Health Economics in Clinical Practice Guidelines: The Know-Do Gap - - PowerPoint PPT Presentation

Health Economics in Clinical Practice Guidelines: The Know-Do Gap

Ann Scott, Carmen Moga, Christa Harstall April 16, 2019

Disclosure I have no actual or potential conflict of interest in relation to this topic or presentation.

The Ambassador Guideline Adaptation and Development Program

• Started in 2004 as a knowledge

translation strategy for promoting the use of current research evidence to encourage and support best practice in pain management across Alberta

• Program for moving research

evidence into practice by:

– Increasing clinician knowledge about best evidence – Encouraging clinicians to incorporate research evidence into practice

• Evolved into a guideline adaptation

program that has since expanded into other areas beyond the original chronic pain remit

Objectives

• 1. Forecasting economic impact during guideline

construction

– How to incorporate economic information into the construction of guideline recommendations – How to forecast the potential economic ramifications of guideline recommendations

• 2. Measuring economic impact after guideline

implementation

– Create an inventory of methods for evaluating the economic impact

• f guidelines

Outline of Methods

• Forecasting economic impact during guideline construction

– Theoretical frameworks

• Guidance from internationally recognized standards (IOM, GIN, AGREE)
• Literature search

– Practical methods

• Guideline sample from adaptation process for low back pain
• Guideline manuals (CMA, CTFPS, NICE, NHMRC, USPSTF, WHO)
• Literature search
• Measuring economic impact after guideline implementation

– Modeling and “real world” studies

• Literature search
• Studies published in 2005, 2007, 2009, 2011, and 2013
• Interventions for prevention, diagnosis, and treatment

Results

Forecasting economic impact

What we’re supposed to be doing…

Theoretical Frameworks

• AGREE II tool (criterion #20)

– Involve appropriate experts in finding and analyzing the cost information – Report economic consequences of implementing CPG recommendations (if applicable) – Describe methods by which the cost information was sought (e.g. inclusion of health economist in GDG) – Identify the types of cost information considered (e.g. economic evaluations, drug acquisition cost)

• G-I-N

– Include information on cost, if possible – Templates for health economic assessment are under development

• IOM

– No information available

Results

Forecasting economic impact

What we’re supposed to be doing…

Theoretical Frameworks

• Peer reviewed literature (n=6) key themes

– GDG should include a health economist – Health economist’s role is to analyze and educate – Discuss economic aspects in parallel not post hoc – Only include resource aspects when necessary – Present analyses in natural units (e.g. days in hospital) – Patient/carer costs only important with respect to compliance – Focus on “barrier” and “balanced” interventions – Not always necessary in “simple” guidelines – Published analyses are of limited use – Keep models simple and transparent

Results

Forecasting economic impact

What we are doing…

Selected guideline development groups

• Australia (NHMRC), Canada (CMA, CTFPHC), UK

(NICE), USA (USPSTF), international (WHO) main messages:

– Include economists or experts in health economics to advise on search strategies, conduct analyses, and interpret relevant economic data; include a separate decision modelling support team; commission the work if needed – Conduct full economic evaluation (cost- effectiveness, cost-utility, cost-benefit analyses), conduct new modelling studies, or provide contextual information regarding costs – Recommend interventions that increase effectiveness at an acceptable level of increased cost – Describe resource implications and economic consequences of recommended practice – Use a health care payer or societal perspective

Results

Forecasting economic impact

What we are doing…

Peer reviewed literature

• 3 SRs of over 300 CPGs (1985-1998)

– 14% to 30% considered costs

• 1 review of 30 largest US physician

specialty societies (CPGs 2008-2012)

– 57% considered costs, half of which used an explicit methodology – Usually for risk factor reduction or preventive care

• 1 SR of over 16 CPGs (2003-2015)

– “Cost effectiveness” mentioned 14 times – Increasing trend over time

• 1 SR of over 100 most cited CPGs in the

NGC (2014)

– 43% considered costs and utilized only 6% of the relevant available cost analyses – Factors likely to increase use: quality, transparency, direct association of costs to patient

• utcomes

Results

Forecasting economic impact

What we are doing…

• Seed guidelines from Ambassador Program

Sample of 12 CPGs (1st + 2nd edition LBP CPG) – No economic experts were involved in CPG development – Narrative synthesis of studies on economic evaluation in 9 CPGs – Perspective of analysis was reported in six CPGs: societal, provider, purchaser (n=2), health system (n=4) – Four recommendations on economic aspects were reported in two CPGs

Results

Measuring economic impact

Modeling studies (n=45)

• Majority conducted by non-stakeholders or

guideline developers/implementers (76%)

• Perspective: 3rd party payer (64%), provider

(13%), societal (9%)

• Around half (56%) specified a willingness-to-pay

threshold

• 7% (3 studies) evaluated capacity effects

CEA 20% Cost Analysis 27% CEA & Cost Analysis 11% CEA & Cost Utility 40% Other 2%

Type of Analysis

Results

Measuring economic impact

Mapping studies (n=38)

• Post hoc comparison of guideline practice
• Majority conducted by non-stakeholders or

guideline developers/implementers (79%)

• Perspective: 3rd party payer (63%), provider

(24%), societal (8%)

• 5% specified a willingness-to-pay threshold
• 8% (3 studies) evaluated capacity effects

CEA 8% Cost Analysis 89% CEA & Cost Analysis 3%

Type of Analysis

Results

Measuring economic impact

“Real world” studies (n=43)

• Majority conducted by non-stakeholders or

guideline developers/implementers (93%)

• Perspective: provider (53%), 3rd party payer

(37%)

• 9% (4 studies) evaluated capacity effects

Retrospective Pre-test/Post-test 42% Prospective Pre-test/Post-test 25% Prospective Comparison 21% Retrospective Comparison 4% Other 8%

Study Types

CEA 9% Cost Analysis 72% CEA & Cost Analysis 2% CEA & Cost Utility 12% Other 5%

Type of Analysis

• Use health economic analyses

wisely; focus on “problem” areas only

• Get help
• Keep it simple
• Use a healthcare payer or

societal perspective

• Don’t forget to consider

capacity effects

• Steer away from published

analyses unless you need modeling inputs

• There is no “ideal” method for

measuring economic impact

Key Messages for Guideline Developers

capstone@shaw.ca 1.780.448.4881 www.ihe.ca