Interactive session design cost effectiveness

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Interactive session design cost effectiveness

• Jan J. v. Busschbach, Ph.D.
• Erasmus MC
• Institute for Medical Psychology and
  PsychotherapyPO Box 17383000 DR Rotterdam31
  10 4087807J.vanbusschbach_at_erasmusmc.nl
• Psychotherapeutic centre 'De Viersprong
• PO Box 74660 AA Halsteren 31 164
  632200Jan.Busschbach_at_deviersprong.nl
• Presentations can be found at
• http//www.xs4all.nl/jannetvb/busschbach/

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Questions to be solved

• Who is the audience?
• Whos perspective?
• Should we evaluated at all?
• What are the costs?
• What are the effects?
• How do effects relate to the costs in practice?
• Model
• Who to interpret the cost effectiveness ratio?

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The societal perspective

• Standard in health economics
• Determine cost (and effects) from the societal
  viewpoint
• Resource used by all parties concerned
• The cost for society as a whole
• No matter who paying
• Other perspectives are possible
• Insurance, government, hospital, patient,
  industry, doctor

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When to evaluated?
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Tariffs

• Cutback operation, correction of anus anterior
• Small operation
• Halve hour
• Tariff 1571 Euro
• Posterior Saggital Anorectoplasty (PSARP)
• Large operation
• 3 to 5 hours
• Tariff 374 Euro

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Cost price investigations

• Measure only volumes of major costs drivers
• Estimated real market prices
• One should include all resources used
• The societal perspective
• Shadow pricing
• Tariffs are only used in health economics
• If they are a reasonable accurate indication of
  the resources used
• If they are a small proportion of the total costs
• If they volumes do not contribute to the
  incremental costs
• (the difference between to alternative programs)

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We are in need of uni-dimensional effects

• For instance
• 10,000 .- 1 hip transplantation
• 15,000 ,- 1 wheelchair
• Costs can be compared
• Are uni-dimensionaal
• Effects are less easy to compare
• Effects are multi-dimensional
• How to make the effects also uni-dimensional?

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How to make the effects uni-dimensional?

• Three methods
• Cost Benefit Analysis
• Express effects in money
• Cost Effectiveness Analysis
• Focus on one effect
• Cost per QALY Analysis (Utility)
• QALY

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QALY league table
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Visual Analogue Scale
Normal health

• VAS
• Also called category scaling
• From psychological research
• How is your quality of life today ?
• X marks the spot
• Response in centimeters
• Rescale to 0..1
• Different anchor point possible
• Normal health (1.0) versus dead (0.0)
• Best imaginable health versusworse imaginable
  health

X
Dead
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Time Trade-Off

• TTO
• Wheelchair
• With a life expectancy 50 years
• How many years would you trade-off for a cure?
• Max. trade-off is 10 years
• QALY(wheel) QALY(healthy)
• Y V(wheel) Y V(healthy)
• 50 V(wheel) 40 1
• V(wheel) .8

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The EuroQol EQ-5D

• MOBILITY
• I have no problems in walking about
• I have some problems in walking about
• I am confined to bed
• SELF-CARE
• I have no problems with self-care
• I have some problems washing or dressing myself
• I am unable to wash or dress myself
• USUAL ACTIVITIES (e.g. work, study, housework
  family or leisure activities)
• I have no problems with performing my usual
  activities
• I have some problems with performing my usual
  activities
• I am unable to perform my usual activities
• PAIN/DISCOMFORT
• I have no pain or discomfort
• I have moderate pain or discomfort
• I have extreme pain or discomfort
• ANXIETY/DEPRESSION
• I am not anxious or depressed
• I am moderately anxious or depressed

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Validated Questionnaires

• Describe health states
• Have values from the general public
• Rosser
• QWB
• 15D
• HUI Mark 2
• HUI Mark 3
• EuroQol EQ-5D

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Patient Perspective
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The Societal Perspective
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How to get these societal values?

• Patient fills in questionnaire
• Choose the value function from the literature
• Calculate societal value

COMPUTE MVH_A1 1. VARIABLE LABELS MVH_A1 'York
A1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) lt
5 ). RECODE MVH_A1 (1 SYSMIS). END IF. IF
(MAX(mo, sc, ua, pd, ad) gt 1) MVH_A1 MVH_A1
-.081. IF (mo 2) MVH_A1 MVH_A1 - .069. IF (mo
3) MVH_A1 MVH_A1 - .314. IF (sc 2) MVH_A1
MVH_A1 - .104. IF (sc 3) MVH_A1 MVH_A1 -
.214. IF (ua 2) MVH_A1 MVH_A1 - .036. IF (ua
3) MVH_A1 MVH_A1 - .094. IF (pd 2) MVH_A1
MVH_A1 - .123. IF (pd 3) MVH_A1 MVH_A1 -
.386. IF (ad 2) MVH_A1 MVH_A1 - .071. IF (ad
3) MVH_A1 MVH_A1 - .236. IF (MAX(mo, sc, ua,
pd, ad) gt 2) MVH_A1 MVH_A1 - .269.
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An example of a value function
SPSS syntax Dolan 1997, Medical Care,
1997351095-108. mo mobility, sc self care,
ua usual activities, pd pain discomfort ,
ad anxiety and depression. COMPUTE MVH_A1
1. VARIABLE LABELS MVH_A1 'York A1 tariff'. DO
IF (NVALID(mo, sc, ua, pd, ad) lt 5 ). RECODE
MVH_A1 (1 SYSMIS). END IF. IF (MAX(mo, sc, ua,
pd, ad) gt 1) MVH_A1 MVH_A1 -.081. IF (mo 2)
MVH_A1 MVH_A1 - .069. IF (mo 3) MVH_A1
MVH_A1 - .314. IF (sc 2) MVH_A1 MVH_A1 -
.104. IF (sc 3) MVH_A1 MVH_A1 - .214. IF (ua
2) MVH_A1 MVH_A1 - .036. IF (ua 3) MVH_A1
MVH_A1 - .094. IF (pd 2) MVH_A1 MVH_A1 -
.123. IF (pd 3) MVH_A1 MVH_A1 - .386. IF (ad
2) MVH_A1 MVH_A1 - .071. IF (ad 3) MVH_A1
MVH_A1 - .236. IF (MAX(mo, sc, ua, pd, ad) gt 2)
MVH_A1 MVH_A1 - .269.
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Some values

• Broken arm
• 12211
• no problems in walking about
• some problems washing or dressing
• some problems with performing usual activities
• no pain or discomfort
• not anxious or depressed
• Societal value 0.779

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Some values

• Broken hip
• 22222
• some problems in walking about
• some problems washing or dressing
• some problems with performing usual activities
• moderate pain or discomfort
• moderately anxious or depressed
• Societal value 0.516

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Outcome Research

• Clinical research
• Does it work?
• Efficacy
• Perfect patient
• No co morbidity
• Randomized Clinical Trial
• Controlled conditions

• Outcome research
• Does it work in practice
• Effectiveness
• Every day patient
• Normal co morbidity
• Trials in a naturalistic setting
• Real life conditions

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Trial versus Clinical Practise

• Subject homogeneity
• Double blind
• Placebo comparison
• Forced compliance
• Fixed procedures
• High motivation

• Representativeness
• Open treatment
• Usual care
• Real compliance
• Flexible procedure
• Daily motivation

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Trial versus Clinical Practise

• Validity
• High internal
• Low external
• Increase validity by
• Search for large deviations of practice
• Model outcomes to practice
• Modelling
• Use trial effect
• Add external elements

• Validity
• Log internal
• High external
• Increase validity by
• Search for causal relations
• Model outcomes to new situation
• Modelling
• Use natural history
• Add effect

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Modelling depression
Cure
Depressive patient Sex Age Number of
relapses Duration of illness
suicide
Natural death
Still depressive
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Books

• Oostenbrink, J. B., M. A. Koopmanschap, et al.
• "Handleiding voor Kostenonderzoek. Methoden en
  Richtlijnprijzen voor Economische Evaluaties in
  de Gezondheidszorg. 2000, College voor
  Zorgverzekeringen
• Rutten-van Mölken MPMH, Busschbach JJV, Rutten
  FFH.
• Van Kosten tot Effecten Een Handleiding voor
  Evaluatiesstudies in de Gezondheidszorg. Elsevier
  Gezondheidszorg, Maassen, ISBN 90 352 2281 4.
  Zomer 2000