Assessing Health and Economic Outcomes

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

2. Background Health outcomes Economic outcomes Cost-Effectiveness Analysis Outline

3. Geography is destiny More is not better Patient preferences matter “Outcomes”

4. US Health Care Expenditures http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage

5. Health Expenditures by Country, 2006

6. Life Expectancy by Country

7. Growth in physician services

8. Determine what works Assess pt preferences Deliver appropriate care “Outcomes”

9. Hierarchical Model of Efficacy Level 1. Technical Level 2. Diagnostic accuracy Level 3. Diagnostic thinking Level 4. Therapeutic Level 5. Patient outcome Level 6. Societal Fryback & Thornbury. Medical Decision Making 1991;11:88-94.

10. SE = Pr(T+| D+) SP = Pr(T-| D-) Az = Area under ROC curve Accuracy

12. Baseline Values P 0.5 B, C 1.0 LEN 2.0 LED 0.0 SE, SP 0.8

13. Treat 1.0 Test 1.3 No Treat 1.0 Expected Utility

14. Disease spectrum Accuracy of test Natural History of dz Effectiveness of treatment Limitations

15. 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.

16. Measure Health Related QOL Measure costs Analyze cost-effectiveness Outcomes & Economic Core Lab

17. Global rating Symptoms Functional status Health Related QOL

18. Non-preference based Generic, e.g., EVGFP, SF-36 Disease-specific, SAQ Preference based Direct, e.g., VAS Indirect, e.g., SF-6D Health Related QOL

20. Rating scale Standard gamble Time-tradeoff Measuring Preferences - Direct

21. Visual Analogue Scale

22. Standard Gamble

23. Quality of Well Being Health utilities index EuroQoL-5D Short Form -6D Measuring Preferences - Indirect

24. SF-6D • Physical functioning • Role limitations • Social functioning • Pain • Mental health • Vitality

25. Brazier et al. J Health Econ 2002;21:271-92. SF-6D Utility Scoring U = 1.000 + ∑Score – 0.070

26. Quality Adjusted Life Year • 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

27. Quality Adjusted Life Years 1.0 QALY = 0.5+0.25 = 0.75 Quality of Life 0.5 0 0.5 1.0 Quantity of Life

28. Direct inpatient care outpatient care medications Indirect time and travel Economic Outcomes

29. Triggered by patient questionnaire ICD-9, DRGs, and CPTs coded by MRA Medicare reimbursement Part A MEDPAR Part B Physician Fee Schedule Hospitalization Costs

30. Triggered by patient questionnaire ICD-9 and CPTs coded by MRA Medicare Physician Fee Schedule Red Book avg wholesale prices Outpatient Costs

32. Triggered by patient questionnaire Travel and other expenses Timefrom usual activities Indirect Costs

33. Societal perspective In-trial and lifetime horizons Discounting @ 3% Sensitivity analysis CEA

34. Incremental Cost Effectiveness Ratio ∆COSTS ∆QALYS ICER =

35. c cost K II IB IA effect IIIA IIIB IV Black. Med Decis Making 1990. 10(3): 212-4.

36. STRATEGY COST QALYS CER Do Nothing Do Something Comparison 0 0 NA $100,000 4 $25,000

37. Chart Abstraction Process

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