Economics in Dissemination and Im Implementation Research Todd H. Wagner, PhD Jean Yoon, PhD Angela So, MPH Josephine Jacobs, PhD Wei Yu, PhD
Acknowledgements & Disclosures • Director, Health Economics Resource Center, Palo Alto VA & Associate Professor, Stanford • All errors are my own • The views and opinions expressed in this presentation are those of the authors and do not necessarily reflect those of Stanford or the VA • No disclosures
Far from Perfect • 30% of health spending in 2009 -- roughly $750 billion -- was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. 1 1. Smith M, Saunders R, Stuckhardt L, et al., editors. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, D.C.: Institute of Medicine. The National Academies Press, 2012.
Improving Value • Considerable interest and debate about how to improve the value of health care • Value= outcomes gained per dollar spent Change in outcomes Value= Change in cost • When outcomes =quality adjusted life years, then value= cost effectiveness analysis (CEA) 1. Owens D, Qaseem A, Chou R, et al. High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Annals of Internal Medicine 2011;154(3):174-80.
Limitations of CEA • CEAs are expensive, slow and prone to misinterpretation. 1 • CEAs are rarely done on existing treatments • Limited impact on providers • Make assumptions that may not hold Important lessons • Perceptions that results do not apply to for implementation & learning health “my patients” care systems • Incentives depend on the perspective 1. Houlind K, Kjeldsen BJ, Madsen SN, et al. OPCAB surgery is cost-effective for elderly patients. Scand Cardiovasc J 2013;47(3):185-92.
Concerns are not new • ISPOR recommendations on BIA: • Mauskopf J, Sullivan SD, Annemans L, et al. Principles of Good Practice for Budget Impact Analysis: Report of the ISPOR Task Force on Good Research Practices – Budget Impact Analysis. Value in Health 2007;10(5):336-347. • Sullivan SD, Mauskopf JA, Augustovski F, et al. Principles of good practice for budget impact analysis II: Report of the ISPOR Task Force on Good Research Practices – Budget Impact Analysis. Value Health 2014:17:5-14 www.ispor.org/budget-impact-health-study-guideline.pdf
VA implementation & value • VA has funded a large number of quality improvement efforts through QUERI (Quality Enhancement Research Initiative). • QUERI’s mission is “to improve the health of Veterans by supporting the more rapid implementation of effective clinical practices into routine care.” • QUERI is increasingly interested in understanding the value and budgetary impact of these improvement efforts
Needs Assessment • QUERI currently funds 15 national programs https://www.queri.research.va.gov/about/default.cfm • Each program has 3-4 separate studies, with the majority being implementation trials • We conducted a needs assessment to understand the need for economics support
Methods • We emailed the principal investigator(s) and co- investigators of each program • 14 of the 15 programs responded and participated • Each structured interview was conducted by telephone and lasted approximately 60 minutes • All of participants agreed to audio recording; many shared their grant proposals • Transcripts were coded for rapid analysis
Three main results • Gap in health economics knowledge • Lack of economic expertise • Confusion about methods and analysis
Gap In Knowledge • The vast majority of the programs stated that understanding the program’s budgetary impact was critical to the long-term success of the initiatives • Only a third of the programs had specified an economic analysis in their grant • Among those that did, there was large variation in objectives and methods
Lack of economic expertise • The respondents noted a dearth of experienced health economics investigators • Most noted insufficient funds to include an economic analysis as part of their program • Lack of expertise reflected a broader scarcity in health economists, even when funding existed
Confusion about methods and analysis • There was uncertainty about how to estimate costs • Intervention and implementation costs were often blurred • Differing opinions about the best way to include patients’ health care costs that could have been affected by the intervention • There was uncertainty about how to analyze the data • Site-level variation
Filling the gap • Based on the needs assessment, we developed two parallel work streams to support the QUERI programs: • Tailored support for three QUERI programs • General support for twelve QUERI programs
Tailored support • We connected with three QUERI programs: • Chronic Pain QUERI: Improving Pain-Related Outcomes for Veterans (IMPROVE) • Measurement Science QUERI (cardiac rehab) • Personalized Care QUERI: PrOVE – PeRsonalizing Options through Veteran Engagement (exercise) • In collaboration with each program, we developed a data analysis plan for: • Implementation costs • Intervention costs • Consequence costs
General support • We are utilizing the lessons learned from the tailored support to develop tools and resources for the other QUERI programs. • These tools include: • A toolbox to inform economic data measurement and analysis • Educational materials • A help desk
General support • We created a web page with tools and resources www.herc.research.va.gov/include/page.asp?id=implementation
Lessons learned to date 1. A cost analysis may not be necessary 2. Causality and context matter 3. Savings may be a mirage
A cost analysis may not be necessary • Good opportunities • Interventions that have a large impact on health care costs • Widely adopted interventions • Intervention designed to meet an economic objective or to replace existing care • Limited or uncertain opportunity use • Close substitutes • If economic findings depend on proof of effectiveness • Low-cost interventions
Causality and context matter Context is noise Context is meaningful • Generalizability • Leadership • Causality • Culture
Savings may be a mirage • A program was designed to reduce patient admission and length of stay in the intensive care unit (ICU) • Each day in the ICU costs ~$5000, but the first day is the most expensive • Keeping patients out of the ICU may reduce that patient’s cost, but ICU beds are often filled by others • Savings will only be achieved if the ICUs are closed
Questions twagner@Stanford.edu or todd.wagner@va.gov
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