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

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

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

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

5. Health Expenditures by Country, 2006

6. Life Expectancy by Country CountryLife ExpRank Macau84.41 Japan82.13 Canada81.27 United Kingdom79.036 United States78.149 Mexico76.171 China73.5108 Iraq70.0145

7. Growth in physician services

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

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

12. Baseline Values P0.5 B, C1.0 LEN2.0 LED0.0 SE, SP0.8

13. Expected Utility Treat1.0 Test1.3 No Treat1.0

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

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

17. Health Related QOL Global rating Symptoms Functional status

18. 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

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

21. Visual Analogue Scale

22. Standard Gamble

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

24. SF-6D 1.Physical functioning 2.Role limitations 3.Social functioning 4.Pain 5.Mental health 6.Vitality

25. SF-6D Utility Scoring Physical Functioning TermScore 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

26. 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

27. Quality Adjusted Life Years 00.51.0 0.5 1.0 Quantity of Life Quality of Life QALY = 0.5+0.25 = 0.75

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

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

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

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

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

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

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

36. Comparison Do Nothing Do Something STRATEGYCOSTQALYSCER 0 $100,000 0 4 NA $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