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Cost analysis of narrowband UVB phototherapy in psoriasis
HEALTH
SERVICES RESEARCH
Cost analysis of narrowband UVB phototherapy in psoriasis Sinead M. Langan, MRCP(UK),a Adrienne Heerey, BSc,b Michael Barry, FRCPI,b and Louise Barnes, FRCPIa Dublin, Ireland Background: There are few data available to health care providers regarding the costs of treating patients with psoriasis, and specifically the cost of phototherapy. Objectives: As narrowband UVB (TL-01) has now become an established therapy for patients with psoriasis requiring phototherapy, we determined the annual cost of delivering TL-01 treatment in a university hospital. Methods: The costing evaluation was from a hospital perspective and the strategy used was a microcosting detailed collection of resources used. Results: The annual cost of TL-01 treatment in our teaching hospital was 53,555.00 euros. Staffing accounted for 70% of the cost. The average individual costs were 325.00 euros (range: 57.20-972.40). Conclusion: These costs are significant but remain less expensive than inpatient treatment. (J Am Acad Dermatol 2004;50:623-6.)
I
n recent years narrowband UVB (TL-01) has become an important treatment for patients with psoriasis requiring phototherapy.1 The benefits, in costing terms, of effective outpatient treatments for psoriasis may include a requirement for fewer interventions and for less inpatient admissions than other standard psoriasis treatments. Thus, phototherapy in an outpatient setting has significant cost implications and is an important alternative to inpatient hospitalization.2 This does not detract, however, from the absolute need for admission in some patients. The cost of various psoriasis treatments is of importance as this is a common chronic condition, often requiring lifelong intensive therapy. Therefore, the cumulative costs of psoriasis treatments have a significant impact on the annual hospital budget. There is a dearth of data available for physicians
From the Departments of Dermatologya and Pharmacoeconomics,b St James’s Hospital. Funding sources: None. Conflicts of interest: None identified. Reprint requests: Louise Barnes, FRCPI, Department of Dermatology, St James’s Hospital, James’s St, Dublin 8, Ireland. E-mail: [email protected]. 0190-9622/$30.00 © 2004 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2003.09.028
and health planners on the annual costs of treating psoriasis and, in particular, on the costs of phototherapy.2-4 A recent cost-effectiveness analysis compared outpatient dithranol, inpatient dithranol, and UVB phototherapy costs.5 Our aim in this study was to estimate the annual cost to our hospital of providing narrowband UVB phototherapy to patients attending for treatment of their psoriasis.
BACKGROUND St James’s Hospital is a 700-bed university hospital in Dublin, Ireland. An outpatient department within the hospital provides the focus for outpatient treatment of patients with a primary diagnosis of psoriasis. Narrowband UVB treatment was initiated in our outpatient department in September 1998. Initially there was one 7001-UV Waldman (Waldman GmbH & Co, Villingen-Schwenningen, Germany) in use; a second unit was added in March 2000. A minimal erythema dose is determined in the majority of patients. All patients are treated three times weekly with 20% increments at each visit. Treatment is administered by dermatology staff nurses. As a safety precaution, 2 nurses are always present to calculate and confirm delivered doses. One of the department’s consultants (L. B.) is the director of the department. 623
624 Langan et al
Inclusion criteria In all, 165 patients with psoriasis attended the outpatient department between September 1998 and September 2000 for narrowband UVB. We excluded from our study any patient receiving this treatment for other diagnoses including atopic eczema, mycosis fungoides, and severe pruritus.
METHODS The annual cost to the hospital of delivering a TL-01 phototherapy service to the patients who were included in the study were calculated using standard pharmacoeconomic microcosting methods.6,7 The costs consisted of the following: 1. Operational costs of the phototherapy department were calculated on the basis of percentage of hospital size in square feet and, therefore, the percentage of total annual expenditure from the hospital budget. The suite is 625 sq ft, which is 0.071% of total hospital size and, therefore, a similar percentage of hospital expenditure using standard methods. 2. Nursing costs were calculated on the basis of annual salary. Time spent in the phototherapy department was calculated from the nursing roster. The remainder of nursing time is spent doing ward work and outpatient services, and is not included in our costs. Two nurses each spent 4 half-days per week dedicated to phototherapy, of which 90% is allocated to narrowband UVB phototherapy. 3. Consultant time was calculated on the basis of annual salary, with 1.5 hours per week dedicated to phototherapy. This involves supervision of phototherapy, updating protocols, and paperwork. 4. Secretarial time was calculated on the basis of annual salary. Half of a session per week is dedicated to phototherapy. This involved updating protocols, providing summary reports both for general practitioners and medical notes, and general filing. 5. Physics support was calculated on the basis of 20 days of senior physicist time per year involved in meter calibration, radiation protection, training, and maintenance. 6. Nonconsultant hospital doctor costs were calculated on the basis of a specialist registrar spending 7 1-hour sessions on phototherapy per year Currently, 1 euro is equivalent to US $1.
J AM ACAD DERMATOL APRIL 2004
RESULTS Demographic data In all, 165 patients attended for narrowband UVB therapy for psoriasis at our institution during the 2-year period; 95 female and 70 male patients. Of these patients, 78 (47%) had undergone previous phototherapy. Of the patients, 43 (26%) had previous broadband UVB therapy, 31 (19%) had previous psoralen-UVA therapy, and 37 (22%) had previous TL-01 treatment. During the 2-year period, the range of TL-01 exposures varied between 3 and 64 (this included patients who required more than 1 course within the 2-year period), with the majority of patients (72%) having between 10 and 30 exposures per course. A number of patients (n ⫽ 30) required more than 1 course of TL-01 during the 2-year period. The range in the number of treatments accounts for the significant variations in individual costs. The total annual costs of narrowband UVB phototherapy were calculated using the methods outlined above. Detailed costs are as follows: 1. Operational costs of the phototherapy suite were 15,961.00 euros per year. 2. Nursing costs were 26,787.00 euros per year. 3. Consultant costs were 4746.00 euros per year. 4. Secretarial support was 1328.00 euros per year. 5. Physics support was 4571.00 euros per year. 6. Nonconsultant hospital doctor costs totaled 162.00 euros per year. Total annual costs of TL-01 phototherapy were calculated as 53,555.00 euros. Of the total costs, 70% were staffing costs as follows: nursing (50%); consultant (8.8%); secretarial (2.4%); nonconsultant hospital doctor (0.3%); and physics support (8.5%). The overheads for the phototherapy department amounted to 30% of total costs (Fig 1). Individual patient costs were estimated on the basis of number of exposures (Fig 2) and the number of courses of TL-01 during the 2-year period. The average costs were 325.00 euros (range: 57.20972.40).
DISCUSSION Economic data are valuable to supplement clinical decisions and to weigh the costs and benefits of different therapeutic measures. There are minimal data available on the costs of psoriasis treatments in general and specifically on the costs of phototherapy and photochemotherapy. It is well documented that the economic impact of psoriasis varies according to the severity of disease, but few data are available on the absolute and real costs of psoriasis treatments.2-5 This study accurately calculates the costs of TL-01 phototherapy in a teaching hospital
Langan et al 625
J AM ACAD DERMATOL VOLUME 50, NUMBER 4
Fig 1. Breakdown of costs. NCHD, Nonconsultant hospital doctor.
Fig 2. Number of TL-01 exposures per patient during a 2-year period.
setting. This information should be useful for clinicians involved in psoriasis treatment to help calculate treatment costs and to plan health budgets. Marchetti et al4 reported that annual outpatient costs for patients with psoriasis ranged from US $1400 to US $6600 per patient with a total of US $3.2 billion spent each year in the United States in 1998. Our data represent the running costs of treating psoriasis with TL-01 in a large teaching hospital.
The costs were high but, not surprisingly, the most expensive resource was staff. In this study 70% of the costs were attributed to the salaries of the various people working together in the department to deliver the treatment to the patients. The operational costs have been calculated using a standard microcosting method in this study. Microcosting is a well-recognized pharmacoeconomic tool to facilitate accurate cost calculation. Direct comparisons in
626 Langan et al
costs between different centers is difficult to calculate because of differences in patient selection, size of phototherapy department, and indirect savings such as reduction in time off work and the costs of inpatient or systemic treatments. We did not include the costs of setting up a phototherapy service, including factors such as procurement of equipment, but concentrated on the day-to-day running costs of the service. Capital depreciation costs are an essential component of the cost of care, as all equipment depreciates over time. Assuming a useful clinical life of 5 years for medical equipment and discounting health care programs at 5% per annum, the value of the equipment after 5 years would be approximately 54,846 euros. If we take into account both depreciation and the opportunistic cost (2%), for instance the next best use of resources embodied in the purchase of the equipment, the net present value of the equipment would be approximately 64,363 euros. These rates are specific to the Irish context. Although it was not our primary aim to calculate the cost of the individual patient TL-01 therapy, the data collected allowed us to calculate costs of treating the individual patient. Factors such as transpor-
J AM ACAD DERMATOL APRIL 2004
tation costs to and from the service and time missed off work were not examined. Further similar studies estimating the costs of other psoriasis treatments will be valuable to allow comparative costing of therapeutic interventions. REFERENCES 1. Ferguson J. The use of narrow-band UV-B (tube lamp) in the management of skin disease. Arch Dermatol 1999;135:589-90. 2. Sander HM, Morris LF, Phillips CM, Harrison PE, Menter A. The annual cost of psoriasis. J Am Acad Dermatol 1993;28:422-5. 3. Feldman SR, Fleischer AB, Reboussin DM, Rapp SR, Bradham DD, Exum ML, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997;37:564-9. 4. Marchetti A, LaPensee K, An P. A pharmacoeconomic analysis of topical therapies for patients with mild-to moderate stable plaque psoriasis: a US study. Clin Ther 1998;20:851-69. 5. Hartman M, Prins M, Swinkels OQJ, Severens JL, De Boo T, Van der Wilt GJ, et al. Cost-effectiveness analysis of a psoriasis care instruction programme with dithranol compared with UVB phototherapy and inpatient dithranol treatment. Br J Dermatol 2002; 147:538-44. 6. Heerey A, McGowan B, Ryan M, Walsh M, Feely J, Barry M. Cost of treating acute myocardial infarction in an Irish teaching hospital. Ir Med J 2001;94:144-6. 7. Heerey A, McGowan B, Ryan M, Barry M. Microcosting versus DRG’s in the provision of cost estimates for use in pharmacoeconomic evaluation. Expert Rev Pharmacoeconomics Outcomes Res 2002;2:29-33.
SERVICES RESEARCH
Cost analysis of narrowband UVB phototherapy in psoriasis Sinead M. Langan, MRCP(UK),a Adrienne Heerey, BSc,b Michael Barry, FRCPI,b and Louise Barnes, FRCPIa Dublin, Ireland Background: There are few data available to health care providers regarding the costs of treating patients with psoriasis, and specifically the cost of phototherapy. Objectives: As narrowband UVB (TL-01) has now become an established therapy for patients with psoriasis requiring phototherapy, we determined the annual cost of delivering TL-01 treatment in a university hospital. Methods: The costing evaluation was from a hospital perspective and the strategy used was a microcosting detailed collection of resources used. Results: The annual cost of TL-01 treatment in our teaching hospital was 53,555.00 euros. Staffing accounted for 70% of the cost. The average individual costs were 325.00 euros (range: 57.20-972.40). Conclusion: These costs are significant but remain less expensive than inpatient treatment. (J Am Acad Dermatol 2004;50:623-6.)
I
n recent years narrowband UVB (TL-01) has become an important treatment for patients with psoriasis requiring phototherapy.1 The benefits, in costing terms, of effective outpatient treatments for psoriasis may include a requirement for fewer interventions and for less inpatient admissions than other standard psoriasis treatments. Thus, phototherapy in an outpatient setting has significant cost implications and is an important alternative to inpatient hospitalization.2 This does not detract, however, from the absolute need for admission in some patients. The cost of various psoriasis treatments is of importance as this is a common chronic condition, often requiring lifelong intensive therapy. Therefore, the cumulative costs of psoriasis treatments have a significant impact on the annual hospital budget. There is a dearth of data available for physicians
From the Departments of Dermatologya and Pharmacoeconomics,b St James’s Hospital. Funding sources: None. Conflicts of interest: None identified. Reprint requests: Louise Barnes, FRCPI, Department of Dermatology, St James’s Hospital, James’s St, Dublin 8, Ireland. E-mail: [email protected]. 0190-9622/$30.00 © 2004 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2003.09.028
and health planners on the annual costs of treating psoriasis and, in particular, on the costs of phototherapy.2-4 A recent cost-effectiveness analysis compared outpatient dithranol, inpatient dithranol, and UVB phototherapy costs.5 Our aim in this study was to estimate the annual cost to our hospital of providing narrowband UVB phototherapy to patients attending for treatment of their psoriasis.
BACKGROUND St James’s Hospital is a 700-bed university hospital in Dublin, Ireland. An outpatient department within the hospital provides the focus for outpatient treatment of patients with a primary diagnosis of psoriasis. Narrowband UVB treatment was initiated in our outpatient department in September 1998. Initially there was one 7001-UV Waldman (Waldman GmbH & Co, Villingen-Schwenningen, Germany) in use; a second unit was added in March 2000. A minimal erythema dose is determined in the majority of patients. All patients are treated three times weekly with 20% increments at each visit. Treatment is administered by dermatology staff nurses. As a safety precaution, 2 nurses are always present to calculate and confirm delivered doses. One of the department’s consultants (L. B.) is the director of the department. 623
624 Langan et al
Inclusion criteria In all, 165 patients with psoriasis attended the outpatient department between September 1998 and September 2000 for narrowband UVB. We excluded from our study any patient receiving this treatment for other diagnoses including atopic eczema, mycosis fungoides, and severe pruritus.
METHODS The annual cost to the hospital of delivering a TL-01 phototherapy service to the patients who were included in the study were calculated using standard pharmacoeconomic microcosting methods.6,7 The costs consisted of the following: 1. Operational costs of the phototherapy department were calculated on the basis of percentage of hospital size in square feet and, therefore, the percentage of total annual expenditure from the hospital budget. The suite is 625 sq ft, which is 0.071% of total hospital size and, therefore, a similar percentage of hospital expenditure using standard methods. 2. Nursing costs were calculated on the basis of annual salary. Time spent in the phototherapy department was calculated from the nursing roster. The remainder of nursing time is spent doing ward work and outpatient services, and is not included in our costs. Two nurses each spent 4 half-days per week dedicated to phototherapy, of which 90% is allocated to narrowband UVB phototherapy. 3. Consultant time was calculated on the basis of annual salary, with 1.5 hours per week dedicated to phototherapy. This involves supervision of phototherapy, updating protocols, and paperwork. 4. Secretarial time was calculated on the basis of annual salary. Half of a session per week is dedicated to phototherapy. This involved updating protocols, providing summary reports both for general practitioners and medical notes, and general filing. 5. Physics support was calculated on the basis of 20 days of senior physicist time per year involved in meter calibration, radiation protection, training, and maintenance. 6. Nonconsultant hospital doctor costs were calculated on the basis of a specialist registrar spending 7 1-hour sessions on phototherapy per year Currently, 1 euro is equivalent to US $1.
J AM ACAD DERMATOL APRIL 2004
RESULTS Demographic data In all, 165 patients attended for narrowband UVB therapy for psoriasis at our institution during the 2-year period; 95 female and 70 male patients. Of these patients, 78 (47%) had undergone previous phototherapy. Of the patients, 43 (26%) had previous broadband UVB therapy, 31 (19%) had previous psoralen-UVA therapy, and 37 (22%) had previous TL-01 treatment. During the 2-year period, the range of TL-01 exposures varied between 3 and 64 (this included patients who required more than 1 course within the 2-year period), with the majority of patients (72%) having between 10 and 30 exposures per course. A number of patients (n ⫽ 30) required more than 1 course of TL-01 during the 2-year period. The range in the number of treatments accounts for the significant variations in individual costs. The total annual costs of narrowband UVB phototherapy were calculated using the methods outlined above. Detailed costs are as follows: 1. Operational costs of the phototherapy suite were 15,961.00 euros per year. 2. Nursing costs were 26,787.00 euros per year. 3. Consultant costs were 4746.00 euros per year. 4. Secretarial support was 1328.00 euros per year. 5. Physics support was 4571.00 euros per year. 6. Nonconsultant hospital doctor costs totaled 162.00 euros per year. Total annual costs of TL-01 phototherapy were calculated as 53,555.00 euros. Of the total costs, 70% were staffing costs as follows: nursing (50%); consultant (8.8%); secretarial (2.4%); nonconsultant hospital doctor (0.3%); and physics support (8.5%). The overheads for the phototherapy department amounted to 30% of total costs (Fig 1). Individual patient costs were estimated on the basis of number of exposures (Fig 2) and the number of courses of TL-01 during the 2-year period. The average costs were 325.00 euros (range: 57.20972.40).
DISCUSSION Economic data are valuable to supplement clinical decisions and to weigh the costs and benefits of different therapeutic measures. There are minimal data available on the costs of psoriasis treatments in general and specifically on the costs of phototherapy and photochemotherapy. It is well documented that the economic impact of psoriasis varies according to the severity of disease, but few data are available on the absolute and real costs of psoriasis treatments.2-5 This study accurately calculates the costs of TL-01 phototherapy in a teaching hospital
Langan et al 625
J AM ACAD DERMATOL VOLUME 50, NUMBER 4
Fig 1. Breakdown of costs. NCHD, Nonconsultant hospital doctor.
Fig 2. Number of TL-01 exposures per patient during a 2-year period.
setting. This information should be useful for clinicians involved in psoriasis treatment to help calculate treatment costs and to plan health budgets. Marchetti et al4 reported that annual outpatient costs for patients with psoriasis ranged from US $1400 to US $6600 per patient with a total of US $3.2 billion spent each year in the United States in 1998. Our data represent the running costs of treating psoriasis with TL-01 in a large teaching hospital.
The costs were high but, not surprisingly, the most expensive resource was staff. In this study 70% of the costs were attributed to the salaries of the various people working together in the department to deliver the treatment to the patients. The operational costs have been calculated using a standard microcosting method in this study. Microcosting is a well-recognized pharmacoeconomic tool to facilitate accurate cost calculation. Direct comparisons in
626 Langan et al
costs between different centers is difficult to calculate because of differences in patient selection, size of phototherapy department, and indirect savings such as reduction in time off work and the costs of inpatient or systemic treatments. We did not include the costs of setting up a phototherapy service, including factors such as procurement of equipment, but concentrated on the day-to-day running costs of the service. Capital depreciation costs are an essential component of the cost of care, as all equipment depreciates over time. Assuming a useful clinical life of 5 years for medical equipment and discounting health care programs at 5% per annum, the value of the equipment after 5 years would be approximately 54,846 euros. If we take into account both depreciation and the opportunistic cost (2%), for instance the next best use of resources embodied in the purchase of the equipment, the net present value of the equipment would be approximately 64,363 euros. These rates are specific to the Irish context. Although it was not our primary aim to calculate the cost of the individual patient TL-01 therapy, the data collected allowed us to calculate costs of treating the individual patient. Factors such as transpor-
J AM ACAD DERMATOL APRIL 2004
tation costs to and from the service and time missed off work were not examined. Further similar studies estimating the costs of other psoriasis treatments will be valuable to allow comparative costing of therapeutic interventions. REFERENCES 1. Ferguson J. The use of narrow-band UV-B (tube lamp) in the management of skin disease. Arch Dermatol 1999;135:589-90. 2. Sander HM, Morris LF, Phillips CM, Harrison PE, Menter A. The annual cost of psoriasis. J Am Acad Dermatol 1993;28:422-5. 3. Feldman SR, Fleischer AB, Reboussin DM, Rapp SR, Bradham DD, Exum ML, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997;37:564-9. 4. Marchetti A, LaPensee K, An P. A pharmacoeconomic analysis of topical therapies for patients with mild-to moderate stable plaque psoriasis: a US study. Clin Ther 1998;20:851-69. 5. Hartman M, Prins M, Swinkels OQJ, Severens JL, De Boo T, Van der Wilt GJ, et al. Cost-effectiveness analysis of a psoriasis care instruction programme with dithranol compared with UVB phototherapy and inpatient dithranol treatment. Br J Dermatol 2002; 147:538-44. 6. Heerey A, McGowan B, Ryan M, Walsh M, Feely J, Barry M. Cost of treating acute myocardial infarction in an Irish teaching hospital. Ir Med J 2001;94:144-6. 7. Heerey A, McGowan B, Ryan M, Barry M. Microcosting versus DRG’s in the provision of cost estimates for use in pharmacoeconomic evaluation. Expert Rev Pharmacoeconomics Outcomes Res 2002;2:29-33.