . . . . . . . . 44,006 57,209 61,609 66,010

a

See table 3
BMT COST IN PERSPECTIVE

A review of the literature shows a surprising

degree of variation in the cost effectiveness of

lifesaving procedures. This variation is difficult

to justify on the basis of economic efficiency.

Unequal cost-effectiveness ratios for various

programs, at least at the margin, imply that additional lives or years of life could be saved by

reallocating resources among programs. As a

few examples will illustrate, however, the

criterion of equal marginal cost effectiveness of

alternative programs is rarely applied in practice. Neuhauser (6) estimates that elective

inguinal herniorrhaphy costs approximately

$120,000 per life saved. Barnes (1) estimates that

treatment for end-stage renal disease costs from

$22,000 to $27,000 per life saved if a kidney

transplant is employed, assuming a 5-year survival period. Benedixen (2), who studied the

costs per year of life saved by intensive care

treatment, found the figures to range from $84

for treatment for an overdose of barbiturate to

$180,000 for hepto-renal failure.

A large part of the BMT patient population is

young. Therefore, the high cost of BMT treatment is amortized over a far longer period than

POLICY IMPLICATIONS

The significance of this case study for policy

analysis extends in two directions. First, the

study highlights several complexities associated

with performing CEAS, including the effort to

take into account quality of life. One finds that

BMT therapy has substantially different costs

per life saved or year of life extended when it is

applied to different patient populations (i. e.,

aplastic anemia v. acute leukemia). Thus, generalizations about a procedure for all patients

are not always appropriate. One also observes

the importance of selecting an appropriate alternative procedure to the one being analyzed. In

the case of BMT, conventional treatment is the

existing alternative notwithstanding its limited

efficacy.

The study also suggests a new approach to

controlling the process of technological diffuare the costs of some other life-extending programs that affect an older population (e.g., cardiac care or other cancer treatments). Chronic

dialysis for end-stage renal disease costs an

estimated $6,000 to $30,000 per year of life extended (1). Coronary artery bypass surgery,

though apparently not lifesaving, may improve

the quality of remaining years of life. Weinstein,

et al. (10) estimate the cost of such surgery to be

from $25,000 to $53,000 per quality-adjusted

year of life. Multiple trauma treatment costs just

over $6,000 per year of life extended (2).

With adjustments for quality of life, the cost

effectiveness of BMT therapy is worsened, especially for one of the target populations—

patients suffering from acute leukemia. For

aplastic anemia patients who undergo BMT

therapy, the adjustment factor is close to 1.0, so

adjustment for quality of life only slightly

worsens the cost-effectiveness ratios. Acute leukemia patients who undergo BMT therapy have

a worse short- and long-term outcome, so the

adjustment for quality of life more adversely affects the cost-effectiveness ratios.

sion. Under conditions of scarce resources,

allocation decisions must be made which, by

definition, will deny life to some while extending it for others. Third-party intermediaries,

both public and private, might well consider

this issue in deciding which services to cover

and for whom, as they act as “agents” for large

numbers of patients, or in the case of public

agencies, for society at large. Failure to consider

it tacitly assumes no resource scarcity—an assumption that will continue to drive health care

expenditures up at an unmoderated rate, as the

most expensive therapy is provided for all in

need,

Third-party payers commonly reimburse for

any service that is deemed “medically necessary, ” the judgment of which is generally left to

the physician in charge. However, a more con-
14 ● Backround Paper #2: Case Studies of Medical Technologies

servative approach, incorporating some of this

judgment into the insurer’s own policy process,

is equally feasible. In the case of a new technology, the policy options for third-party payers

are more numerous than they are in the case of

procedures that have already been widely diffused and employed. The major difference is

that in the case of a new technology such as

BMT, a third-party intermediary maybe able to

specify the sites at which the procedure will be

reimbursed, as well as patient characteristics of

those entitled to coverage. In the case of BMT,

six centers currently perform the procedure on a

significant scale; given its high degree of complexity and reliance on various subsystems (tissue-typing, laboratory, radiology, etc. ), one

might wish to discourage this technology’s

widespread diffusion, while at the same time

accepting current or somewhat altered treatment levels.

Another role for third parties in the case of a

new technology is to define a procedure as either

“treatment” or “research’ ’-depending on either

its success or cost (or a combination of the two)

—with the implication that “research” should be

supported in demonstration-type settings, on

limited numbers of patients, and from a totally

separate budget from the budget for “treatment”

(which, morally, might be offered to all in

need). One would define a procedure as being

REFERENCES

1.

2.

3.

4.

5.

Barnes, B., “An Overview of the Treatment of

End-Stage Renal Disease and a Consideration of

Some of the Consequences, ” in Costs, Risks, and

Benefits of Surgery, J. P. Bunker, et al. (eds. )

(New York: Oxford University Press, 1977).

Benedixen, H. H., “The Cost of Intensive Care, ”

in Costs, Risks, and Benefits of Surgery, J. P.

Bunker, et al. (eds. ) (New York: Oxford University Press, 1977).

Cahan, M., and Lyddane, N., “Bone Marrow

Transplantation at UCLA,” Cancer Nursing

1:47, 1978.

Cline, M., et al., “Bone Marrow Transplantation in Man, ” Ann. Int, Med. 83(5): 691, 1975.

National Center for Health Statistics, Vital

Statistics of the United States: 1976, vol. II, sec.

5—Life Tables (Washington, D. C.: Department

of Health, Education, and Welfare, 1978).

treatment rather than research as soon as its efficacy or costs (or both) approached some frequently observed level. Little of this sort of policy analysis is currently being done. The degree

of freedom open to the third parties is far greater than typically practiced, and more judicious

use of the reimbursement instrument would certainly have an enormous impact on the diffusion and distribution of new technology.

One last caveat is in order as one translates a

CEA into the language of policy. Analyzing a

new medical procedure is inherently difficult

because the data tend to be obsolete as soon as

the procedure is analyzed. New developments

occur rapidly. With regard to BMT, for example, altered protocols appear to be leading to

improved results, though more recent data do

not lead themselves to long-term extrapolation.

For these reasons, a CEA of a particular technology is somewhat like a single brick, which,

no matter how well made, cannot provide shelter. A single piece of analysis cannot indicate

how resources might be allocated until it is put

beside other pieces, Only after many comparable studies are analyzed can one see where

limited resources might best be put. Our CEA of

BMT therapy, therefore, is little more now than

a single element in the entire technology assessment picture.

6.

7.

8.

9,

10.

Neuhauser, D., “Elective Inguinal Herniorrhaphy Versus Truss in the Elderly, ” Costs, Risks,

and Benefits of Surgery, J. P. Bunker, et al.

(eds. ) (New York: Oxford University Press,

1977).

“OTA Issues Report on CT Scanners, ” COTH

Report 12(9):7, 1978.

UCLA Bone Marrow Transplant Team, “Bone

Marrow Transplantation in Acute Leukemia, ”

Lamet 2:1197, 1977.

“Bone Marrow Transplantation in Severe Aplastic Anemia, ” Lancet 2:921, 1976.

Weinstein, M. C., et al., “Coronary Artery Bypass Surgery: Decision and Policy Analysis, ” in

Costs, Risks, and Benefits of Surgery, J. P.

Bunker, et al. (eds. ) (New York: Oxford University Press, 1977).
Case Study #6 The Cost Effectiveness of Bone Marrow transplant Therapy and lts Policy lmplications ● 15

APPENDIX: MEAN HOSPITAL COSTS AND PROFESSIONAL FEES

FOR PATIENTS AND DONORS IN

TRANSPLANTATION PROGRAM

Table A-1 .—Mean Expected Charges for Hospital

Costs8 for a Hospital Stay of a UCLA BMT Patientb

9.

10.

11.

12.

13.

14.

15.

16.

17.

b. IV solutions. . . . . . . . . .

c. Take-home drugs

Blood bank. ., . . . . . . . . . . . . . . . . . . . . .

Radiology: a. X-ray ... ... . . . . . . . . . . . . . .

b. Isotopes or therapy .,

Laboratories: a. Outside. ., ., ., .

b. Blood gases. . . . .

c. Clinical

Pathology ., ., ., ., ., ., . . . . .

Outpatient services .,

Physical and occupational therapy. .,

Maxillo-facial prosthetics.

Special private duty RNs ., . . . . . . .

Echogram. . . . . . . . . . . . . . . . . . .

1,209.35

671.51

4,129.30

1,042.50

1,074.10

321.37

215.70

19,722.47

118.70

121.10

329.17

329.17

304.00

22.00

UCLA’S BONE MARROW

Table A.2.—Mean Expected Charges for

Professional Feesa for a Hospital Stay of

a UCLA BMT Patientb

1. Office examination—extended ., . . . . . . . . $ 132.00

2. Office examination—hematology. ... . . . . . 19.50

3. Initial hospital examination . . . . . . . . . . . . . . . 49.50

4. Hospital reexamination ., ., . . . . . . . . . . . 240,00

5. Initial hospital visits . . ... . . ... ... 375.00

6. Hospital visits ... ., . . . . . . . . . . . . . . . . 1,678.50

7. Physical—complete. ., . . . . . . . . 12.50

8

9

10

11

12

13.

14,

15.

16.

17.

18.

19.

20.

21.

22.

23.

24

25.

26.

Consult—cardiology . . . . . . . . . . . . . . . . . . . .

Consult—comprehensive ., . . . . . . . . . . .

Consult—dermatology. . . . . . . . . . . . . . . .

Consult—hematology . . . . . . . . . . .

Consult—infectious disease, . . . ...

Consult—liver. . . . . . . . . . . . . . . . . . . . . . . . . .

Consult—respiratory . . . . . . . ... . . . . .

Bone marrow tray . . . . . . . . . . . . . . . . . . . . . .

Bone marrow. . . . . . . . . . . . . . . . . . . .

Bone marrow aspiration . . . . . . . . . . . . . . . . .

Spinal puncture tray ., . ... ...

Scalp-vein ., ., ... ... . .

Chemotherapy—parental. . . . . . . . . . . . . . . . .

Esophagastroduodenopsy. . . . . . . ...

Pericardiocentesis . . . . ... . . . . . . . . . . . .

Fiberoptic bronchoscopy. . . . . . . . . . . . .

Biopsies. . . . . . . . . . . . . . . ... ...

Echocardiogram ... . . . . ... ., . .

Medical report . . . , , ., . ... , . . . . . . . .

46.50

46.50

10.00

25.00

42.00

12.00

24.00

1.90

2.50

20.00

1.90

0.45

4.00

20.00

10.00

71.00

10.00

46.40

0.60

Table A3.—Mean Expected Charges for Hospital

1981 341 -844/1006