Cost Effectiveness

1. Cost Effectiveness

2. Cost-Effectiveness and Outcomes Research Setting value to what we do

3. Objectives 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

4. What is Cost-Effectiveness? • What it is - “a method for evaluating the health outcomes and resource costs of health interventions” Russell, et al., JAMA 1996;276:1172

5. What is Cost-Effectiveness? Interventions • Nutrition Support • MNT Protocols • Presence of the RD on the health care team, in the public health jurisdiction, etc.

6. What is Cost-Effectiveness? Outcomes in CEA • Traditional Medical Outcomes (Ex. Albumin, body weight) • Expanded definition Patient centered outcomes Quality of life; Client satisfaction

7. What is Cost-Effectiveness? • 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

8. Terms • Outcome The result of the performance (or nonperformance) of a function or process(es). • Outcome Indicator Measures whathappens (or does not happen) to a patient after something is done (or not done) to the patient. NLHI

9. Terms • Cost Benefit Analysis An 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.

10. Terms • Cost Effectiveness An 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.

11. 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

12. Terms • DFLE “Disability-free life expectancy” Life expectancy free of class I (or worse) disability Disability classes based on person-trade off method

13. Objectives • Define CE terms • Review methods of evaluation in health care • Review examples • Identify activities that may promote CE studies

14. Features of Cost Effectiveness • Outcomes Research • Process • Identify the outcome (what we effect) • Set a clear definition of the outcome • Implementation • Measure • Analyze • Evaluate

15. 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

16. 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

17. 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

18. 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.

19. Objectives • Define CE terms • Review methods of evaluation in health care • Review examples • Identify activities that may promote CE studies

20. Fundamental Health Economic Questions • 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 Healthcare Northeastern University, Boston MA

21. Hoch JS: Health Econ. 11: 415–430 (2002), Published online 31 January 2002 in Wiley InterScience (www.interscience.wiley.com).

22. Incremental Economic Analyses: 4 Possible Situations 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

23. Incremental Cost-effectiveness Dietitian Usual Care Costs $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. Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare Northeastern University, Boston MA

24. Incremental Cost-effectiveness Dietitian Usual Care Costs $2,500 $2,200 Effects 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 Healthcare Northeastern University, Boston MA

25. Incremental Cost-effectiveness Dietitian Usual Care Costs $2,500 $2,200 Effects 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 Healthcare Northeastern University, Boston MA

26. Cost-Effectiveness Concept Checks 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?

27. Cost-Effectiveness League Tables 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

28. 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

29. 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 Healthcare Northeastern University, Boston MA

30. ‘Effective’ Clinical Services Concept Checks 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?

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

32. Risk Management / CQI

33. Risk Management / CQI Objectives: • Review issues on patient safety • Characterize ‘risk’ situations in health care • Identify components of quality assurance processes

34. I N S T I T U T E O F M E D I C I N E Shaping the Future for Health November 1999 TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM Health care in the United States is not as safe as it should be--and can be At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies

35. 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.

36. Patient Safety Concept Checks 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.

37. Risk Management / CQI • 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

39. Risk Management / CQI • Clinical Nutrition and Food Service Systems

40. Risk Management / CQI • Clinical Nutrition and Food Service Systems • High risk areas * Equipment - knives / blades * Wet floors * Cleaning solutions * High turnover in personnel

41. Risk Management / CQI • Risk Management • Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself

42. 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

43. Risk Management / CQI Clinical Nutrition and Food Service Systems High risk areas

44. Risk Management / CQI • Clinical Nutrition and Food Service Systems

45. Risk Management Concept Checks 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?

46. Risk Management / CQI Quality Assurance • is a dynamic, systematic process that assures the delivery of high-quality care to clients

47. Risk Management / CQI QA 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

48. Risk Management / CQI Clinical Indicators: • Measurement tool used to monitor and evaluate quality • Process indictor • Outcome indicator • Rate-based indicator

49. Risk Management / CQI Process Indicator - measures an activity • Easy to Measure • May not directly impact safety Examples • Volume Indicators / Service Trends • Screening • Patient Satisfaction

50. Risk Management / CQI Outcome Indicator • Measures what happens after an activity Examples: Weight loss Infection