Economics of Implementation: Moving beyond Traditional CEA

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Economics of Implementation Moving beyond
Traditional CEA

• Mark Smith
• Paul Barnett
• VA Health Economics Resource Center

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Outline

1. Background
2. Cost-effectiveness analysis (CEA)
3. Budget impact analysis (BIA)
4. QUERI economics research

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Policy Needs

• Need to improve evidence base for quality
  improvement
• Need to find most cost-effective combinations of
• Best practices
• Methods to implement them in actual practice
• ? Implementation research

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Stages of Implementation

• 1. Define best practice
• Randomized controlled trials (RCTs)
• Literature reviews
• Expert panels
• Disseminate best practice
• Journal articles, books
• Conferences
• Presentations to clinicians
• Presentations to managers

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Stages of Implementation

• Problem dissemination doesnt work!
• - Providers often ignore journal articles
• - Continuing medical education changes little
• - Handing out guidelines often fails, too
• What to do?
• - Implementation a more structured approach

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Stages of Implementation

• 3. Implementation intervention
• Goal to implement the best practice in a new
  setting
• Common methods
• Electronic clinical reminders
• Education passive, active
• Audit and feedback
• Often done as a quasi-experiment, with results
  published
• Example TIDES, ReTIDES in VA

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Questions

• Are you affiliated with a QUERI center?
• Have you studied the cost of implementing a best
  practice, or will you soon?

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VA QUERI Program

• Goal To locate clinical best practices and to
  implement them throughout the VA system
• Structure 9 research centers focused on diseases
  or conditions (e.g. mental health CHF)
• URL http//www.hsrd.research.va.gov/queri/program
  .cfm

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VA QUERI Program

• Oversight Review board of VA policymakers,
  clinicians, researchers, and a VSO
  representative.
• - promotes policy relevant research
• - promotes spread of findings to policymakers
• in VA headquarters
• Status At several centers, research has reached
  the stage of regional or national roll-out

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Policy Question

• Do the benefits justify the expense of the
  implementation project, including both the
  clinical best practice and the strategy to
  implement it?

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Two Types of Analysis

• Reference case CEA
• shows cost-effectiveness from societal
  perspective
• Budget impact analysis (BIA)
• shows cash flow, total program cost
• from providers perspective

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Outline

1. Background
2. Cost-effectiveness analysis (CEA)
3. Budget impact analysis (BIA)
4. QUERI economics research

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Reference Case CEA

• Standard method for performing cost-effectiveness
  analysis in health
• Promulgated by US Public Health Service task
  force in 1996
• Used to develop formularies and set practice
  guidelines
• Some properties
• Societal perspective ? all costs counted
• Outcome in QALYs ? lifetime horizon

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CEA of Implementation Projects

• Measure cost of clinical effort (traditional CEA)
• Measure cost of implementation effort
• Distinguish cost of implementation from net cost
  of best practice
• Net cost actual cost less any savings (e.g.,
  from prevented care)

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Implementation Cost Elements 1

• Clinical Care
• Include
• Inpatient, outpatient, Rx care
• Patient-incurred costs time spent obtaining
  care, home health care
• Exclude
• Development costs
• Research costs

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Implementation Cost Elements 2

• 2. Dissemination
• - Staff time for creating and presenting results
• - Travel to meetings
• - Supplies
• QUERI definition of dissemination
• An active, versus passive, effort to communicate
  tailored information to target audiences with the
  goal of engagement and information use.
• - Excludes journal articles, conference
  presentations

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Implementation Cost Elements 3

• 3. Implementation intervention
• IT costs (electronic clinical reminders)
• Staff time (training audit/feedback)
• ? Consider start-up vs. maintenance costs

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Issues in Implementation CEA

• Adaptation over time due to
• - Formative evaluation
• - Competing priorities
• Adaptation across locations due to
• - Formative evalution
• - Differences in technology, staffing

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Implications of Adding Implementation

• 1. The combination of implementation and
  best-practice may not be cost-effective.
• Hypothetical example case management for heart
  disease prevention
• - In RCT, 35,000 / QALY
• - When implemented with provider education
  component,
• 75,000 / QALY

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Implications of Adding Implementation

• 2. If the combination isnt cost-effective,
  consider whether the implementation intervention
  can be changed
• Reduce the cost per provider/patient
• Less expensive staff ?
• Less travel ?
• Simpler IT ?
• Limit it to a subset of providers/patients

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Outline

1. Background
2. Cost-effectiveness analysis (CEA)
3. Budget impact analysis (BIA)
4. QUERI economics research

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Budget Impact Analysis Overview

• Definition Analysis of providers expenditures
  for a program over a short period (often 1-3
  years), including the effect of any offsetting
  savings.
• QUERI context
• Perspective of VA
• Counts the clinical intervention and the
  implementation intervention

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Budget Impact Analysis Perspective

• Reference case CEA societal perspective
• Business case provider/payers perspective
• Meaning
• CEA counts patient-incurred costs.
• BIA excludes them except to the extent
  that reputation, plan enrollment, or
  recruitment/retention are affected.
• Practical Effect
• Interventions will be less expensive in a budget
  impact analysis.

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Budget Impact Analysis vs. CEA

• Reference case CEA lifetime horizon
• Budget impact analysis shorter horizon
• Meaning
• Reference case values net present value (NPV) of
  all future costs and benefits.
• Budget impact analysis focuses on short-run
  costs only (typically 1-3 years).
• Practical Effect
• Reductions in health costs in far future do not
  offset initial costs.

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Budget Impact Analysis vs. CEA

• Utility
• BIA typically ignored
• CEA used to estimate quality-adjusted life years
  (QALYs)

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Budget Impact Analysis Drawbacks

• - Some benefits cannot easily be monetized
• - Prestigious journals often wont publish them
• - Costs can vary from site to site
• - Create a method for inputting local prices
• ? Complement of CEA, not substitute

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Why Both CEA and BIA?

• CEA addresses societal perspective
• ? implementation wont occur without proof that
  best practice is cost-effective
• BIA addresses provider perspective
• ? more influential in implementation
• decisions

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Outline

1. Background
2. Cost-effectiveness analysis (CEA)
3. Budget impact analysis (BIA)
4. QUERI economics research

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QUERI Economics Overview

• Cost analyses in gt 50 projects across all QUERI
  centers
• Randomized controlled trials (RCTs)
• Decision models
• Other

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QUERI Economics Studies

• 1. Development of best practice
• Sanders G, et al. Cost-effectiveness of
  screening for HIV in the era of highly active
  antiretroviral therapy. NEJM 2005
• 2. RCT of new intervention
• Pyne J, et al. Cost-effectiveness of a primary
  care depression intervention. JGIM 2003.

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QUERI Economics Studies

• 3. Review of cost studies
• Krumholz H, et al. Preventive cardiology How
  can we do better? Task Force 2 The cost of
  prevention Can we afford it? Can we afford not
  to do it? J Am Coll Cardiology 2002.
• 4. Informatics
• Yu W, et al. Using GIS to profile health-care
  costs of VA Quality Enhancement Research
  Initiative diseases. J Medical Systems 2004

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QUERI Economics Studies

• 5. Cost of implementation
• Liu CF, et al. What does it take to implement
  an evidence-based depression treatment in primary
  care? Presentation at HSRD National Meeting.
  March, 2005.

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Looking Ahead

• Studies on newer topics
• Formative evaluation cost
• Cost of dissemination implementation
• Budget impact analysis
• International collaboration
• Implementation Science journal (free, open
  access)
• www.implementationscience.com
• Emphasis on complex issues, comorbid conditions

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Forthcoming article

• Smith MW, Barnett PG.
• QUERI and the economics of implementation
  studies.
• Implementation Science (late 2007 or early 2008)