Assessing Health and Economic Outcomes for Diagnostic Imaging William C. Black, M.D. Dartmouth-Hitchcock Medical Center

Outline “ Outcomes” research Relevance to imaging Methods –Health outcomes –Economic outcomes –CEA

“ Outcomes” - History Geography is destiny More is not better Pt preferences matter

US Health Care Expenditures

Health Expenditures by Country 2006

Life Expectancy by Country CountryLife ExpRank Macau84.41 Japan82.13 Canada81.27 United Kingdom Bosnia United States Mexico China Iraq Angola

Factors Increasing Spending Congressional Budge Office. Nov 2007 New medical technology & services Increases in income and insurance Aging population

Growth in physician services

Imaging Boom Washington GHC XS imaging vol ↑2X pm CT vol ↑2X pm, MR vol ↑3X pm Costs for all imaging ↑2X pm XS 54-70% imaging costs Smith-Bindman et al. Health Aff, (6): p

“ Outcomes” - Mission Determine what works Assess pt preferences Deliver appropriate care

To ensure that observed differences in outcome depend only on the interven- tions under investigation and not on other factors that affect outcome. Randomized Clinical Trial

Heirarchical 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.

Evaluation of Accuracy Binary model of disease SE & SP interdependent SE & SP independent of P and effects of treatment

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

Baseline Analysis Treat1.0 Test1.3 No Treat1.0

Limitations of Binary Model Disease spectrum Accuracy of test Natural History of dz Effectiveness of treatment

RCT of Test Prevalence of disease Rate of adverse events Accuracy of testing Test-treatment strategy Collaboration

ACRIN OECL Measure HRQOL Measure costs Analyze cost-effectiveness

HRQOL Global rating Symptoms Functional status

HRQOL Non-preference based –Generic, e.g., EVGFP, SF-36 –Disease-specific, SAQ Preference based –Direct, e.g., VAS –Derived, e.g., SF-6D

Measuring Preferences - Direct Rating scale Standard gamble Time-tradeoff

Standard Gamble

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

Measure of patient utility Measured on a scale of Can be assessed directly or derived from health survey, e.g., SF-36 Quality Adjusted Life Year

Quality Adjusted Life Years Quantity of Life Quality of Life QALY = = 0.75

QALYs

Methods of Cost Analysis Cost Minimization Analysis (CMA) Cost Effectiveness Analysis (CEA) Cost Benefit Analysis (CBE)

Methods of Cost Analysis MethodCostsHealth CMADollarsNone CEADollarsLYs, QALYs CBANMB

Cost Perspective Rad DeptRadiologists, technologists, technology (payment) HospitalOther physicians, nurses, technicians, technology (payment) PayerPlus outpatient costs SocietalPlus other public agencies, patients, family Tarride et al. J Am Coll Radiol, (5):

CER = ∆COSTS ∆QALYS

Comparison Do Nothing Do Something STRATEGYCOSTQALYSCER 0 $100, NA $25,000

c e III ? Cost-Effective III ? Not Cost-Effective IV Black. Med Decis Making (3):

c e IIIB IV IIIA IA IIIB K Black. Med Decis Making (3):

Incremental vs Average CE STRATCOSTQALYSAVG CERICER -$250,000 $250,000 $750, $50,000 $12,500 $30,000 $33,333 $100,000

$THOUS QALYS

Efficient Frontier e c

Uncertainty Sensitivity analysis Scatterplot of ICE CE Acceptability curves

Copyright ©2008 American Heart Association Weintraub, W. S. et al. Circ Cardiovasc Qual Outcomes 2008;1:12-20 Scatterplot ICE

Copyright ©2008 American Heart Association Weintraub, W. S. et al. Circ Cardiovasc Qual Outcomes 2008;1:12-20 CE Acceptability curve

RESCUE Health outcomes Economic outcomes CEA

Medical Record Abstraction Coordinated by CSS at Brown University 6, 12, 18, and 24 months –Health Status and Medical Utilization –Time and Travel Central MRA company

Medical Record Abstraction Coordinated by CSS at Brown University Triggered by exam results, Q responses MACE/revascularization events Medical care for cardiac care and IFs

Health Outcomes MACE/ Revacularization Life years (Vital Status) QALYs BL, 12 mos Angina Status BL, 6, 12, 18, & 24 mos BL, 12 mos

Life Years All observed deaths thru trial All projected deaths after trial –Framingham survival estimates based on age, sex, and cardiovascular events

QALYs Derived from BL, 1 yr SS-6D utility scoring Adjusted for age after trial

Economic Outcomes Direct cardiac* –inpatient care –outpatient care –medications Indirect cardiac* –time and travel

Economic Outcomes Based on 201x dollars Adjusted for timing w MC CPI Projected by age beyond trial

Hospitalization Costs Triggered by patient questionnaire DRGs and CPTs coded by MRA Medicare reimbursement –Part A MEDPAR –Part B Physician Fee Schedule

Outpatient Costs Triggered by patient questionnaire CPTs coded by MRA Medicare Physician Fee Schedule Red Book avg wholesale prices

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

CEA Societal perspective In-trial and lifetime horizons 3% Sensitivity analysis ICER with 95% CI –nonparametric bootstrapping

Base Case StrategyCostQALYs  Cost  QALYs ICER CCTA SPECT

Copyright ©2008 American Heart Association Weintraub, W. S. et al. Circ Cardiovasc Qual Outcomes 2008;1:12-20

Copyright ©2008 American Heart Association Weintraub, W. S. et al. Circ Cardiovasc Qual Outcomes 2008;1:12-20

US Life Expectancy

Sensitivity Analysis Bootstrap methods 1-way sensitivity analysis Prob sensitivity analysis