1. 1 Is it cost-effective to kill patients? Edward Broughton, PhD., MPH Director, USAID Health Care Improvement Project, University Research Co.

2. USAID HEALTH CARE IMPROVEMENT PROJECT Objectives What is cost-effectiveness analysis? What is QI in health care? Why do we do CEAs on QI interventions? How do we do CEAs of QI interventions? How do we interpret the results? What do we do with the results? What does it all really mean?

3. USAID HEALTH CARE IMPROVEMENT PROJECT What is cost-effectiveness analysis? A way to measure efficiency of an intervention Cost-effectiveness = costs ÷ effects Cost-effectiveness ANALYSIS is the cost-effectiveness of one intervention relative to a baseline One of many forms of economic analysis. Others include cost-minimization, cost-utility analysis and cost- benefit analysis

4. USAID HEALTH CARE IMPROVEMENT PROJECT What is cost-effectiveness analysis? Willingness to pay = Cost of treatment = $50 Cost of no treatment = $0 Effect of treatment = 1 hr pain relief Effect of no treatment = 0 hrs pain relief

5. USAID HEALTH CARE IMPROVEMENT PROJECT Is it cost-effective? StrategyCostIncremental cost EffectIncremental effect Inc. cost- effectivenes s ratio Treatment$50 1 hr pain relief $50 / hr pain relief No treatment $00

6. USAID HEALTH CARE IMPROVEMENT PROJECT Cost effectiveness plane 6 Higher cost Lower cost More effective Less effective Willingness-to-pay threshold $50 1 hr pain relief

7. USAID HEALTH CARE IMPROVEMENT PROJECT What is cost-effectiveness analysis? Willingness to pay = Cost of treatment = $50 Cost of no treatment = $100 Effect of treatment = 1 hr pain relief Effect of no treatment = 0 hrs pain relief

8. USAID HEALTH CARE IMPROVEMENT PROJECT Is it cost-effective? StrategyCostIncremental cost EffectIncremental effect Inc. cost- effectivenes s ratio Treatment$50-$501 hr pain relief -$50 / hr pain relief No treatment $1000

9. USAID HEALTH CARE IMPROVEMENT PROJECT Cost effectiveness plane 9 Higher cost Lower cost More effective Less effective Willingness-to-pay threshold $50 -$50 1 hr pain relief

10. USAID HEALTH CARE IMPROVEMENT PROJECT Why do cost-effectiveness analysis of QI programs? Compare the QI intervention to doing nothing Compare one QI intervention to another Compare a QI intervention to another health intervention Determine what the biggest contribution to the cost- effectiveness of a program is Determine whether a program is affordable / sustainable

11. USAID HEALTH CARE IMPROVEMENT PROJECT VAP prevention in Nicaragua Ventilator –associated pneumonia: pnuemonia occuring >48h after initiation of intubation / mech vent Evidence shows decreased occurrence with standard bundle of interventions HCI staff coached clinical staff on bundle in 2 pediatric ICUs Teams worked on common set of evidence-based care practices, monitored indicators and shared successful changes

12. USAID HEALTH CARE IMPROVEMENT PROJECT Nicaragua VAP Prevention Program Dr. Oscar Nunez, Dr. Sergio Lopez, Dra. Ivonne Gomez

13. USAID HEALTH CARE IMPROVEMENT PROJECT Defining the study What is the specific question we are asking? From whose perspective are we asking it? What is the time-frame? What are the outcomes we are considering?

14. USAID HEALTH CARE IMPROVEMENT PROJECT Study details Perspective: funders (MINSA and USAID-HCI project) Timeframe: One year Data from a case-cohort study of VAP and non-VAP ventilated patients in PICU CEA: Deaths averted, Hosp days, Cases averted

15. USAID HEALTH CARE IMPROVEMENT PROJECT Data Costs –Costs of the intervention: HCI/USAID, MOH, (patients) –Change in costs of services (deliveries) –(costs to the MOH if they were doing the intervention) Effectiveness –Process measures Compliance with treatment standards –Patient outcomes Cases of VAP averted, deaths averted –Composite measures DALYs, QALYs

16. USAID HEALTH CARE IMPROVEMENT PROJECT Results StrategyCostInc costEffectInc effect C/E ICER Prevention program 44570.8565207 Business as usual 51206330.809-0.0456329-14733

17. USAID HEALTH CARE IMPROVEMENT PROJECT Results StrategyCostInc costEffectInc effectC/E Prevention program 44570.8565207 Business as usual 51206630.809-0.0456329 ICER = inc cost / inc effects = 663 / -0.045 = $14 733 / VAP death averted

18. USAID HEALTH CARE IMPROVEMENT PROJECT Cost effectiveness plane 18 Higher cost Lower cost More effective Less effective Willingness-to-pay threshold Accept Reject Accept Reject Accept (?)

19. USAID HEALTH CARE IMPROVEMENT PROJECT

20. But….. Efficiency is only one criteria for health resource allocation decisions We should consider equity We should consider affordability We should consider sustainability

21. USAID HEALTH CARE IMPROVEMENT PROJECT Thank you!