and $670,000 is to be spent by other agencies.
b. Short-Term Benefits

From an estimated base of 6,800 deaths in the population screened
which would occur without this program component ~~” a 14 reduction in
immediate mortality is anticipated due to the successful treatment of
acute pyelonephritis (if it is detected at an early stage before severe
tissue damage has occurred) Therefore, a reduction in mortality of
70 deaths per year is estimated.

In addition, there is a reduction in the prevalence of significant
bacteriuria in 3,231,260 patients (50% of 6,462,520). This 50% reduc-
tion is based on the supposition that the majority of cases detected
will be of simple bacteriuria, in the absence of tissue infection, which
responds well to treatment. It is understood that the first course of
therapy for patients with bacteriuria in acute infections would be
highly successful, but is is not anticipated that a permanent cure
will be achieved in individuals with chronic urinary tract infections.

With therapy, the number of morbid days could be reduced by 65%

1
from the base of 24,557,580 to 15,962,427 22

c. Long-Term Benefits

A significant benefit from this early detection program will be an
ultimate reduction in mortality due to end-stage renal disease resulting
from earlier urinary tract infections After a diagnosis of infec-
tion is made, further study of the patient would lead to the detection

of factors predisposing to or associated with that infection. It

should be pointed out that new methods of anti-infectious therapy could
20/

 

possibly increase the cure rate for the population-at-risk to 75%.
(1) Annual Long-Term Benefits
At present, it is estimated that 20% (1,750) of an esti-

mated total cases (8,500) of end-stage kidney disease per year
21/

can be averted by current medical therapy.
(2) Cumulative Long-Term Benefits

It is estimated that in time 5% (323,126) of the 6,462,520
individuals having significant bacteriuria may have developed a
significant urinary tract infection. Of this 54, approximately
40% (129,250) may eventually die in renal failure. Implementation
of the above program would be expected to reduce this mortality by

22/
20% (25,850) based on current methods of therapy.

3. Research
Because of problems peculiar to urinary tract infection, [i.e., the
poor response to therapy (20% cure rate) and the difficulty in isolating
bacteria from end-stage kidneys resulting from infection], a great deal
of research, both laboratory and clinical, must be undertaken before a
more effective program can be administered in the prevention of urinary
tract infections.
a. Laboratory Research
Laboratory research should be concentrated in these areas:
1) A relationship of viral agents to renal disease;
2) The identification and treatment of host-factors which
predispose the host to urinary tract infections;
3) The role of immunologic phenomena in bacterial and/or viral
infections of the kidney;
4) The role of vascular and metabolic diseases in urinary tract

infections;
103

5) The role of various chemical agents (e.g., phenacetin) in
renal tissue infection;

6) The nature of the exudative response to renal infection;

7) The nature of connective tissue proliferation in renal
tissue;

8) A classification of the organisms causing renal infections
and the identification of toxins, enzymes, etc., produced
by these organisms; and

9) The pharmacology of specific antibiotics including drug
inhibitors affecting the viability of microorganisms in
renal tissue.

No sound estimate can be made for the cost of each of these
basic research programs, but approximately $1,500,000 should be
made available in the form of research grants from new. 22/

b. Clinical Research

Clinical research must include studies to evaluate therapeutic
programs and long-term follow-up of patients with kidney infections,
and attempts to identify crucial points in the natural history of the
disease at which therapy is most effective. Other studies would be
attempted with susceptible patients (pregnant females, persons
with obstructive uropathy, diabetics, etc.) to discover pertinent
facts in the pathogenesis of renal infection. It is estimated that
each large scale clinical study will cost approximately $500,000 per
year This amount is based on existing cooperative studies and
does not include the cost of hospitalization or laboratory tests

which must be borne by other sources. Four cooperative studies

will be developed, each costing $500,000: one study will address
104

itself to a study of the natural history of renal infection; two,
to therapeutic trials; and a fourth to the pathogenesis of the
disease in susceptible sub-groups of patients.

An additional $500,000 will be used for detailed studies on
a small group of patients with renal infection. This study would
encompass the definition of changes in renal function, the effects
of specific antibacterial agents on the infection, the trial of new
treatments such as chronic water loading, etc.

Total clinical research expenditures will amount to $2,500,000

supported by HEW.

Total costs for research will be $5,330,000 of which HEW would
contribute $4,000,000; $1,330,000 would come from other sources.
4. Training

Training includes the financial support of research fellows engaged
in clinical laboratory studies, and the cost of relevant facilities.
Support and laboratory facilities for approximately 12 fellows for one
year would cost HEW approximately $400,000 plus $130,000 from other
sources, yielding a total of $530,000. —~
5. Facilities

This program utilizes only existing facilities; however, laboratory
and hospital space is limited at present and in order to develop an
efficient program as outlined, expanded facilities would undoubtedly be
required for research and for the screening of patients for urinary
tract infection. Consequently, it is anticipated that about $1,000,000
would be expended by HEW and an additional $330,000 by other sources,

yielding a total of $1,330,000.
105

A benefit-cost summary associated with this program is presented

in Table I.
BCOT

Table I

INFECTIOUS DISEASES OF THE URINARY TRACT, HYPOTHETICAL PROGRAM
AT CURRENT HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

Short-Term Benefits

Long-Term Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reduction Reduction In
Expenditures Per Year In End-Stage Uremia
HEW Total
Program ($1,000) ($1,000) Mortality |Prevalence|Morbid Days | Per Year |Cumulative
I.A,. Screening, diagnosis and treatment of
individuals in short and long-term
hospitals and nursing homes as well
as non-hospitalized pregnant females |
and diabetics,
1. Screening 1,803 9,017
2. Confirming test 84,457
3. Treatment 54,931
Sub~ Total 1,803 148,405
B. Supportive education and administra-
tion : 2,000 2,670
Sub-Total 3,803 151,075
II. Research 4,000 5,330
Ill. Training 400 530
IV. Facilities 1,000 1,330
TOTAL 9,203 158,265 70 3,231,260; 15,962,420 1,750 25,850

 

 
Infectious Diseases of the Urinary Tract, Hypothetical Program
at Intermediate HEW Expenditure Level, Based on Current State
of the Art
1. Introduction

This program has four components:

1) Screening, diagnosis, treatment, and supportive education and

administration;

2) Research;

3) Training; and

4) Facilities.

As illustrated in Figure 2, the total cost for this program is
estimated to be $174,252,000, of which HEW funds would account for
$20,179,000. A discussion of the various program components follows.

2. Screening, Diagnosis, Treatment, and Supportive Education and
Administration

This program is concerned with the screening, diagnosis and treat-
ment of infections of the urinary tract similar to those described in
Section B.2. above. It has, however, been expanded to include all
females 6 to 9 years of age who can realistically be reached in a
screening program. It is felt that this group can best be reached
through screening tests applied in elementary schools.

a. Relevant Population and Program Component Costs

Because of the difficulties anticipated in attempting to reach
the entire female population 6 to 9 years of age, it is assumed
that a successful program covering a two-year span will be able

26/ 27/
to reach about 62% of these individuals. Of 8,134,000 females

in this age group, 5,040,000 will be reached every two years, and

50% (2,520,000) of these individuals will be screened each year.
sosts ($1,000,000)

174-3
150
100
Diagnosis and
Treatment
(155.3)
50
20.2 Diagnosis and

Treatment (5.9) Research (7.3)

Research (5,5 Training (1.0)

Training (.75)

Facilities (8.0 Facilities (10.
“HEW TOTAL

PROGRAM

 

Fig. 2. Infectious Diseases of the Urinary Tract, Hypothetical Program
Costs at Intermediate HEW Expenditure Level, Based on the
. Current State of the Art.

106a
107

Cost of screening per individual in this additional population
is estimated at $0.25 (as part of a general screening program).

If 2,520,000 are screened annually, the total cost will be
$630,000 ($126,000 from HEW) yearly.

Total cost for screening all the population-at-risk, reached
by a general screening program, will be $9,647,000 ($1,929,000
from HEW).

It is believed that 1% of these young females (25,200) will
have significant bacteriuria.” It is still assumed that only 85%
(21,420) of these individuals can be screened, and that the test
has associated with it a 5% false positive value so that 22,491
will have positive results. Confirmatory tests will be necessary
both before and after therapy; therefore, at $7.50 per test, the
total cost for confirmatory tests will be $330,000. For the
entire surveyed population, the cost for these confirmatory tests
will amount to $84,787,000, none of which will come from HEW.

The treatment costs for each of the females 6 to 9 years of age
is estimated at $10.00 for drugs and $15,00 for physicians’
services, or a total cost for all of these individuals of $557,000.
Total treatment costs for all groups surveyed having renal infections
are $55,488,000.

The costs outlined above are minimal and are based on conserva-
tive estimates. They do not include, for example, intravenous pyelo-
grams and other diagnostic studies necessary for complete diagnosis.

Also note that the overlap in the female population 6 to 9
years of age and the other high-risk groups (that is, the individuals

in short and long-term hospitals, nursing homes and the non-~
£08

hospitalized pregnant females and diabetics) has not. been taken
into account and some double-counting may be present.
The supportive education and administration portions of this
program component are estimated at a level of $4,000,000 from
HEW and $1,330,000 from other sources 2 The educational program
involves the extensive education of medical personnel throughout
the country in the proper uses of catheters and antibiotics, the
importance of follow-up studies on individuals with urinary tract
infections, the natural history of pyelonephritis, the proper use
of diagnostic techniques, etc. The focal centers of the educational
program will be community hospitals from which information will be
disseminated among appropriate personnel.
Total costs for this program component are estimated at
$155,252,000 ($5,929,000 from HEW).
b. Short-Term Benefits

In addition to the short-term benefits described in Section B.2.
above, the following benefits are expected to result from the screen-
ing of these young females:

1) Due to the current low mortality rate from urinary infec-
tions in females 6 to 9 years of age, no estimate on the
reduction of immediate mortality is made;

2) A 50% reduction in the prevalence rate from a base of 25,200
to 12, 600;22" and

3) A 65% reduction of 311,220 in morbid days from a base of
478,000."

Total short-term benefits for all groups surveyed are 70

prevented deaths, a reduction in prevalence by 3,243,860, and a
wl
203
reduction in morbid days by 16,273,640.

c. Long-Term Benefits

(1) Annual Long-Term Benefits

 

Early diagnosis and treatment of urinary tract infections
in this group of females 6 to 9 years of age will decrease the
number of cases of renal failure by 20 per year. (A 33%
reduction from a base line of 60 which would eventually have

33/
acquired end-stage uremia without this program).

There will be a reduction by 1,770 cases of end-stage

34/

uremia in all relevant groups from a base line of 8,560.

(2) Cumulative Long-Term Benefits

 

35/
Approximately 5% (2,520) of the 50,400 females with

bacteriuria could eventually develop significant urinary tract
infections. Approximately 40% (1,010) of these individuals
would have developed end-stage uremia. Since the females in
this age group can be reached at a very early stage of the
disease, a reduction in end-stage uremia by 33% (340) is
anticipated.
About 26,190 cases of eventual renal failure in all

groups surveyed will be avoided.

3. Research

Again, clinical and laboratory research are the two major areas
of effort. Given increased resources, it is realistic to project that
two additional clinical research programs at $500,000 each could be

added to the four existing ones at a total cost of $3,000,000.

Laboratory research project expenditures could feasibly be increased
110

to $2,000,000 (i.e., an increase of $500,000). Again, a $500,000
project designed to study susceptible sub-groups of patients is
also anticipated. The total HEW support for research is $5,500,000,
and it is anticipated that about $1,830,000 will be. generated from other
sources.
4. Training

Training expenditures are estimated to be $750,000 from HEW with
an additional $250,000 from other sources.

"5, Facilities

In the intermediate health program, it is estimated that HEW will

provide $8,000,000 in addition to an expected $2,670,000 from other

sources.

A benefit-cost summary associated with this program is presented in

Table II.
Table II

INFECTIOUS DISEASES OF THE URINARY TRACT, HYPOTHETICAL PROGRAM
AT INTERMEDIATE HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

Short-Term Benefits

Long-Term Benefits

 

 

 

 

 

 

 

 

 

 

 

 

Reduction Reduction In
Expenditures Per Year In End-Stage Uremia
HEW Total
Program ($1,000) ($1,000) Mortality} Prevalence|Morbid Days | Per Yearj Cumulative
I.A. Screening, diagnosis and treatment of
individuals in short and long-term
hospitals and nursing homes as well
4 as non-hospitalized pregnant females,
diabetics and females 6 to 9 years of
age,
1. Screening 1,929 9,647
4 2. Confirming 84,787
2
* 3. Treatment 55,488
Sub-Total 1,929 149,922
B. Supportive education and administra-
tion 4,000 5,330
Sub-Total 5,929 155,252
II. Research 5,500 7,330
III. Training 750 1,000 ;
IV. Facilities 8,000 10,670
}
TOTAL 20,179 174,252 70 | 3,243,860; 16,273,640 1,770 | 26,190

 

 

 

 

 

 

 

 
111

Infectious Diseases of the Urinary Tract, Hypothetical Program
at Accelerated HEW Expenditure Level, Based on Current State of
the Art
1. Introduction
This program has four components:
1) Screening, diagnosis, treatment, and supportive education and
administration;
2) Research;
3) Training; and
4) Facilities.
As illustrated in Figure 3, the total cost for this program is
estimated at $189,013,000, of which HEW will contribute $27,394,000.

A detailed discussion of the various program components follows.

2. Screening, Diagnosis, Treatment, and Supportive Education and
Administration

In addition to the high risk groups surveyed in Section B.2., this
Program component has been expanded to include all females 21 years of
age and under. It is again postulated that the expected rewards from
controlling infectious diseases of the urinary tract in these females
would be sizeable enough to merit its consideration. It is desirable to
reach the majority of females in this age group through schools, colleges,
and various youth programs such as Operation Headstart.

a. Relevant Population and Program Component Costs

A successful program will probably reach approximately 60% of

the relevant female population. This program will again cover a

two-year span so that one-half of this population will be screened

every year. Therefore, of the 41,065,000 females 21 years of age

and under in the U. S.,~ 12,319,500 will be screened each year

[i.e., 24,639,000 (approximately 60%) of the total will be reached in
Costs ($1,000,000)

189) pp

156 F—

50;

 

 

 

 

 

 

 

 

Diagnosis and
Treatment
(165.7)

 

 

 

 

 

 

27.4 -—
Diagnosis and
Treatment (9.9) Research (8.7)
Research (6.5) Training
Training (.98)
Facilities (10) Facilities
(13.3)
HEW TOTAL
PROGRAM
Fig. Infectious Diseases of the Urinary Tract, Hypothetical Program

Costs at Accelerated HEW Expenditure Level, Based on the

Current State of the Art.

llla

(1.
212

two years, and 50% of these, or 12,319,500, will be reached every
year]. It is estimated that about 1% of the females 21 years of age
and under, 246,390, will have significant bacteriuria; therefore,
123,195 will be detected each year. It is to be emphasized that
this figure is quite conservative since it is known that females

12 to 16 years of age have a high incidence of bacteriuria” and
while no information was available regarding the incidence of
bacteriuria in college-age females, it may be even higher than that
of other school-age females.

Screening costs in this female population are estimated at $0.25
per person (as part of a general screening program). If 12,319,500
are screened annually, the total cost will be $3,080,000 ($616,000
from HEW).

Total screening costs for all the surveyed populations (includ-
ing those described in Section B.2.) will be $12,097,000 ($2,419,000
from HEW.

The number of confirmatory tests required for females 21 years
of age and under will be 109,952 pre-therapy and 104,716 post-therapy

40/
tests, and the cost for these tests will be $1,610,000 assuming a

rate of $7.50 per test.

For all the surveyed populations (including those described in
Section B.2.) the total cost for confirmatory tests will be
$86,067,000, none of which is assumed to come from HEW.

The treatment costs for each female 21 years of age and under
with a confirmed diagnosis of renal infection is estimated at $10.00

for drugs and $15,00 for physicians’ services. This means that the
213

total cost for these affected females is $2,618,000, all of which
comes from sources other than HEW.

Total treatment costs for all population groups surveyed
having renal infections are $57,549,000.

The costs outlined are minimal and do not include such items
as intravenous pyelograms and other diagnostic studies which are
necessary for a complete diagnosis.

Again, the overlap of the female population, 21 years of age
and under, and the other high-risk groups has not been taken into
account and some repetitious counting may be present.

The supportive education and administrative portion of this
program component is estimated to be $7,500,000 from HEW and
$2,500,000 from other sources. It is anticipated that the educa-
tional program will be intensified and similar to the one described
in Section C.2.a.

The total cost for this program component is estimated at
$165,713,000 ($9,919,000 from HEW).

b. Short-Term Benefits

In addition to the short-term benefits described in Section
B.2.b. above, the following results can be anticipated from a
screening program in females 21 years of age and under:

1) No estimates were made on the reduction of immediate
mortality due to the very low mortality rates from urinary
tract infection in this population;

2) A 50% reduction (61,600) in prevalence rate from a base of

41/
123,195; | and

3) A 65% reduction of 1,521,460 in morbid days from a base
bs
yee
<<

42/
of 2,340,710.

Total short-term benefits in all groups surveyed with renal
infections are 70 prevented deaths, a reduction in prevalance of
cases by 3,292,860, and a reduction in the number of morbid days
by 17,483,880.

c. Long-Term Benefits
(1) Annual Long-Term Benefits

As a result of the early diagnosis and administration of
treatment of urinary tract infections, a 33% reduction in the
number of annual cases of renal failure is anticipated. This
would amount to a decrease of 120 cases from a base line of
360 cases per year.

There will be a reduction by 1,870 cases of renal failure
in all relevant groups from a base line value of 8,860 cases
which would have occurred without this program 12!

(2) Cumulative Long-Term Benefits

Of the 246,390 females with significant bacteriuria who
can be reached by this program, approximately 5% (12,320) would
eventually develop significant urinary tract infection” Of
this group approximately 40%, 4,930, would eventually die in

45/
renal failure. Implementation of the above program would be

expected to reduce this mortality figure by 33%, or 1,630.72
A total of 27,480 cases of renal failure in all groups
surveyed would be avoided.
3. Research

Given the increased resources of this accelerated program, the number

of clinical research projects could be doubled from the current level of 4
215

to 8 projects at $500,000 each for a total of $4,000,000.

Laboratory research expenditures could feasibly be set at $2,000,000,
with an additional $500,000 available for projects designed to study
susceptible sub-groups of patients.

Thus, the total HEW support for research would be $6,500,000. It
is anticipated that an additional $2,170,000 would be contributed by
other sources.

4, Training

Training costs are estimated to be 15% of the research expenditures
i.e., $1,300,500, of which $975,000 comes from HEW, and an additional
$325,500 from other sources.

5, Facilities

With an accelerated health program, it is estimated that HEW will

expend about $10,000,000 for facilities in addition to $3,330,000 contributed

by other sources.

A benefit-cost summary associated with this program is presented in Table III.
Table IIL

INFECTIOUS DISEASES OF THE URINARY TRACT, HYPOTHETICAL PROGRAM
AT ACCELERATED HEW EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

 

 

 

 

 

eCltt

 

 

 

 

 

 

 

 

 

 

 

 

Short-Term Benefits Long-Term Benefits
Reduction Reduction In
Expenditures Per Year In End-Stage Uremia
HEW Total
Program ($1,000) ($1,000) Mortality] Prevalence] Morbid Days | Per Year] Cumulative
I.A. Screening, diagnosis and treatment of
individuals in short and long-term
hospitals and nursing homes as well
as non-hospitalized pregnant females,
diabetics, and females 21 years of age
and under.
1. Screening 2,419 12,097
2, Confirming 86,067
3. Treatment 57,549
Sub-Total 2,419 155,713
B. Supportive education and administra-
tion 7,500 10,000
Sub-Total 9,919 165,713
Il. Research 6,500 8,670
III. Training 975 1,300
IV. Facilities 10,000 13,330
TOTAL 27,394 189,013 70 3,292,860} 17,483,880 1,870 27,480

 

 

 

 

 

 
A 1

Infectious Diseases of the Urinary Tract, Hypothetical Program for
Fiscal Year 1975, at Accelerated HEW Expenditure Level, Based on
Expected State of the Art in 1975

 

1. Introduction

This program has four components:

1) Screening, diagnosis, treatment, and supportive education and

administration;

2) Research;

3) Training; and

4) Facilities.

The total estimated cost for this program is $215,471,000 of which
HEW will contribute $31,228,000 (see Figure 4). Under an advanced
state of the art it is assumed that the research efforts undertaken
have made possible 1) more effective antimicrobial therapy, and 2)
a better understanding of the pathophysiology of urinary tract
infection, with new treatment methods for predisposing factors which
sometimes lead to bacteriuria. A detailed discussion of the various
program components follows.

2. Screening, Diagnosis, Treatment and Supportive Education and
Administration

 

47/
In 1975 the total U. S. population will have increased by 14%

but there are no anticipated changes in the nature of the relevant
population.

a. Relevant Populations and Program Component Costs

 

It is estimated that of a projected 33,227,580 hospitalized

and nursing home residents, 6,645,520 will have significant bacter-

48/ .
iuria (a 20% prevalence rate). The non-hospitalized pregnant

49/ .
female population is estimated to be 5,126,580;" assuming a
Costs ($1,000,000)

 

 

 

 

 

 

 

 

 

 

 

215.5
200 LU
° See
ae Nal
100 [TT
Diagnosis &
Treatment
(188.9)
50 Le
31.2 -
Diagnosis &
Treatment
(11.3) Research
Research pO) Training
pS)’ -4) aw Training (1.5)
eyage (1.1) Facilities
Facilities
(11.4) (15.2)
HEW TOTAL

PROGRAM

Fig. 4. Infectious Diseases of the Urinary Tract, Hypothetical Program
Costs for Fiscal Year 1975, at Accelerated HEW Expenditure Level,
Based on Expected Advanced State of the Art in 1975.

ll6a
prevalence rate of 6% for bacteriuria, 307,590 persons will have
positive screening tests. The non-hospitalized diabetic population
will be 2,761,080 and approximately 414,160 will have
bacteriuria (assuming a 15% prevalence rate in the diabetic
population). While it is possible that significant improvements
in the treatment and diagnosis of diabetics will have occurred,
this assumption was not made. It is anticipated that 14,044,230
females under 21 years of age will be screened yearly; 140,440

of these women will have significant bacteriuria, assuming a 1%
prevalence rate (Note it is still assumed that only 60% of

the females 21 years of age and under can be reached, and that the
screening program will cover a two-year span.)

Cost of screening will be $13,790,000 ($2,758,000 to be borne
by HEW). It is still assumed that the cost per test under a general
screening program will be $0.25, and this cost is applied to the
55,159,440 individuals to be screened each year.

The cost of confirmatory tests remains at $7.50 per person.
Total cost is approximately $98,150,000, excluding a second repeat
test for false-positive patients.

Treatment costs also remain the same, i.e., $10.00 for drugs
for those individuals who are already under a physician's care. It
is estimated that there are 6,262,180 of these individuals yielding
a cost of $62,622,000. For those individuals who would not have
been under a physician's care (the female population 21 years of age
and under), $15.00 per individual for physicians’ services is added.

53/
The cost of treatment for this group is $2,984,000 (119,374 x $25).
fea
C&

" Total cost of treatment is thus estimated to be $65,606,000.
HEW is not responsible for the cost of confirmatory tests or
treatment.

Total cost for this initial portion of the program component
is $177,511,000, of which $2,758,000 is to be borne by HEW.

Support for education and administration is estimated to cost
$8,550,000 for HEW, to include a more extensive educational program
to reach the increased population. An additional $2,850,000 will
come from outside sources.

Therefore, the total cost for this program component is
$188,911,000, of which $11,308,000 comes from HEW.
b. Short-Term Benefits

The estimated short-term benefits are as follows:

1) From a base line of 7,750 deaths in the group surveyed
which would have occurred in the absence of any program,

354/
a reduction of 80 deaths is estimated;

2) It is estimated that there will be an 85% reduction
(5,630,780) in prevalence from 7,507,710 cases {35 of the 85%
(1,876,930) can be attributed to advances in the state of

55/
the art]; and

3) It is estimated that the number of morbid days will be
reduced by 854 (26,064,430) from a base line figure of
30,664,040 (20 of the 85% reduction, i.e., 6,132,810 is

56/

attributed to advances in the state of the art).

c. Long-Term Benefits

(1) Annual Long-Term Benefits

 

It is estimated that approximately 7,500 of the group
119

surveyed per year will have developed end-stage renal failure
without the program. Ideally this program would reduce this
number by 55%, or 4,125 per year [of which 2,250 (approximately
30 of the 55% reduction) are due to advances in the state of
the art)
(2) Cumulative Long-Term Benefits

About 54 of the individuals with bacteriuria would have
developed significant urinary tract infections in the absence
of any program. Approximately 40% of these persons would
eventually die from uremia. Within the relevant population,
there would be 7,658,160 individuals having bacteriuria”
It can then be said that some 382,400 will probably develop
significant urinary tract infections and 40%, or 153,000, of
these would eventually die from uremia. It is estimated that
the number of deaths resulting from end-stage kidney failure
can be reduced by 55% or 84,150 (approximately 30 of the 55%,
or 45,900, of the reduced number of deaths is due to advances

59/
in the state of the art).

3. Research

Research expenditures will be increased in amount to $7,410,000
which will come from HEW, and an additional $2,470,000 to come from
other sources. It is anticipated that a cure for urinary tract
infections may be found through the development of new antibiotics and

new treatment methods for predisposing factors which sometimes lead to

bacteriuria.
4. Training

Money expended for training purposes will total $1,480,000, about
120

15% of that spent for research. Of this amount, $1,110,000 will come .
from HEW and an additional $370,000 from other sources.
5. Facilities

In an accelerated Health Program it is estimated that HEW will con-

tribute $11,400,000 for facilities, Additional sources will contribute

$3,800,000.

A benefit-cost summary associated with this program is presented in,

Table IV.
60/
F. Benefits Dependent on New Research Developments

An annual reduction by 1,876,930 in the prevalence rate of renal infection
and by 6,132,810 in the number of morbid days will be the short-term effects of
new research developments. These statistics take into account a postulated
14% increase in the population of the U. S. from 1966 to 1975. Benefits based
on 1966 population figures reveal a reduction in prevalence by 1,646,430 and
in the number of morbid days by 5,379,660.

In assessing the annual long-term benefits dependent on new developments,
it is estimated that there will be a reduction of 2,250 cases of end-stage
kidney disease per year, (1,970 cases based on 1966 U. S. population).
Cumulative long-term benefits reveal that 50,650 (44,430 based on 1966 U. S.
population) cases of renal failure will be avoided with the advent of new

developments and techniques concerned with chronic kidney infections.
Table IV

INFECTIOUS DISEASES OF THE URINARY TRACT, HYPOTHETICAL PROGRAM FOR FISCAL YEAR 1975
AT ACCELERATED HEW EXPENDITURE LEVEL, BASED ON EXPECTED ADVANCED STATE OF THE ART IN 1975

 

 

 

Short-Term Beneifts Long-Term Benefits
Reduction Reduction In
Expenditures Per Year In End-Stage Uremia
Program ($1,000) ($1,000) Mortality| Prevalence} Morbid Days | Per Year| Cumulative

 

 

PITT

 

I.A. Screening, diagnosis and treatment of
individuals in short and long-term
hospitals and nursing homes as well
as non~hospitalized pregnant females,
diabetics, and females 21 years of
age and under.

 

1. Screening 2,758 13,790
2. Confirming 98,115
3. Treatment 65,606

Sub-Total 2,758 177,511

 

B, Supportive education and administra-

 

 

tion 8,550 11,400
Sub-Total 11,308 188,911

II. Research 7,410 9,880
IIL. Training 1,110 1,480
IV. Facilities 11,400 15,200

 

 

 

 

 

 

 

 

TOTAL 31,228 215,471 80 15,630,780 | 26,064,430) 4,125 84,150

 

 
121

III. HYPERSENSITIVITY DISEASES OF THE KIDNEY

Ae Introduction

This section describes program efforts projected to control renal disease
resulting from hypersensitivity phenomena.

In 1966, an estimated 12,7192/aeaths resulted from kidney disease associ-
ated with hypersensitivity reactions; 106, 000 individuals are estimated to
nave had hypersensitivity diseases of the kidney, requiring 4,074,000 days of
-estricted activity, 1,834,000 days of bed disability, as well as TTT 000 —
work- loss aeys 02! |

Four programs are considered in this analysis and discussed in detail
pelow (see Chapter 5, Research Methodology).

g. Kidney Diseases Related to Hypersensitivity Phenomena, Hypothetical

Program at Current HEW Expenditure Level, Based on the Current State

of the Art

1. Introduction

This program has four components:

1) Education and administration;

2) Research;

3) Training; and

4) Facilities.

The total cost for this program is estimated to be $9,975,000 of
which HEW's share is $7,480,000. Figure 5 illustrates costs for the

various program components, and they are discussed below.

2, Education and Administration

 

In order to pring an effective educational program to physicians,
it is necessary to supply the approximately 7,000 hospitals in the U. S.
with appropriate materials and other educational support. Estimating

a cost of $140 per hospital, approximately $1,000,000 will be needed for
Costs ($1,000,000)

 

 

 

 

 

 

 

 

 

150 ~—
100. =F
50 -F-
. Education and
Education and Administration
10.0] sen (2.0)
7.5 ——}—
Research (5.2) Trairing (.6) Research (7.0) LTraining (.7;
(a Facilicics (2) bed rac litics (.3)
HEW TOTAL
PROGRAM

Fig. 5. Kidney Diseases Related to Hypersensitivity Phenomena,
Hypothetical Program Costs at Current HEW Expenditure
Level, Based on Current State of the Art.

l2la
p>
bho
NO

instruction in this area of kidney disease as part of a general educa-
tional program. In addition, about $500,000 will be required for the
administration and implementation of this program. The total cost for
HEW is then estimated at $1,500,000. An additional $500,000 is expected
from other sources.
Under the current state of the art postgraduate physician education
seems to be the most effective approach for achieving immediate benefits.
a. Short-Term Benefits
It is estimated that this educational program would decrease
the immediate annual mortality due to hypersensitivity diseases by
approximately 5% (610) from a base line of 12,71903/aeaths per year.
This figure is based on the assumption that improved understanding
of diseases such as acute glomerulonephritis, and improved knowledge
of fluid, electrolyte, and steroid therapy will have some impact on
the immediate mortality from diseases associated with hypersensitivity
phenomena.
be Long-Term Benefits
Under the present state of the art, no long-term benefits are
anticipated.
3. Research
This most important program component is separated into clinical and
laboratory research efforts.
a. Clinical Research
Following are some areas of disease which need clarification
and study to determine their significance in hypersensitive renal:

disease:
1)

3)
4)
5)
6)
7)
8)

223

Minimal persistent proteinuria;

Orthostatic proteinuria;

Childhood nephrotic syndrome;

Adult nephrotic syndrome;

Acute glomerulonephritis;

Systemic lupus erythematosus;

Miscellaneous collagen diseases; and

Any other related hypersensitivity diseases having renal

involvement.

The estimated cost for each study area is $500,000, yielding

a total cost of $4,000,000 ($3,000,000 from HEW).

Following are some comments on the present status in each of

the above study areas:

1)

2)

4)

several universities have been approached on the possibility
of conducting cooperative studies on the diseases listed
above and have expressed interest in them. No further
progress has been made due to a shortage of funds.

The Air Force is currently studying orthostatic proteinuria
at Lackland Air Force Base, Texas.

There is an international cooperative study being conducted
on the childhood nephrotic syndrome under the direction of
Dr. Henry Barnett of the Albert Einstein Medical Center in
New York City.

There is no coordinated activity on the adult nephrotic
syndrome at the present time in the United States. However,

in Great Britain, there is a study sponsored by the British
Medical Research Council on the controlled treatment of
adult nephrotics with steroids.

5) There is a loose cooperative study on acute glomerulonephritis
under way in New York City. There is also a study being
supported on the island of Trinidad which is designed to
follow patients with acute glomerulonephritis. The re-
surgence of the Red Lake epidemic of acute glomerulonephritis
is also under study by Dr. Wanamaker's group at the University
of Minnesota.

6) There is a loose cooperative study by several university
centers emphasizing the pathology in nephritis resulting
from systemic lupus erythematosus.

7) Other disease processes that might be grouped under the
heading of hypersensitivity diseases are sub-acute glomerulo-
nephritis, chronic glomerulonephritis, serum sickness
nephritis, and nephrotoxic nephritis in animals.

b. Laboratory Research

There are at present approximately 30 immunology research units
in existence. It is estimated that approximately 15 of these units
are currently engaged in work which is applicable to hypersensitivity
diseases of the kidney. The total contribution of funds for relevant
studies to these laboratories would be approximately $1,500,000
($100,000 each) per year, of which HEW would contribute $1,125,000.
In addition, it is estimated that an additional $1,500,000 ($1,125,000

from HEW) should be made available for grant support of individual
projects in other laboratories. At an average cost of $25,000
each this amount would support the work of 60 investigators.

It is assumed that the total of $7,000,000 as described in the
above categories will come from both federal and private funds, with
the majority coming from HEW.

4, Training
It is anticipated that each of the 15 involved immnology laboratories
would provide training for two research fellows per year. The cost for

this program would be approximately $50,000 per laboratory per year ,Ot/
or a total of $750,000 for the whole program ($560,000 from HEW).

D- Facilities

In order to continue expanding research capabilities and updating
the necessary equipment, it is estimated that 15% of the yearly cost of
laboratory research operations will be spent. The total cost of equip-
ment updating for 15 laboratories amounts to $225,000 per year (15% of
which, $170,000, comes from HEW).
6. Summary

The preceding discussion and estimates presume activity on a level
considerably above the current status. There is a substantial initial
cost in achieving the new elevated level of activity. Principal among
these costs is the expense of constructing and providing adequate facilities.
This amount should not be confused with the facilities estimate discussed
above which is for the improvement of equipment intended to keep research

workers supplied with the best equipment for their varied programs.

A benefit-cost summary associated with this program is found in

Table V.
KIDNEY DISEASES RELATED TO HYPERSENSITIVITY PHENOMENA, HYPOTHETICAL PROGRAM AT CURRENT HEW

Table V

EXPENDITURE LEVEL, BASED ON THE CURRENT STATE OF THE ART

 

Short-Term Benefits

Long-Term Benefits

 

 

 

 

 

 

 

 

 

 

 

Reduction Reduction In

Expenditures Per Year In End-Stage Uremia
HEW Total

Program ($1,000) ($1,000) Mortality] Prevalence] Morbid Days | Per Year Cumulative
I. Education and administration 1,500 2,000
II. Research 5,250 7,000
III, Training 560 750
IV. Facilities 170 225

TOTAL 7,480 9,975 610 —_— —_—— —_—— —___~

 

 

 

 

 

Bcél