Post on 04-Aug-2020
Economic evaluation in primary care and
chronic disease management
Braden Manns
Svare Chair, Health Economics
Outline:
1. Economic evaluation in primary care
• Case study
• Basic principles of economic evaluation
• Is health economics relevant to primary care?
• An example of economic evaluation within diabetes care
• How to engage health care providers in taking costs into account?
2. Blended capitation – improving accountability for care that provides good value for money
3. Exercise: Incorporating costs into policy making.
Objectives:
Is health economics relevant to primary care?
Case study
Basic Principles of economic evaluation
How to engage health care providers in
taking costs into account?
An example of economic evaluation within
diabetes care
Case study
Glucose testing strips in diabetes
67 year old woman, with Type 2 Diabetes and
Albuminuria.
Follow-up of blood pressure and kidney disease.
Medications; metformin (500 mg bid), glyburide (2.5
mg bid) and Ramipril (5 mg daily).
No hypoglycemic episodes, BP 126/80.
HbA1c high (8.6%): You recommend watching diet,
exercise and increasing glyburide to 5 mg bid.
You request she monitor her blood sugar intermittently
during the day and request follow-up in few months.
You also wonder if she would benefit from a nurse
case manager?
Basic principles of
economic evaluation
What is economic evaluation?
Comparative analysis of alternative
courses of action in terms of both their
costs and consequences.
Opportunity cost, scarcity of resources,
and choice.
Funding diabetes nurses or a foot screening
program in people with diabetes?
Diabetes nurses help with blood sugar
control.
Reduces eye and kidney complications.
Annual costs $150,000 per clinic.
Foot screening program in high-risk
diabetes: Reduces amputation.
Set up cost $100,000
Annual costs $100,000
3 types of economic evaluation:
Cost- effectiveness analysis.
Cost- utility analysis.
Cost- benefit.
What is the role of economic
evaluation within health care
priority setting ?
Why use economic evaluation?
Improved clinical
outcomes Increased costs
How to interpret a cost-effectiveness ratio:
Cost/QALY ratio Recommendation
<$20,000 Strong evidence for adoption and appropriate utilization.
$20,000-100,000 Moderate evidence for adoption and appropriate utilization.
>$100,000 Weak evidence for adoption.
Other Important factors to consider
when setting priorities
Life saving intervention versus gain in life expectancy.
Impact on quality of life.
Is the treatment for a large or small number of people?
Is the treatment for older or younger patients?
Is the treatment for those with good or poor baseline health?
What is the budget impact?
Equality of access to therapy.
Is it a priority for government / the health care system?
Is health economics
relevant to primary care?
Is health economics relevant to
primary care?
What is the goal of health care providers?
What is the goal of health care-policy makers?
“I will apply, for the benefit
of the sick, all measures
which are required”
An example of economic
evaluation within
diabetes care
Glucose testing
strips in diabetes
Cost-effectiveness of self-
monitoring of blood glucose in
patients with type 2 diabetes
mellitus managed without insulin
CMAJ, Jan. 12, 2010, 182(1)
C. Cameron, D. Coyle, E. Ur, S. Klarenbach
Self-monitoring for patients with Type 2 Diabetes (not using insulin)
Background:
• self-monitoring of blood glucose is recommended for patients who are not using insulin (CDA guidelines).
• $350 million per year in Canada.
• In 2010, cost of strips exceeded those for all oral anti-diabetes drugs combined.
• ~ 50% of the total expenditure on blood glucose test strips is for patients with type 2 diabetes who are not using insulin.
Effectiveness:
• 7 randomized trials, enrolling 2270 patients with type 2 diabetes managed with oral antidiabetesagents or lifestyle measures.
• All trials compared self-monitoring of blood glucose (and education) with no self-monitoring.
• Average number of tests 1.29 per day ($0.73 per test strip).
• The pooled difference in HbA1C was in favour of self-monitoring (weighted mean difference –0.25%, 95% CI –0.36% to –0.15%).
Self-monitoring for patients with Type 2 Diabetes
(not using insulin)
Table: Cumulative incidence of diabetes-related complications over 40 years
Overall %
(95% CI)
1 Chronic Condition
Only % (95% CI)
2+ Chronic Conditions
% (95% CI)Comparison
Cumulative incidence %
ConditionNo self-
monitoringSelf-monitoring
Absolute risk
reduction, %
Number needed to
treat
Myocardial infarction 36.58 36.21 0.38 266
Heart failure 17.64 17.20 0.44 228
Stroke 16.34 16.14 0.20 500
End-stage renal disease 2.29 2.21 0.08 1299
Self-monitoring for patients with type 2 diabetes not using insulinImpact on clinical outcomes:
How do you interpret the results?
High quality systematic review shows small changes in HbA1C,
which translate into small changes in clinical events noted in the
economic evaluation
Improvements in clinical outcomes are uncertain
Baseline cost per QALY ~$110,000 – higher than most
interventions we pay for in Canadian health care
- though health care providers are the gatekeeper
- governments have created funding policies using this data
Message for primary care
Don’t prescribe self-monitoring in stable
patients except when
• changes to therapy are being made
• patients who are prone to
hypoglycemia.
Self-monitoring in patients with diabetes
managed without insulin provides VERY
small (and uncertain) improvements,
and money would be better invested
elsewhere
How to engage health
care providers in taking
costs into account?
Getting physicians to be stewards of resources?
• Education
• Key performance indicators
• New payment models – blended capitation
1. Education: Balancing the patient in front of you with the
patients in your waiting room: Answer 3 Questions
Does the intervention you’re considering really work?
What are the resource implications of the new treatment?
Should you say “no” based on cost-effectiveness?
The uncomfortable truth.
Resources are limited / choices must be made.
Obligation to patient vs. obligation to society.
Goal of health care system is to maximize the health of
all its population under the constraint of a fixed budget -
considering cost- effectiveness is a reasonable tool to
help make these choices.
Saying “No” based on cost-effectiveness
Clinical practice guidelines should take cost
into account.
Formularies that consider costs can help you
care for your patients in a cost-conscious
manner, while still providing the vast majority
of “effective” therapies.
Developing local guidelines which your care
can be consistent with (i.e. guidelines for your
specialty clinic, or ward).
Helping health care providers say “NO”
Returning to Hippocrates:
• I will apply, for the benefit of the sick, all
measures which are required, avoiding those
twin traps of overtreatment and therapeutic
nihilism.
• I will remember that I do not treat a fever chart,
a cancerous growth, but a sick human being,
whose illness may affect the person’s family
and economic stability. My responsibility
includes these related problems, if I am to care
adequately for the sick
• I will remember that I remain a member of
society, with special obligations to all my fellow
human beings.
• I will remember that there is art to medicine as
well as science, and that warmth, sympathy
and understanding may outweigh the
surgeon’s knife or the chemist’s drug.
Importance of following established processes
Valid data sources
Indicators should represent high-value care
Issues: Targets / Physician buy-in and ownership critical / Enforcement
Role for SCNs
2. Key performance indicators?
Indicators of high value Kidney Care in Alberta: Examples
1. Use of home dialysis: Proportion of new dialysis patients being
treated with peritoneal dialysis within 180 days after initiating
dialysis
2. Pre-emptive kidney transplantation: Proportion of new kidney
failure patients who are potential transplant candidates (<60 yrs
old; with no heart disease or cancer) who receive a transplant
rather than dialysis
3. Documentation of level of care: Goals of Care Designation Order
signed for all patients on dialysis.
The goal of the new compensation model is to provide:
• Albertans – with increased access to primary health care, through strong relationships to their primary care physicians and improved continuity of care.
• Physicians – with the flexibility to provide services in different ways so they can spend more time with patients and deliver comprehensive care that encourages health promotion, wellness and enhanced collaborative care.
• Government – with a more sustainable health system with better accountability, stability and budget predictability.
3. Blended Capitation payment model for primary care
• Includes a mix of patient-based (capitation) payments (85%) and volume-based payments through fee-for-service (15%).
• Capitated payments for each rostered patient
• A basket of medically insured services has been developed to reflect the typical activities of a non-specialized general practitioner in an office-based setting.
• The capitation amount is estimated on the average use of the basket of services based on a patient’s age, sex and risk status.
Compensation
Comprehensive evaluation planned (led by IHE):
Cost and cost-effectiveness embedded in many domains
Data sources:
• Panel/Roster analysis (demographic, chronic disease, continuity)
• Patient Experience Survey (HQCA)
• Quality Indicators (ASaP, NICE)
• Team Based Surveys
• Qualitative Interviews
• System Utilization Baseline (ED, Hospital, etc.)
Domains:
• Access to care
• Continuity of care
• Quality, comprehensiveness, efficiency of care
• Patient experience
• Team-based care
• Patient-centred care
• Complex patients receiving multi-disciplinary care
• Referral rate to specialty care
• Health are costs
Care Domain Patient Eligibility Indicator Source
Colorectal Cancer
Screening
50 – 74 years
Completed fecal immunochemical test (2
years), sigmoidoscopy (<5 years),
colonoscopy (<10 years)
AHS administrative data
EMR
Breast Cancer Screening Females 50 – 74 years Completed mammogram (2 years) AHS administrative data
EMR
Cervical Cancer Screening Females 25 – 69 years Completed pap test (3 years) AHS administrative data
EMR
Cardiovascular Disease
Risk Assessment
50 – 74 years
Measurement of CVD Risk using a calculator
and/or counselling or
Lipid panel (<3 years)
AHS administrative data
EMR
Hypertension Assessment >18 years Completed blood pressure measurement
(<1 year)
EMR
Obesity Screening >18 years Completed BMI (<2 year) EMR
Tobacco Use Cessation >18 years Identified patients as tobacco user
or non-user
AHS administrative data
EMR
Diabetes Screening >40 years Completed Fasting Glucose
or HgA1C (5 years)
AHS administrative data
EMR
Indicators – High Value Preventive care
Care Domain Patient Eligibility Indicator Source
Congestive Heart Failure
>18 years with CHF % of patients with
ACE/ARB prescriptions
AHS administrative data
EMR
Diabetes
>18 years with diabetes % patients with
ACR and HgA1C (1 year) or
Retinopathy (<2 years)
AHS administrative data
EMR
>18 years with diabetes and
ACR>30mg/g (or >3mg/mmol)
% of patients with
ACE/ARB prescriptions AHS administrative data
Chronic Kidney Disease >18 years with GFR <60/mls/min
(<2years)
% patients with ACR or PCR (<3years)
AHS administrative data
EMR
>18 years with GFR <60/mls/min and
ACR >3mg/mmol or PCR>15mg/mmol
or Urinalysis protein 1+ or greater
% of patients with
ACE/ARB prescriptions
Cardiovascular Disease >18 years with a CVD Risk >20 or prior
MI or stroke or diabetic
% patients on a statin (<3 years) AHS administrative data
EMR
Indicators – High Value chronic disease care
Open discussion – incorporating costs into policy making in
primary care
The Mosaic PCN has a surplus of $800,000 for the next 3 years.
They have placed a priority on care of vulnerable patients with
chronic diseases including diabetes, and heart disease. They are
considering hiring nurse clinicians to assist patients with self-
management, funding additional enhancements to their electronic
medical record (to facilitate reminders, clinician prompts), or
establishing a comprehensive audit and feedback system. What
factors should they be considering in their decision making?
Evaluation
Question
Intended
Outcome
Indicator Data
Source
High Level
Impact/Value
Can patients access
the care they need,
when they need it?
Same day access to the physician and team
Third Next Available appointment with
Physician and Team Alberta AIM
website
Timely AccessContinuity
Patients are satisfied with their ability to
access their regular primary care provider
% of patients reporting desirable access to
their provider on patient experience
questionnaire
HQCA Patient
Experience
Patients decrease their activity within the
emergency department for conditions best
treated in primary care
% of patients who accessed the emergency
department for family practice/ambulatory
care sensitive conditions
AHS
Administrative
Data
Patients decrease their hospitalizations for
conditions best treated in primary care
% of patients with a reported in-patient
stay for ambulatory care sensitive
conditions
AHS
Administrative
Data
Patients discharged from hospital have
timely follow up with physician/team
% of patients with a visit to primary care
after discharge from hospital
AHS
Administrative
Data
How often do
patients see their
own physician in
their medical home?
Patients have more visits to their own
physician or to other members of the
medical home consistent with their needs
% of patients with visits to their own
physician or to other physicians within the
medical home
Clinic EMR
AHS
Administrative
DataTimely Access
Continuity
% of patients with visits to other physicians
outside their medical home
Patients report being able to regularly see
their own physician or team within their
medical home consistent with their needs
% of patients reporting consistent access
to their own provider on patient
experience questionnaire Q16
HQCA Patient
Experience
Evaluation
Question
Intended
Outcome
Indicator Data
Source
High Level
Impact/Value
Are patients receiving
quality, comprehensive care
when they access their
physician or medical home?
Patients receive appropriate
preventative care and chronic disease
management according to clinical
practice guidelines and in alignment
with Choosing Wisely
recommendations
% of patients are screened according
to Alberta Screening and Prevention
maneuvers (appendix B)
Clinic EMR
AHS
Administrative
Data
Comprehensive
Care
Team based Care
Continuity
% of patients with chronic disease are
managed appropriately according to
UK Quality & Outcomes Framework
/National Institute for Health and
Care Excellence guidelines (appendix
B)Patients with chronic disease have a
care plan to assist with management
of their conditions
% of patients with chronic disease
who have an care plan in place with
their own provider/team
Clinic EMR
AHS
Administrative
DataPatients reporting feeling satisfied
with the quality of care received.
% of patients who feel they are
receiving comprehensive care on
patient experience questionnaire
HQCA Patient
Experience
Are patients’ expressed
needs, values and
preferences around their
care being met in a
respectful and responsive
manner?
Patients report feeling respected and
involved in the decisions around their
health care
% of patients with a patient
experience questionnaire feeling
satisfied with their own involvement
in decisions around their care.
HQCA Patient
ExperiencePatient Centred
Patients have been asked about their
current health care state and ability to
manage their own care
% of patients with an EQ-5D indicating
maintaining or improving functional
health status.
Evaluation
Question
Intended
Outcome
Indicator Data
Source
High Level
Impact/Value
To what extent have
patients accessed team-
based care for their
desired health care needs?
Patients access a variety of
health care professionals at
their medical home that
meet their needs
% of patients with a visit to an
interdisciplinary team member
Clinic EMR
AHS Administrative
Data
Team-Based Care
Continuity
Timely Access
% of patients with >1 visit to an
interdisciplinary team member
% of patients with visits to >1
interdisciplinary team member
Do the providers feel
satisfied and supported in
their goal to deliver
quality, comprehensive
patient centred care?
Providers report greater
satisfaction around in their
perceived care delivery
% of providers with a completed Health
Team Effectiveness survey reporting high
general work satisfaction
Health Care Team
Effectiveness SurveyTeam-Based Care
Patient Centred
Have patients with more
complex needs been
formally rostered to the
program and are they
receiving the care
coordination they require?
Patients with complex
needs are identified within
their medical home and are
linked with the services
they need within their
medical neighbourhood
% of complex needs patients rostered to the
BCM programClinic EMR
AH Administrative Data
Timely Access
Team Based Care
Comprehensive
Care
Care Coordination
System Support
% of complex needs patients with an action
plan for their care% of complex needs patients with a
community care referral
Patients with chronic
disease or complex
conditions have a lower
number of hospital
admissions and emergency
departments
% of emergency department visits and
hospital admissions/readmissions in patients
with chronic or complex conditions post-
implementation (for chronic disease and all
cause)
Evaluation
Question
Intended
Outcome
Indicator Data
Source
High Level
Impact/Value
What is the level of consensus
in the team around the clinics’
engaged leadership, capacity
for improvement and
approach to panel and
continuity?
All staff consistently champion quality
improvement in care and have clear
understanding around accountability
related to their roles.
% of ‘Level A’ items endorsed by physicians and teams in the Phase 1 Medical home assessment
Medical
Home
Assessment
Survey
System Support
Comprehensive Care
Team Based Care
Patient Centred
Clinic supports a culture of continuous
quality improvement that includes
comprehensive measures that involve
all team members and patients
Panel and disease registries for chronic
disease are maintained to manage care
for the practice population and used for
proactive care
Has the referral rate to
specialty care been affected by
the change in physician
remuneration?
Referral rates are lower after switching
from fee-for-service to a blended
capitated model.
% of patients with specialty
care visit
Clinic EMR
AHS
Administrativ
e Data
System Support
Comprehensive Care
Team Based CareHas there been a shift in
ordering patterns (labs,
diagnostic imaging, and
prescriptions) after the change
in physician remuneration?
The change to blended capitation does
not result in an increase in ordering
behaviour activity.
% of laboratory, diagnostic imaging and prescriptions ordered by physicians post implementation