Comparative Effectiveness and Patient- Centered Outcomes ...
Cost-Effectiveness and Outcomes Research Setting value to what we do.
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Transcript of Cost-Effectiveness and Outcomes Research Setting value to what we do.
Cost-Effectiveness and Outcomes Research
Setting value to what we do
Define CE terms Review methods of evaluation
in health care Review examples Identify activities that may
promote CE studies
Objectives:
What it is -
What is Cost-Effectiveness?
What it is not-
What it is -“a method for evaluating the health outcomes and resource costs of health interventions”
Russell, et al., JAMA 1996;276:1172
What is Cost-Effectiveness?
What is Cost-Effectiveness?
Interventions– Nutrition Support– MNT Protocols– Presence of the RD on
the health care team, in the public health jurisdiction, etc.
What is Cost-Effectiveness?
Outcomes in CEA– Traditional
Medical Outcomes
– Resource Costs
– Expanded definitionPatient centered outcomes
Quality of life; Client satisfaction
What is Cost-Effectiveness?
Cost-Savings
Cheaper bang
Cost-Benefit Analysis
All benefits cost in dollars
?? Putting dollar value on life years
What it is not -
What it is -
Health Care Expenditure as a Share of Gross National Product (%)
Year 1960 1970 1980 1990
Canada 5.5 7.1 7.4 9.0
Germany 4.7 5.9 .4 8.1
France 4.2 5.8 7.6 8.9
I taly 3.3 5.2 6.8 7.6
J apan 2.9 4.4 6.4 6.5
Netherlands 3.9 6.0 8.0 .1
Switzerland 4.7 7.2 9.4 8.7
Sweden 3.3 5.2 7.3 7.4
UK 3.9 4.5 5.6 6.1
USA 5.3 7.4 9.3 12.4
Zweifel P: Health Economics, 1997
OutcomeThe result of the performance (or
nonperformance) of a function or process(es). JCAHO 1996
Outcome IndicatorMeasures what happens (or does not
happen) to a patient after something is done (or not done) to the patient. NLHI
Terms
Cost Benefit AnalysisAn analytic tool for estimating the net
social benefit of a program or intervention as the incremental benefit of the program less the incremental cost, with all benefits and costs measured in dollars.
Cost Effectiveness in Health and Medicine. Gold, Martha, et al 1996 University Press
Terms
Cost EffectivenessAn analytic tool in which costs and effects
of a program and at least one alternative are calculated and presented in a ratio of incremental costs to incremental effects. Effects are health outcomes such as cases of a disease presented, years of life gained or quality adjusted life years rather than monetary measures as in cost benefit analysis.Cost Effectiveness in Health and Medicine. Gold, Martha, et al 1996 University Press
Terms
QALY“Quality-adjusted life year”
“A measure of health outcome which assigns to each period of time a weight, ranging from 0 to 1, corresponding to the health-related quality of life during that period, where a weight of 1 corresponds to optimum health and a weight of 0 corresponds to a health state judged equivalent to death: these are then aggregated across time periods.”Gold 1996
Terms
Terms
DFLE“Disability-free life expectancy”
Life expectancy free of class I (or worse) disability
Disability classes based on person-trade off method
Terms
DALE“Disability-adjusted life expectancy”
HLHLxx = L = Lxx ( 1 - ( 1 - PPixix DDixix ))
Where:
HLx =the number of years of healthy life lived at age
x
Lx = the number of years of life lived at age x from a
life table
Pix =the prevalence of disabling sequelae j at age x
Dix =the disability severity weight for disabling
sequelae j at age x
DiscountingThe process of converting future dollars
and future health outcomes to their present values. (Gold 1996)
BootstrappingA simulation method for deriving
nonparametric estimates of variances of interest (e.g. the variance in the C/E ratio) from a data set. (Gold 1996)
Bayesian methodA branch of statistics that uses prior
information on beliefs for estimation and inference. (Gold 1996)
Terms
Objectives:
Define CE terms Review methods of
evaluation in health care Review examples Identify activities that may
promote CE studies
Outcomes ResearchOutcomes Research– Process
• Identify the outcome (what we effect)• Set a clear definition of the outcome
– Implementation• Measure• Analyze• Evaluate
Features of Cost Effectiveness
Methods of Evaluation in Health Care: CEA
Method of evaluation would be cost-effectiveness analysis (CEA). Only for mutually exclusive projects.
t1CEA = costs in units of money
benefits in mmHg
and
t2CEA = costs in units of money
benefits in additional life years
Zweifel P: Health Economics, 1997
Methods of Evaluation in Health Care
Limitations of CEA
Implies that it is not relevant who obtains the additional life years
It does not lend itself to the evaluation of projects with several different (positive) effects.
Provides a rank order of preference among mutually exclusive projects, it does not answer the question which of the projects should be realized and which should not
Zweifel P: Health Economics, 1997
Methods of Evaluation in Health Care: Cost Utility Analysis
Method of evaluation that takes account of the multidimensionality of the concept ‘health’ by trying to encompass all effects of an intervention - prolonging life and changing health status.
tCUA = costs in units of money
benefits in QALYsThe index value may be interpreted as ‘QALYs’ gained.
Again, only for mutually exclusive projects.
Unlike CEA, suitable for comparing medical interventions of heterogeneous kind and purpose
Zweifel P: Health Economics, 1997
Methods of Evaluation in Health Care: Cost Benefit Analysis
Zweifel P: Health Economics, 1997
Monetary equivalents are assigned to prolongations of life and change of health status.
tCBA = costs in units of money
benefits in units of money
Methods of Evaluation in Health Care:
Zweifel P: Health Economics, 1997
Unlike cost-benefit analysis, cost-effectiveness analysis and cost-utility analysis circumvent the problem of monetary evaluation of life and health. However, they provide only a relative evaluation of mutually exclusive projects, while CBA permits evaluation of each
project on its own.
Objectives
Define CE terms Review methods of
evaluation in health care Review examples Identify activities that may
promote CE studies
What is the question (intervention)?– Compared to what?
Who is the decision maker? Over what time period for study? What is (are) the unit of outcome?
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Fundamental Health Economic Questions
Hoch JS: Health Econ. 11: 415–430 (2002), Published online 31 January 2002 in Wiley InterScience (www.interscience.wiley.com).
Intervention -- Weight Reduction ProgramComparing usual care to dietitian consult
Your Effects < usual Your Effects > usual
Your $ < usual A BYour $ > usual C D
What can be said about A, B, C, and D?D -- Need for incremental cost-effectiveness
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Incremental Economic Analyses: 4 Possible Situations
Dietitian Usual CareCosts $2,500 $2,200Effects 15 lbs 10 lbs
What is the additional cost for an additional unit of gain?
($2,500 - 2,200)/(15lbs-10lbs) = $300/5 or $60 for each additional pound lost.
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Incremental Cost-effectiveness
Dietitian Usual CareCosts $2,500 $2,200Effects 20% 16% reduction in Hemoglobin A1c
What is the additional cost for an additional unit of gain?
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Incremental Cost-effectiveness
Incremental Cost-effectiveness
Dietitian Usual CareCosts $2,500 $2,200Effects 20% 16%
($2500-2300)/(20-16% reduction in HbA1c) $300/4% reduction in HbA1c $75/1% reduction in HbA1c
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Incremental Cost-effectiveness
League Tables progressive listing of costs per unit of effectiveness/outcome Unit of Outcome: Cost per Life Year Saved– Hypertension screening
40 year male $9,800/LY 40 year female $45,869/LY
– Mammography 55-65yr women $44,550/LY– Pap screening (Pap Net) 20-65y$122,888/LY– Exercise ECG 40 yr male
$135,116/LY– Exercise ECG 40 yr female $364,170/LY
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Cost-Effectiveness League Tables
American Society for Internal Medicine and American College of Physicians used CEA in recommendations concerning:– hypertension– exercise ECG– screening
breast prostate cervical
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Are CEA Studies Being Used?
MAJOR midwest hospital with strong ties to managed care organizations and industry
Used it over last few years for policy– hepatitis B screening for neonates– Smoking cessation– cystic fibrosis– flu inoculation reminders– anticoagulation clinic– lipid management– some drug formulary decisions
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Are CEA Studies Being Used?
Activities on CE
Lewin Study A study at Group Health Cooperative
in Puget Sound Area Covered dietitian services as a
supplemental benefit for Medicare enrollees covered under risk contract
Examined use and costs over time of services in this Medicare population with diabetes and CVD who did and did not use RD servicesJudith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Activities on CE
Lewin Study For DM patients using RD services
hospital admissions were reduced by 9.5% and MD visits by 23.5%
For CVD the use of RD services was associated with an 8.6% decrease in hospital utilization and a 16.9% decrease in MD visits.
Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in HealthcareNortheastern University, Boston MA
Barriers and Limitations
ExpectationsTrainingSupportOutcomes difficult to measureTime of follow-upCo-MorbiditiesResearch training
Strengths
Documentation of worthBenchmark for change
Objectives:
Define CE terms Review methods of
evaluation in health care Review examples Identify activities that may
promote CE studies