and Im Implementation Research Todd H. Wagner, PhD Jean Yoon, PhD - - PowerPoint PPT Presentation

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
• When outcomes =quality adjusted life years, then

value= cost effectiveness analysis (CEA)

Change in outcomes Change in cost Value=

• 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
• Perceptions that results do not apply to

“my patients”

• Incentives depend on the perspective

Important lessons for implementation & learning health care systems

• 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
• f 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
• bjectives 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

• Generalizability
• Causality

Context is meaningful

• Leadership
• 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

• r todd.wagner@va.gov