cost effectiveness. cost-effectiveness and outcomes research setting value to what we do

Cost Effectiveness

Cost-Effectiveness and Outcomes Research

Setting value to what we do

At the end of the session the student will be able to: Define CE terms Review methods of evaluation in health

care Review examples Identify activities that may promote CE

studies

Objectives

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?

Interventions Nutrition Support MNT Protocols Presence of the RD on the health

care team, in the public health jurisdiction, etc.


Outcomes in CEA Traditional

Medical Outcomes (Ex. Albumin, body weight)

Expanded definitionPatient centered outcomes

Quality of life; Client satisfaction


What it is – What it is not -

Cost-Benefit Analysis All benefits cost in dollars ?? Putting dollar value on life years

Cost-Savings Cheaper bang


OutcomeThe result of the performance (or nonperformance) of a

function or process(es).

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.

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.

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

DFLE“Disability-free life expectancy”

Life expectancy free of class I (or worse) disability

Disability classes based on person-trade off method

Terms

Define CE terms Review methods of evaluation in

health care Review examples Identify activities that may

promote CE studies

Objectives

Outcomes 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

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

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

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 QALYs

The 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

Methods of Evaluation in Health Care:

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.

Define CE terms Review methods of evaluation in

health care Review examples Identify activities that may

promote CE studies

Objectives

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 Program Comparing usual care to dietitian consult

Your Effects < usual Your Effects > usual

Your $ < usual A B

Your $ > 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 Healthcare; Northeastern University, Boston MA

Incremental Economic Analyses: 4 Possible Situations

Dietitian Usual CareCosts $2,500 $2,200

Effects 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.


Incremental Cost-effectiveness


Effects 20% 16%

reduction in Hemoglobin A1c

What is the additional cost for an additional unit of gain?




Effects 20% 16%

($2500-2300)/(20-16% reduction in HbA1c) $300/4% reduction in HbA1c $75/1% reduction in HbA1c



Dzator article What is the premise of the article? Define “Economic evaluation” From the methods section – would it be possible to repeat the

study? How was the diet measured? How were the outcomes measures? What were the main findings? What are the strengths and weaknesses of the conclusions?

Cost-EffectivenessCost-Effectiveness

Concept ChecksConcept Checks

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 Healthcare; Northeastern University, Boston MA

Cost-Effectiveness League Tables

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 services

Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare; Northeastern University, Boston MA

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.


Activities on CE

Maciosek article (’06) Summarize the purpose of the review Define the ‘Clinically preventable burden’ What was the inclusion criteria for the review? Summarize the findings for nutrition related services. Do you think there is additional evidence that would alter the

conclusions? What types of studies are necessary to provide evidence of effectiveness?

The authors describe the limitations of their work – do you think aspects of this report should be reflected in public health policy?

‘‘Effective’ Clinical ServicesEffective’ Clinical Services


Concept Checks

What do you define as a limitation in demonstrating the cost-effectiveness of nutrition services In clinical care In prevention / PH

Risk Management / CQI


Objectives:Objectives: Review issues on patient safety Characterize ‘risk’ situations in health

care Identify components of quality

assurance processes

TO ERR IS HUMAN:BUILDING A SAFER HEALTH SYSTEMHealth care in the United States is not as safe as it should be--and canbe At least 44,000 people, and perhaps as many as 98,000 people, diein hospitals each year as a result of medical errors that could havebeen prevented, according to estimates from two major studies

I N S T I T U T E O F M E D I C I N EShaping the Future for HealthNovember 1999

Patient Safety

2005 proposed budget for patient safety is $84 million.

The Centers for Medicare & Medicaid Services (CMS) has made it clear that patient safety is indistinguishable from quality of care.

Rodham Clinton - Obama What do the authors pose as the potential benefit of a National

Medical Error Disclosure and Compensation Bill (MEDiC Bill)? Compare their proposal to patient safety initiatives that stress a

change in the culture of patient safety.

Patient SafetyPatient Safety



What are Medical Errors?Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place

Where do they happen:

Medical errors can occur anywhere in the health care system:

Hospitals Clinics Outpatient Surgery Centers Doctors' Offices Nursing Homes Pharmacies Patients' Homes

http://www ahrq gov/consumer/20tips htm


Clinical Nutrition and Food Service Systems


Clinical Nutrition and Food Service Systems High risk areas

* Equipment - knives / blades* Wet floors

* Cleaning solutions

* High turnover in personnel


Risk ManagementRisk Management Clinical and administrative activities Clinical and administrative activities

undertaken to identify, evaluate, and undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, reduce the risk of injury to patients, staff, and visitors and the risk of loss to the and visitors and the risk of loss to the organization itselforganization itself

Concept Discussion:

Other safety issues in a health care facility.

What are high risk areas in food service?

How can a culture of a safety be applied to staff training



High risk areas

Glabman What are some of the ‘proven methods’ to reduce medical error

the author refers to from the medical literature? What are the ’10 most common causes of medical malpractice’

according to the author? What do you think about using robots to fill prescription orders? How can dietitians, as members of the health care team, address

these common causes?

Risk ManagementRisk Management



Quality AssuranceQuality Assurance is a dynamic, systematic process

that assures the delivery of high-quality care to clients


QA ProcessQA Process Identify or define the problem Establish a method to evaluate the problem Set a timeline for data collection Collect the data Analyze the results Discuss the findings and make conclusions Suggest alternatives to rectify the problem Try a solution – evaluate Develop a system to monitor the success Implement a system to reevaluate the plan with set

time criteria


Clinical IndicatorsClinical Indicators: Measurement tool used to

monitor and evaluate quality Process indictor Outcome indicator Rate-based indicator


Process Indicator - measures an activityProcess Indicator - measures an activity Easy to Measure May not directly impact safety

ExamplesExamples Volume Indicators / Service

Trends Screening Patient Satisfaction


Outcome IndicatorOutcome Indicator Measures what happens after an Measures what happens after an

activityactivity

Examples:Examples: Weight lossWeight loss InfectionInfection


Rate-based indicator:Rate-based indicator:Assesses an event for which a Assesses an event for which a certain proportion of the events that certain proportion of the events that occur are expected occur are expected

Example:Example: Proportion of patients NPO 24 Proportion of patients NPO 24 hours after surgeryhours after surgery

Prevention Quality Indicators:

• The PQIs are a set of measures that can be used with hospital inpatient discharge data to identify "ambulatory care sensitive conditions" (ACSCs).

• ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease.

Prevention Quality Indicators:

AR = admission rateAR = admission ratePrevention Quality Indicators: developed by Stanford University under a contract with the (AHRQ)

• Diabetes short-term complication AR • Congestive heart failure AR

• Perforated appendix AR • Dehydration AR

• Diabetes long-term complication AR • Bacterial pneumonia AR

• Pediatric asthma AR • Urinary tract infection AR

• Chronic obstructive pulmonary disease

• Angina admission without procedure

• Pediatric gastroenteritis • Uncontrolled diabetes AR

• Low birth weight rate • Adult asthma AR

• Hypertension AR • Rate of lower-extremity amputation among patients with diabetes

In-Patient Quality IndicatorsComplications of Anesthesia Birth Trauma – Injury to Neonate

Death in Low-Mortality DRGs Postoperative Sepsis

Decubitus Ulcer Postoperative Wound Dehiscence

Failure to Rescue Accidental Puncture or Laceration

Foreign Body Left During Procedure Transfusion Reaction

Iatrogenic Pneumothorax Postoperative Physiologic and Metabolic Derangements

Selected Infections due to Medical Care Postoperative Pulmonary Embolism or Deep Vein Thrombosis

Postoperative Hip Fracture Postoperative Hemorrhage or Hematoma

Postoperative Respiratory Failure Obstetric Trauma with or without 3rd Degree Lacerations–

Larson article What is the mission of the ADA Quality Initiative? Why do you think this effort is being undertaken? What are the

potential advantages? Do you agree with the statement on page 1071 – beginning of the

second paragraph “Every dietetics professional ….” In your opinion, is this a good use of members resources (dues)?

‘‘Effective’ Clinical ServicesEffective’ Clinical Services



Elements of successful CQI projectsElements of successful CQI projects Team effort in design Employee involvement at all levels Quality is part of job description Safety in participation Continuous effort

cost effectiveness. cost-effectiveness and outcomes research setting value to what we do

Documents

health outcomes

years of life

healthrelated quality

optimum health

measure of health outcome

health care team

health care limitations

health care review examples