1. Make Nutrition Services Count: Cost-Effectiveness Research & Outcomes Research

2. Outcomes Research and Cost Effectiveness Setting value to what we do

3. ADA’s Commitment to Cost Effectiveness n n National Academy of Sciences Report n n Dietetics Outcomes Research Steering Committee n n Health Services Research Committee n n Quality Management Committee n n Lewin Study

4. n n Define outcomes / CE terms n n Methods of evaluation in health care n n Distinguish the features of cost-effectiveness research n n Identify barriers/ limitations and resources in conducting CE studies n n Identify activities that may promote CE studies Objectives:

5. n Outcome The result of the performance (or nonperformance) of a function or process(es). JCAHO 1996 n Outcome Indicator Measures what happens (or does not happen) to a patient after something is done (or not done) to the patient. NLHI Terms

6. n Cost Benefit Analysis An analytic tool for estimating the net social benefit of a program or intervention as the incremental benefit of the program less the incremental cost, with all benefits and costs measured in dollars. Cost Effectiveness in Health and Medicine. Gold, Martha, et al  1996 University Press Terms

7. n Cost Effectiveness An analytic tool in which costs and effects of a program and at least one alternative are calculated and presented in a ratio of incremental costs to incremental effects. Effects are health outcomes such as cases of a disease presented, years of life gained or quality adjusted life years rather than monetary measures as in cost benefit analysis. Cost Effectiveness in Health and Medicine. Gold, Martha, et al  1996 University Press Terms

8. n QALY “Quality-adjusted life year” Terms

9. n DFLE “Disability-free life expectancy” Life expectancy free of class I (or worse) disability Disability classes based on person- trade off method

10. Terms n DALE “Disability-adjusted life expectancy” HL x = L x ( 1 - P ix D ix ) Where: HL x =the number of years of healthy life lived at age x L x = the number of years of life lived at age x from a life table P ix =the prevalence of disabling sequelae j at age x D ix =the disability severity weight for disabling sequelae j at age x

11. n n Define outcomes / CE terms n n Methods of evaluation in health care n n Distinguish the features of cost-effectiveness research n n Identify barriers/ limitations and resources in conducting CE studies n n Identify activities that may promote CE studies Objectives:

12. Methods of Evaluation in Health Care Measurements A. In natural units on a undimensional scale B. In units of a cardinal utility function, which is used to transform the multidimensional concept of ‘health’ into a scalar index’ C. In monetary units Zweifel P: Health Economics, 1997

13. Methods of Evaluation in Health Care Natural Units: n n A clinical parameter - blood pressure n n Length of life in years This method only makes sense if the alternatives to be compared have one specific effect and not side effects. Zweifel P: Health Economics, 1997

14. Methods of Evaluation in Health Care Natural Units: n n A clinical parameter - blood pressure –compare two different drugs - no side effects –compare two different diet interventions - no side effects OR –two safety measures designed to avoid fatal traffic crashes Zweifel P: Health Economics, 1997

15. Methods of Evaluation in Health Care: CEA Method of evaluation would be cost- effectiveness analysis (CEA). Only for mutually exclusive projects. t 1 CEA = costs in units of money benefits in mmHg and t 2 CEA = costs in units of money benefits in additional life years Zweifel P: Health Economics, 1997

16. Methods of Evaluation in Health Care Limitations of CEA n n Its application implies that who obtains the additional life years is of not relevance n n It does not lend itself to the evaluation of projects with several different (positive) effects. n n Provides a rank order of preference among mutually exclusive projects, it does not answer the question which of the projects should be realized and which should not Zweifel P: Health Economics, 1997

17. Methods of Evaluation in Health Care Measurements A. In natural units on a undimensional scale B. In units of a cardinal utility function, which is used to transform the multidimensional concept of ‘health’ into a scalar index’ C. In monetary units Zweifel P: Health Economics, 1997

18. Methods of Evaluation in Health Care: CUA Method of evaluation that takes account of the multidimensionality of the concept ‘health’ by trying to encompass all effects of an intervention - prolonging life and changing health status. t CUA = costs in units of money benefits in QALYs The index value may be interpreted as ‘QALYs’ gained. Again, only for mutually exlusive projects. Unlike CEA, suitable for comparing medical interventions of heterogeneous kind and purpose Zweifel P: Health Economics, 1997

19. Methods of Evaluation in Health Care: CBA Zweifel P: Health Economics, 1997 Monetary equivalents are assigned to prolongations of life and change of health status. t CBA = costs in units of money benefits in units of money

20. Methods of Evaluation in Health Care: Zweifel P: Health Economics, 1997 Unlike cost-benefit analysis, cost- effectiveness analysis and cost-utility analysis circumvent the problem of monetary evaluation of life and health. However, they provide only a relative evaluation of mutually exclusive projects, while CBA permits evaluation of each project on its own.

21. Objectives n n Define outcomes / CE terms n n Methods of evaluation in health care n n Distinguish the features of cost- effectiveness research n n Identify barriers/ limitations and resources in conducting CE studies n n Identify activities that may promote CE studies

22. n Outcomes Research –Process < Identify the outcome (what we effect) < Set a clear definition of the outcome –Implementation < Measure < Analyze < Evaluate Features of Cost Effectiveness

23. n Examples of research on indictors: Antecedents Epidemiological term similar to exposure _____________ Features of Cost Effectiveness

24. n Examples of outcomes research: _____________ Features of Cost Effectiveness

25. n n What it is - What is Cost-Effectiveness? n What it is not-

26. n n What it is - “a method for evaluating the health outcomes and resource costs of health interventions” Russell, et al., JAMA 1996;276:1172 What is Cost-Effectiveness?

27. Interventions –Nutrition Support –MNT Protocols – Presence of the RD on the health care team, in the public health jurisdiction, etc.

28. What is Cost-Effectiveness? Outcomes in CEA –Traditional Medical Outcomes –Resource Costs –Expanded definition Patient centered outcomes Quality of life; Client satisfaction

29. What is Cost-Effectiveness? Cost-Savings Cheaper bang Cost-Benefit Analysis All benefits cost in dollars ?? Putting dollar value on life years What it is not - n n What it is -

30. Hoch JS: Health Econ. 11: 415–430 (2002), Published online 31 January 2002 in Wiley InterScience (www.interscience.wiley.com).

31. Objectives n n Define outcomes / CE terms n n Methods of evaluation in health care n n Distinguish the features of cost- effectiveness research n n Identify barriers/ limitations and resources in conducting CE studies n n Identify activities that may promote CE studies

32. Barriers and Limitations Expectations Training Support Outcomes difficult to measure Time of follow-up Co-Morbidity's Research training

33. Strengths Documentation of worth Benchmark for change

34. Objectives n n Define outcomes / CE terms n n Methods of evaluation in health care n n Distinguish the features of cost- effectiveness research n n Identify barriers/ limitations and resources in conducting CE studies n n Identify activities that may promote CE studies

35. Cost-Effectiveness