| The group of pathogens
known as STEC O157 includes Escherichia coli
O157:H7 and other serotypes of the Shiga-toxin-
producing E. coli strain O157. Most persons
with symptomatic STEC O157 infections experience
an acute diarrheal illness. Some also develop hemolytic
uremic syndrome (HUS), a systemic complication involving
acute kidney failure that may result in end-stage
renal disease (ESRD) or death. ESRD is a serious
chronic condition that reduces life expectancy.
The ERS STEC O157 cost estimate includes the annual
costs of medical care, lost productivity due to
nonfatal illness, and the cost (value) of premature
deaths due to acute illness, HUS, and chronic ESRD
caused by STEC O157 infections in the United States.
The ERS estimate excludes a number of other potential
costs, such as: disutility (nonfatal illnesses,
resulting in pain and suffering); travel or child
care among others. Calculator users can include
these and other costs in their own estimates.
The ERS estimates are from a joint study by ERS
and the Foodborne Diseases Active Surveillance Network
(FoodNet) of the costs of STEC O157 (Frenzen
et al., 2005). The study reports costs in 2003
dollars but the default year for the ERS estimate
included in the Calculator is 2010. Detailed information
about the estimation methodology and assumptions,
some alternative assumptions, and technical references
are provided below. Please see the
per-case assumptions page for a summary table
of the per-case assumptions used in the calculations.
Use the links below to navigate through the documentation:
Annual Number
of Cases
The ERS estimate uses the most recent estimate
of annual STEC O157 cases by the Centers for Disease
Control and Prevention (CDC) (Mead et al., 1999).
CDC estimates that STEC O157 from all sources is
responsible for 73,480 annual illnesses in the United
States, resulting in 2,168 hospitalizations and
61 deaths.
Calculator users can make their own assumptions
about the annual number of cases.
Foodborne Transmission
Rate
CDC Assumption:
CDC estimates that the share of STEC O157 cases
due to consumption of contaminated food is 85
percent, or 62,458 cases annually (Mead et al.,
1999).
Food Safety and Inspection Service (FSIS) Assumption:
FSIS estimated that 60 percent of E. coli
O157:H7 cases were due to the consumption of contaminated
meat or poultry in 1996, when the final Hazard
Analysis Critical Control Point (HACCP) rule was
published (U.S. Department of Agriculture, 1996).
If this estimate of the proportion of E. coli
O157:H7 cases due to contaminated meat or poultry
is applied to the CDC estimate of annual STEC
O157 cases, the annual number of cases due to
contaminated meat or poultry would be 44,088.
More recently, the FSIS draft risk assessment
of the public health impact of E. coli
O157:H7 in ground beef reported median estimates
of the annual number of E. coli O157:H7
cases (94,000) and cases due to the consumption
of contaminated ground beef (17,500 to 19,000)
(Ebel et al. 2004). The median estimates imply
that about 19 percent of cases were due to ground
beef. If this estimate of the proportion of cases
due to ground beef is applied to the CDC estimate
of annual STEC O157 cases, the annual number of
cases due to ground beef would be 13,961.
Calculator users can make their own assumptions
about the annual number of STEC O157 cases due to
contaminated food or to other sources.
Classification of Cases by
Severity
To provide more detailed information about the
outcome of STEC O157 infections, ERS expanded the
CDC estimate of annual STEC O157 cases, hospitalizations
and deaths to seven severity categories. The Calculator
determines the costs for each severity category
and then sums across categories to obtain total
costs.
The seven severity categories are:
- Severity 1: not hospitalized: didn't visit
physician, survived
- Severity 2: not hospitalized: visited physician,
survived
- Severity 3: hospitalized: didn't have HUS,
survived
- Severity 4: hospitalized: had HUS but not ESRD,
survived
- Severity 5: hospitalized; had HUS and ESRD,
survived
- Severity 6: hospitalized: didn't have HUS,
died
- Severity 7: hospitalized: had HUS, died
Information about each severity category was obtained
primarily from FoodNet (Centers for Disease Control
and Prevention 2005). The FoodNet data sources were:
- Surveillance data on laboratory-diagnosed STEC
O157 infections in 1997-2002
- Surveillance data on HUS cases in 1997-2002
- 2002-2003 FoodNet Population Survey of residents
of the FoodNet surveillance sites
- 1999-2000 E. coli O157 case control study
of laboratory-diagnosed STEC O157 infections.
The FoodNet STEC O157 and HUS surveillance data
were linked to identify cases that developed HUS.
The E. coli O157 case-control study provided
data on persons who had laboratory-diagnosed STEC
O157 infections. The Population Survey provided
data on persons who recently had acute diarrhea
but did not obtain medical care, or else visited
a physician but did not provide a stool sample and
did not require hospitalization. These individuals
were assumed to resemble persons with undiagnosed
STEC O157 infections who did not obtain medical
care or else visited a physician but were not hospitalized.
Frenzen
et al. (2005) provide a detailed description
of the methods and data sources used to estimate
the number of cases in each severity category.
Calculator users can change the distribution of
cases among severity levels.
Adjustments for Price Inflation
The Calculator adjusts each type of cost for price
inflation, using seven annual Consumer Price Index
(CPI) series (Bureau of Labor Statistics 2010).
The seven series are the CPI for all items, medical
care, hospital services, inpatient hospital services,
physician services, prescription drugs and medical
supplies, and internal and respiratory over-the-counter
drugs. The Calculator uses a weighted average of
the CPI series for inpatient hospital services and
physician services to adjust the cost of hospital
admissions. See table
of CPI components.
Calculator users can choose to have costs reported
in dollars for any year from 1997 to 2010 through
the pull-down menu at the top of the main table.
The default year is 2010. Calculator users should
be aware that most of the information about costs
is from 2001 or earlier years, so adjustments for
inflation for years after 2001 may produce estimates
that differ from the results that would be obtained
if more recent cost information was available.
Amount of Medical Care for
Acute Illness
The Calculator estimates the cost of medications,
physician visits, emergency department visits, and
hospital admissions for acute illness due to STEC
O157 infections. Estimates of the average amount
of medications, number of physician visits, and
number of emergency department visits for persons
whose illness was not laboratory-diagnosed were
obtained from FoodNet Population Survey data on
persons who recently had acute diarrhea. Comparable
estimates for persons whose illness was laboratory-diagnosed
were obtained from the FoodNet E. Coli O157
case control study.
No data were available on medication use, physician
visits, or emergency department visits due to acute
illness for cases in severity categories 4-7. Therefore,
these cases were assumed to have used the same amount
of medical care as cases from the most similar severity
category with data available.
The estimates of medication use include the prescription
and nonprescription antibiotics, antidiarrheals,
and antiemetics mentioned by the FoodNet survey
respondents. Because the FoodNet surveys asked about
which medications were used but not about the quantity
consumed, respondents were conservatively assumed
to have used only one course of each prescription
drug and one retail unit of each nonprescription
medication.
Information about the number of hospital admissions
per hospitalized case was unavailable. Therefore,
each hospitalized case was conservatively assumed
to have been admitted to the hospital only once.
The procedures used to estimate the amount of medical
care for acute illness are described in Frenzen et al. (2005). Calculator users can change the amount
of medical care for any or all of the severity categories.
Costs of Medical Care for
Acute Illness
ERS obtained information about the average national
cost of prescription and nonprescription medications,
physician office visits, emergency department visits,
and hospital admissions for acute illness due to
STEC O157 infections from a variety of data sources.
Average Cost of a Prescription Drug:
The average cost of the prescription drugs used
by FoodNet survey respondents was estimated using
data from the 2001 Medical Expenditures Panel
Survey (MEPS) prescribed medicines file, which
provides estimates of expenditures on prescription
drugs for households (Agency for Healthcare Research
and Quality 2004a).
Average Cost of a Nonprescription Medication:
The average cost of the nonprescription medications
used by FoodNet survey respondents was estimated
from the average wholesale price for retail-size
units of each medication in 2004 (Thomson PDR
2004). The average wholesale price was adjusted
upward by the estimated retail markup for nonprescription
medications (Covington 2002), and updated using
the CPI for internal and respiratory over-the-counter
drugs.
Cost of a Physician Office Visit:
The average cost of a physician office visit
was estimated from 2000 National Health Accounts
data on physician and clinical services expenditures
(Centers for Medicare and Medicaid Services 2004),
and the estimated number of physician office visits
in the same year. Expenditures on physician and
clinical services were adjusted to exclude services
other than physician office visits using data
on Medicare physician payments by type of service
(Wassenaar and Thran 2001). The number of physician
office visits was estimated from American Medical
Association data on the average number of weekly
patient visits per physician in 1999, the average
annual number of weeks in practice per physician
in 1998, and the number of office-based patient
care physicians (Pasko and Seidman 2002; Wassenaar
and Thran 2001). The estimated cost was updated
using the physician services CPI.
Cost of an Emergency Room Visit:
The average cost of an emergency room visit
was estimated from national expenditures on emergency
department visits in 1987 (Tyrance et al., 1996),
and the number of emergency department visits
in the same year (U.S. Census Bureau 1991). The
estimated cost was updated using the hospital
services CPI.
Cost of a Hospitalization for a STEC O157 Infection
Not Resulting in HUS:
The average cost of a hospitalization for a
STEC O157 infection not involving HUS was estimated
using data from the 2001 Nationwide Inpatient
Sample (NIS) on admissions with a principal diagnosis
of enterohemorrhagic E. coli infection
(ICD-9 code 008.04) but without a secondary diagnosis
of HUS (ICD-9 code 283.11) (Agency for Healthcare
Research and Quality 2004c). The NIS reports hospital
charges, which exceed the payments actually received
by hospitals because health plans negotiate substantial
price discounts for their enrollees. Therefore,
the average hospital charge was multiplied by
the average cost-to-charge ratio for U.S. hospitals
in 2001, which was 0.454. This ratio was obtained
by weighting the hospital cost-to-charge ratios
for the urban and rural areas of each state in
2001 (Health Care Financing Administration 2001)
by the number of hospital admissions in each area
in 2001 obtained from the Area Resources File
(Health Resources and Services Administration
2003).
The NIS estimate of the average hospital charge
excludes the cost of physician services billed
separately from hospital services. These additional
costs were estimated using the 2001 MEPS hospital
inpatient stays file, which reports expenditures
on hospital inpatient care for households classified
by whether payments were made to hospitals or
physicians (Agency for Healthcare Research and
Quality 2004b). The ICD-9 diagnosis codes on the
MEPS hospital inpatient stays file were not detailed
enough to identify STEC O157 cases, so payments
to physicians were assumed to equal the physician
share of payments for all hospitalizations, which
was 17.3 percent.
Cost of a Hospitalization for a STEC O157 Infection
Resulting in HUS:
The average cost of a hospitalization for a
STEC O157 infection involving HUS was estimated
in the same way as the cost for a hospitalization
not involving HUS, except hospitalizations were
defined as admissions with a principal diagnosis
of HUS (ICD-9 283.11), or else a principal diagnosis
of enterohemorrhagic E. coli infection
(ICD-9 008.04) and a secondary diagnosis of HUS
(ICD-9 283.11).
Calculator users can change the average cost of
medications, physician office visits, emergency
department visits, or hospital admissions for any
or all of the severity categories.
Amount of Time Lost from Work
Due to Acute Illness
The Calculator uses information about time lost
from work and average daily productivity for U.S.
workers to estimate the cost of lost productivity
due to acute illness caused by STEC O157 infections.
Estimates of time lost from work for STEC O157 cases
whose illness was not laboratory-diagnosed were
obtained from FoodNet Population Survey data on
employed persons who recently had acute diarrhea.
Comparable estimates for STEC O157 cases whose illness
was laboratory-diagnosed were obtained from the
FoodNet E. Coli O157 case control study.
Employed persons were classified into two age groups
(15-39 and 40+ years) because employment rates and
productivity vary by age.
Both of the FoodNet surveys asked about the number
of days when respondents missed more than half a
day from work due to their illness. Each reported
day was assumed to equal three-fourths of a full
work day. Population Survey respondents who were
still ill when interviewed were excluded from the
estimates to avoid underestimating lost work days.
Case-control study respondents who were still ill
were included using survival analysis to model their
return to work adjusted for data censoring.
No data were available on time lost from work due
to acute illness by nonfatal cases in severity categories
4 or 5, or by fatal cases prior to death. Therefore,
these cases were assumed to have lost the same average
number of days from work as cases from the most
similar severity category with data available.
In order to simplify the Calculator, the cost of
lost productivity is calculated using the average
employment rate and number of days lost from work
per employed person for each severity category,
instead of separate values for each age group. Calculator
users can change the average employment rate and
number of days lost from work for any or all severity
categories.
Costs of Time Lost from
Work Due to Acute Illness
The average daily productivity of U.S. workers
classified by age was estimated using data on employment
and earnings in 2000 from the March round of the
2001 Current Population Survey (Bureau of Labor
Statistics 2001). Earnings included wages, salaries,
self-employed business income, and farm self-employment
income. The earnings estimate was adjusted to include
employer costs of benefits for civilian wage and
salary workers in March 2001 (Bureau of Labor Statistics
2001). Estimated productivity was updated to 2001
dollars using the all-items CPI.
In order to simplify the Cost Calculator, the cost
of time lost from work is calculated using the average
daily productivity per day lost from work for each
severity category. Calculator users can change the
average daily productivity for any or all of the
severity categories.
Alternative Assumption
The ERS estimate includes the cost of lost productivity
for employed individuals only. An alternative
assumption is to estimate the cost for all individuals,
including persons not in the labor force such
as children, stay-at-home moms, and retirees.
Under this assumption, the average daily productivity
for persons not in the labor force is the same
as for employed persons. Calculator users can
choose this assumption by checking the "all cases"
option.
Lifetime Medical Care Due
to ESRD
The lifetime cost of medical care for chronic ESRD
due to STEC O157 infections was estimated from data
on medical costs for the ESRD population (U.S. Renal
Data System 2003). The present distribution of medical
costs for the ESRD population by age and treatment
mode was assumed to be the schedule of costs that
STEC O157-related ESRD cases would incur during
their lifetime as they aged and alternated between
kidney dialysis and a functioning kidney transplant.
The future period during which STEC O157-ESRD cases
would incur costs was determined by calculating
an abridged life table for the ESRD population.
The data on medical costs for the ESRD population
were 1997-2001 ESRD expenditures by the Medicare
program, which covers most ESRD patients. The age-specific
mean annual Medicare expenditures per ESRD patient
were averaged across treatment mode, adjusted upward
to include expenditures by other payers using the
ratio of total ESRD medical costs to Medicare ESRD
costs, and updated to 2001 dollars using the medical
care Consumer Price Index (CPI). The present value
of future medical costs for ESRD cases was then
estimated by summing the age-specific expenditures
over the life expectancy of cases from the age they
became ill, using a 3 percent annual discount rate.
Calculator users can change the average lifetime
cost of medical care for ESRD cases (severity category
5).
Lifetime Productivity
Costs Due to ESRD
The lifetime cost of lost productivity due to STEC
O157-related ESRD was estimated using data on age-specific
employment rates for the ESRD and general populations.
The difference in employment rates between the two
populations was assumed to be the reduction in employment
due to ESRD. Employment rates for ESRD dialysis
patients were obtained from a national study (Curtin
et al., 1996). Employment for ESRD transplant patients
were assumed to be 83 percent higher than for dialysis
patients on the basis of an earlier national study
(Evans et al., 1985). U.S. employment rates were
obtained from the March 2001 CPS (Bureau of Labor
Statistics 2001).
The age-specific cost of lost productivity for
the ESRD population was determined by multiplying
the age-specific proportion of persons not employed
due to ESRD averaged across treatment mode by the
average annual earnings per U.S. worker in 2000
from the March 2001 CPS classified by age and self-employment
status, adjusted to include employer costs of benefits,
and updated to 2001 dollars using the all-items
CPI. The present value of future lost productivity
for ESRD cases was then estimated by summing the
age-specific costs over the life expectancy of cases
from the age when they became ill, using a 3-percent
annual discount rate.
Calculator users can change the average lifetime
cost of lost productivity for ESRD cases (severity
category 5).
Disutility Costs: Nonfatal
Cases
Disutility costs include all of the factors associated
with diminished well-being due to illness or premature
death, including the costs of pain and suffering,
inconvenience, time lost from regular activities,
and lost productivity. The disutility costs of illness
are typically measured by the amount of money (or
another measure of well-being) that the average
person would be willing to give up to avoid an illness
or premature death. One example is the amount of
money (wages) a person would be willing to give
up to switch from a high-risk to low-risk job.
ERS cost estimates do not include any disutility
costs for nonfatal cases. However, the ERS willingness-to-pay
estimate of the cost of premature death is an estimate
of disutility, like all willingness-to-pay estimates.
Alternative Assumptions
Calculator users may choose to include disutility
costs in their cost estimates for nonfatal cases.
One approach for estimating the loss of well-being
that an individual suffers due to a disease or
condition is by estimating the Quality Adjusted
Life Years (QALYs) or Quality Adjusted Life Days
(QALDs) for each outcome. Researchers establish
the relative disagreeableness of each health state
and assign each one a disutility weight, ranging
from 0 (death) to 1 (perfect health). The FDA
calculated the utility losses from microbial hazards
in juice for the regulatory impact analysis for
proposed juice safety rules (FDA 1998 and 2001).
They calculated the total disutility per day for
nonfatal E. coli O157:H7 infections at
0.5641 for mild cases; 0.5844 for moderate cases;
0.8639 for severe-acute cases; and 0.4469 for
severe-chronic cases. FDA did not calculate a
separate disutility cost for fatal cases because
disutility is included in the estimated cost of
a premature death derived from the value of a
statistical life.
The health disutility value can then be translated
into dollars by applying it to average dollar
utility estimates (though a 2006 Institute of
Medicine report on valuing health recommends that
regulatory analyses should not assign monetary
values to estimates of health-adjusted life years
(IOM 2006)). FDA researchers converted the E.
coli O157:H7 disutility values into dollar
measures using a compensating wage midpoint estimate.
Compensating wage estimates calculate the amount
of money that workers would be willing to forego
in order to reduce job related mortality risk.
These estimates have been used to calculate the
value of a statistical life. Two widely cited
surveys of compensating wage studies place the
most reliable empirical results in the $1.6 million
to $8.5 million range (1986 dollars) (Fisher et
al., 1989) and the $3 million to $7 million range
(1990 dollars) (Viscusi 1993). For their disutility
calculations, FDA researchers assigned a value
of $5 million to premature death and a proportion
of this amount to all other outcomes, depending
on the outcome's disutility weight. Assuming that
the average illness strikes a 40 year old with
an average remaining lifespan of 36 years, FDA
researchers discounted future health benefits
to estimate the value of a "discounted life year"
at $230,000 and the value of a "discounted day"
at $630. FDA used the discounted value of a healthy
day (along with information on duration) to calculate
a dollar measure of utility loss per case of E.
coli O157:H7 of $1,800 for mild cases (equivalent
to Severity 1); $3,300 for moderate cases (equivalent
to Severity 2); $17,200 for severe-acute cases
(equivalent to Severity 3 & 4); and $995,700 for
severe-chronic cases (equivalent to Severity 5)
(FDA 1998, table 7). ERS assumed that the FDA
estimates were in 1998 dollars and updated the
values for inflation using the All Items component
of the CPI, rounding the result to the nearest
hundred dollars. Although calculator users can
include the FDA disutility estimates in the cost
estimate for nonfatal cases, this option is not
available for fatal cases because the ERS estimate
of the cost of premature death already includes
an estimate of disutility costs.
Premature Death Due to
Acute Illness
The cost of premature deaths due to acute illness
caused by a STEC O157 infection was estimated using
a modified value of a statistical life approach
that takes age at death into account (Mauskopf and
French 1991).The value of a statistical life was
assumed to be the midpoint of compensating wage
studies of the wage differential for jobs with higher
mortality risks, or $5.0 million in December 1990
dollars at age 40 (Viscusi 1993), updated to $6.6
million in 2001 dollars using the all-items CPI.
This estimate of the cost of premature death includes
all disutility costs such as the cost of pain and
suffering.
The value of a statistical life was treated as
if it was the value of a fixed annual annuity paid
over the average U.S. life span at an interest rate
of 3-percent. The cost of a death at any particular
age was therefore the present value of life expectancy
at that age. After adjusting for age at death, the
estimated cost of a premature death ranged from
$9.0 million for an infant aged <1 year to $1.8
million for an adult aged $ 85 years in 2001 dollars,
using the age-specific life expectancies from the
2001 U.S. life table (Arias 2004). The Cost Calculator
uses the average cost of a death not involving HUS
($3.8 million in 2001 dollars) for severity category
6, and the average cost of a death involving HUS
($5.9 million in 2001 dollars) for severity category
7.
The procedures used to estimate the cost of premature
deaths are described in Frenzen et al. (2005). Calculator
users can change the average cost of a premature
death for either severity category 6 or 7.
FDA Assumptions
Like ERS, FDA uses a compensating wage midpoint
estimate of the value of a statistical life, or
$5.0 million at age 40 in December 1990 dollars,
updated to $6.5 million in 2000 dollars (FDA 1993).
Unlike ERS, FDA does not adjust the cost of premature
deaths for age at death.
Calculator users can choose to use the same cost
per premature death as FDA.
Environmental Protection Agency (EPA) Assumptions
EPA estimates of the cost of premature death
are based on a mid-range estimate of the value
of a statistical life derived from 21 compensating
wage studies and 5 contingent valuation studies
conducted during the late 1970's and the 1980's.
To allow for probabilistic modeling of mortality
risk reduction benefits, EPA set the mean value
at $5.8 million in 1997 dollars using a Weibull
distribution (EPA 2000). Although some EPA analyses
include adjustments for age, the EPA Guidelines
for Preparing Economic Analyses do not encourage
such value adjustments (EPA 2000).
Calculator users can choose to use the same cost
per premature death as EPA.
Premature Death Due to ESRD
ERS estimated the cost of premature death due to
STEC O157-related ESRD using the same modified statistical
value of life approach employed for deaths due to
acute illness caused by an STEC O157 infection.
ESRD cases were grouped into the age categories
from the abridged life table for the ESRD population,
and their age at death was assumed to be the age-specific
life expectancy from the life table. The present
value of the reduced life expectancy due to ESRD
was calculated by summing the annuity payments that
would be foregone if ESRD cases experienced the
shorter age-specific life expectancies for the ESRD
population rather than the longer life expectancies
for the general population from the 2001 U.S. life
table (Arias 2004), using a 3-percent annual discount
rate. The Cost Calculator uses the average cost
of an ESRD death ($4.3 million in 2001 dollars)
to determine the cost of premature deaths due to
ESRD.
The procedures used to estimate the cost of premature
deaths are described in Frenzen et al. (2005). Calculator
users can change the average cost of a premature
death from ESRD (severity category 5).
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Agency for Healthcare Research and Quality, U.S.
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