Social and economic implications of cancer in the United States

Calculation of the disease burden associated with environmental chemical exposures: application of toxicological information in health economic estimation

Calculation of costs and the Burden of Disease (BoD) is useful in developing resource allocation and prioritization strategies in public and environmental health. While useful, the Disability-Adjusted Life Year (DALY) metric disregards subclinical dysfunctions, adheres to stringent causal criteria, and is hampered by gaps in environmental exposure data, especially from industrializing countries. For these reasons, a recently calculated environmental BoD of 5.18% of the total DALYs is likely underestimated. We combined and extended cost calculations for exposures to environmental chemicals, including neurotoxicants, air pollution, and endocrine disrupting chemicals, where sufficient data were available to determine dose-dependent adverse effects. Environmental exposure information allowed cost estimates for the U.S. and the EU, for OECD countries, though less comprehensive for industrializing countries. As a complement to these health economic estimations, we used attributable risk valuations from expert elicitations to as a third approach to assessing the environmental BoD. For comparison of the different estimates, we used country-specific monetary values of each DALY. The main limitation of DALY calculations is that they are available for few environmental chemicals and primarily based on mortality and impact and duration of clinical morbidity, while less serious conditions are mostly disregarded. Our economic estimates based on available exposure information and dose-response data on environmental risk factors need to be seen in conjunction with other assessments of the total cost for these environmental risk factors, as our estimate overlaps only slightly with the previously estimated environmental DALY costs and crude calculations relying on attributable risks for environmental risk factors. The three approaches complement one another and suggest that environmental chemical exposures contribute costs that may exceed 10% of the global domestic product and that current DALY calculations substantially underestimate the economic costs associated with preventable environmental risk factors. By including toxicological and epidemiological information and data on exposure distributions, more representative results can be obtained from utilizing health economic analyses of the adverse effects associated with environmental chemicals.

Estimating burden and disease costs of exposure to endocrine-disrupting chemicals in the European union

CONTEXT

Rapidly increasing evidence has documented that endocrine-disrupting chemicals (EDCs) contribute substantially to disease and disability.

OBJECTIVE

The objective was to quantify a range of health and economic costs that can be reasonably attributed to EDC exposures in the European Union (EU).

DESIGN

A Steering Committee of scientists adapted the Intergovernmental Panel on Climate Change weight-of-evidence characterization for probability of causation based upon levels of available epidemiological and toxicological evidence for one or more chemicals contributing to disease by an endocrine disruptor mechanism. To evaluate the epidemiological evidence, the Steering Committee adapted the World Health Organization Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria, whereas the Steering Committee adapted definitions recently promulgated by the Danish Environmental Protection Agency for evaluating laboratory and animal evidence of endocrine disruption. Expert panels used the Delphi method to make decisions on the strength of the data.

RESULTS

Expert panels achieved consensus at least for probable (>20%) EDC causation for IQ loss and associated intellectual disability, autism, attention-deficit hyperactivity disorder, childhood obesity, adult obesity, adult diabetes, cryptorchidism, male infertility, and mortality associated with reduced testosterone. Accounting for probability of causation and using the midpoint of each range for probability of causation, Monte Carlo simulations produced a median cost of €157 billion (or $209 billion, corresponding to 1.23% of EU gross domestic product) annually across 1000 simulations. Notably, using the lowest end of the probability range for each relationship in the Monte Carlo simulations produced a median range of €109 billion that differed modestly from base case probability inputs.

CONCLUSIONS

EDC exposures in the EU are likely to contribute substantially to disease and dysfunction across the life course with costs in the hundreds of billions of Euros per year. These estimates represent only those EDCs with the highest probability of causation; a broader analysis would have produced greater estimates of burden of disease and costs.

Cost differences between hospice and nonhospice care. A comparison of insurer payments and provider charges

Although it has been postulated that hospice care savings are "biased" when costs are measured in terms of insurer payments instead of provider charges, this claim has not been documented by research. This article examines cost differences between hospice and nonhospice care, first, by analyzing Medicare Part A payments and, second, by studying provider charges for services rendered to a population of 24 cancer patients during their last 24 weeks of life. The exploratory results of the study showed that although the cost savings derived from analyzing provider charges were about double those based on Medicare Part A payments, both approaches to the measurement of cost strongly indicated that hospice home care was less costly than nonhospice care. Further analysis showed that variations in the rates of Medicare reimbursement accounted for 22 to 42% of the differences in the derived cost savings between the two approaches to measuring cost, and that payments to hospitals played a major role in determining this outcome.