Urinary incontinence affects 10 million elderly and is estimated to cost more than $10 billion annually. Treatments for this conditions vary widely in efficacy and cost. Using the Agency for Health Care Policy and Research urinary incontinence guideline, we calculated expected costs for three recommended treatments for stress urinary incontinence in elderly women: (1) behavioral therapy, (2) pharmacologic therapy, and (3) surgical therapy. We constructed decision trees for each treatment option and incorporated treatment efficacy rates stated in the guideline. Costs were determined from the literature.

Using a Markov cohort simulation, 10-year expected costs per patient, in 1994 dollars, were lowest for surgical therapies and were highest for behavioral therapy (needle suspension surgery, $25,388; phenlypropanolamine and estrogen, $62,021; and behavioral therapy, $68,924). All treatment strategies were less costly than that of untreated incontinence ($86,726). Sensitivity analysis revealed that the results were highly affected by the likelihood of the patient's entering a nursing home, the cost of nursing home care, and the long-term relapse rate after surgery.

In conclusion, on the basis of data from the urinary incontinence guideline, early surgical intervention is the least costly treatment for chronic stress incontinence in elderly women. Because the long-term effectiveness of most incontinence surgeries is uncertain, additional studies are necessary to substantiate these findings.

Does government spend too little or too much on child care? How can education dollars be spent more efficiently? Should government's role in medical care increase or decrease? In this volume, social scientists, lawyers, and a physician explore the political, social, and economic forces that shape policies affecting human services.

Four in-depth studies of human-service sectors - child care, education, medical care, and long-term care for the elderly - are followed by six cross-sector studies that stimulate new ways of thinking about human services through the application of economic theory, institutional analysis, and the history of social policy.

This timely study sheds important light on the tension between individual and social responsibility, and will appeal to economists and other social scientists and policymakers concerned with social policy issues.

For the American College of Physicians

The hospital charts and billing records of 250 consecutive admissions for percutaneous transluminal coronary angioplasty (PTCA) at a university hospital were reviewed. Clinical characteristics, performing physician, angiographic features of the dilated lesion, procedural outcome, length of stay, and total and departmental hospital costs were recorded for each patient. We identified several independent predictors of hospital cost, including the physician ($4,400 increase from highest- to lowest-cost physician, P = 0.004), age ($790 increase per 10-year increase in age, P = 0.002), urgency of the procedure ($4,100 increase for urgent vs elective, p 0.001), and combined angiography and PTCA ($850 increase vs separate angiography, P = 0.04). Independent predictors of catheterization laboratory cost included the physician ($1,280 increase from highest- to lowest-cost physician, P = 0.03), American College of Cardiology/American Heart Association lesion type B2 or C ($320 increase, P = 0.03), and combined angiography and PTCA ($430 increase, P = 0.003). Expensive operators used more catheterization laboratory resources than inexpensive operators; however, there were no significant differences in success rate or need for emergent bypass surgery between physicians. PTCA cost is determined by both patient characteristics and the performing physician. The increase in cost due to the physician was not explained by patient variables, lesion characteristics, success rate, or complications.