Assessing Health and Economic Outcomes William C. Black, M.D. Director ACRIN Outcomes & Economics Core Laboratory Dartmouth-Hitchcock Medical Center.

Assessing Health

and Economic

Outcomes William C. Black, M.D.

Director ACRIN Outcomes & Economics Core

Laboratory

Dartmouth-Hitchcock Medical Center

Outline

• Background

• Health outcomes

• Economic outcomes

• Cost-Effectiveness

Analysis

“Outcomes”

• Geography is destiny

• More is not better

• Patient preferences

matter

http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage

US Health Care Expenditures

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

Year

Tri

llio

ns

Health Expenditures by Country, 2006

Life Expectancy by Country

Country Life Exp Rank

Macau 84.4 1

Japan 82.1 3

Canada 81.2 7

United Kingdom 79.0 36

United States 78.1 49

Mexico 76.1 71

China 73.5 108

Iraq 70.0 145

Growth in physician services

“Outcomes”

• Determine what

works

• Assess pt preferences

• Deliver appropriate

care

Hierarchical Model of EfficacyLevel 1. Technical

Level 2. Diagnostic accuracyLevel 3. Diagnostic thinkingLevel 4. TherapeuticLevel 5. Patient outcomeLevel 6. Societal

Fryback & Thornbury. Medical Decision Making 1991;11:88-94.

Accuracy

• SE = Pr(T+| D+)

• SP = Pr(T-| D-)

• Az = Area under ROC

curve

Disease

PLE D + B

No disease

1-PLE N -C

Treat

Test positive

SELE D + B

Test negative

1-SELE D

Disease

P

Test positive

1-SPLE N -C

Test negative

SPLE N

No disease

1-P

Test

Disease

PLE D

No disease

1-PLE N

No Treat

CHOOSE

Baseline Values

P 0.5

B, C 1.0

LEN 2.0

LED 0.0

SE, SP 0.8

Expected Utility

Treat 1.0Test 1.3No Treat 1.0

Limitations

• Disease spectrum

• Accuracy of test

• Natural History of dz

• Effectiveness of

treatment

Randomized Clinical Trial

To ensure that observed

differences in

outcome depend only on the

interven-

tions under investigation and

not on

other factors that affect

outcome.

Outcomes & Economic Core Lab

• Measure Health Related QOL

• Measure costs

• Analyze cost-effectiveness

Health Related QOL

• Global rating

• Symptoms

• Functional status

Health Related QOL

• Non-preference based

– Generic, e.g., EVGFP, SF-36

– Disease-specific, SAQ

• Preference based

– Direct, e.g., VAS

– Indirect, e.g., SF-6D

Measuring Preferences - Direct

• Rating scale

• Standard gamble

• Time-tradeoff

Visual Analogue Scale

Standard Gamble

Measuring Preferences - Indirect

• Quality of Well Being

• Health utilities index

• EuroQoL-5D

• Short Form -6D

SF-6D

1.Physical functioning2.Role limitations3.Social functioning4.Pain5.Mental health6.Vitality

SF-6D Utility ScoringPhysical Functioning

Term Score

PF1 -0.000

PF2 -0.053

PF3 -0.011

PF4 -0.040

PF5 -0.054

PF6 -0.111

Brazier et al. J Health Econ 2002;21:271-92.

U = 1.000 + ∑Score – 0.070

• Measure of patient utility

• Measured on a scale of 0-1.0

• Can be assessed directly or

derived from health survey,

e.g., SF-36

Quality Adjusted Life Year

Quality Adjusted Life Years

0 0.5 1.0

0.5

1.0

Quantity of Life

Qualit

y o

f Li

fe

QALY = 0.5+0.25 = 0.75

Economic Outcomes

• Direct– inpatient care

– outpatient care

– medications

• Indirect

– time and travel

Hospitalization Costs

• Triggered by patient questionnaire

• ICD-9, DRGs, and CPTs coded by

MRA

• Medicare reimbursement – Part A MEDPAR

– Part B Physician Fee Schedule

Outpatient Costs

• Triggered by patient

questionnaire

• ICD-9 and CPTs coded by MRA

• Medicare Physician Fee Schedule

• Red Book avg wholesale prices

Indirect Costs

• Triggered by patient

questionnaire

• Travel and other expenses

• Time from usual activities

CEA

• Societal perspective

• In-trial and lifetime

horizons

• Discounting @ 3%

• Sensitivity analysis

Incremental Cost Effectiveness

Ratio

∆COSTS

∆QALYSICER =

c

effect

II IB

IV

IIIA

IA

IIIB

K

Black. Med Decis Making 1990. 10(3): 212-4.

cost

Comparison

Do Nothing

Do Something

STRATEGY COST QALYS CER

0

$100,000

0

4

NA

$25,000

Chart Abstraction Process

Summary

• Variation in practice• Rising costs unsustainable• Radiologic imaging target• “Outcomes” data collection essential• Role of cost-effectiveness analysis