1. Cost Effectiveness

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

3. At the end of the session the student will be able to:  Define CE terms  Review methods of evaluation in health care  Review examples  Identify activities that may promote CE studies Objectives

4. 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?

5. Interventions  Nutrition Support  MNT Protocols  Presence of the RD on the health care team, in the public health jurisdiction, etc. What is Cost-Effectiveness?

6. Outcomes in CEA  Traditional Medical Outcomes (Ex. Albumin, body weight)  Expanded definition Patient centered outcomes Quality of life; Client satisfaction What is Cost-Effectiveness?

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

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

9. 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. Terms

10. 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. Terms

11. QALY “Quality-adjusted life year” “A measure of health outcome which assigns to each period of time a weight, ranging from 0 to 1, corresponding to the health-related quality of life during that period, where a weight of 1 corresponds to optimum health and a weight of 0 corresponds to a health state judged equivalent to death: these are then aggregated across time periods.” Gold 1996 Terms

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

13. Define CE terms Review methods of evaluation in health care Review examples Identify activities that may promote CE studies Objectives

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

15. Methods of Evaluation in Health Care: CEA 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

16. Methods of Evaluation in Health Care Limitations of CEA Implies that it is not relevant who obtains the additional life years It does not lend itself to the evaluation of projects with several different (positive) effects. 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

17. Methods of Evaluation in Health Care: Cost Utility Analysis 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 exclusive projects. Unlike CEA, suitable for comparing medical interventions of heterogeneous kind and purpose

18. Methods of Evaluation in Health Care: 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.

19. Define CE terms Review methods of evaluation in health care Review examples Identify activities that may promote CE studies Objectives

20. What is the question (intervention)?  Compared to what? Who is the decision maker? Over what time period for study? What is (are) the unit of outcome? Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare Northeastern University, Boston MA Fundamental Health Economic Questions

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

22. Intervention -- Weight Reduction Program Comparing usual care to dietitian consult Your Effects usual Your $ < usual A B Your $ > usual C D What can be said about A, B, C, and D? D -- Need for incremental cost-effectiveness Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare; Northeastern University, Boston MA Incremental Economic Analyses: 4 Possible Situations

23. Dietitian Usual Care Costs $2,500 $2,200 Effects 15 lbs 10 lbs What is the additional cost for an additional unit of gain? ($2,500 - 2,200)/(15lbs-10lbs) = $300/5 or $60 for each additional pound lost. Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare Northeastern University, Boston MA Incremental Cost-effectiveness

24. Dietitian Usual Care Costs $2,500 $2,200 Effects 20% 16% reduction in Hemoglobin A1c What is the additional cost for an additional unit of gain? Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare Northeastern University, Boston MA Incremental Cost-effectiveness

25. Dietitian Usual Care Costs $2,500 $2,200 Effects 20% 16% ($2500-2300)/(20-16% reduction in HbA1c) $300/4% reduction in HbA1c $75/1% reduction in HbA1c Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare Northeastern University, Boston MA Incremental Cost-effectiveness

26. Dzator article What is the premise of the article? Define “Economic evaluation” From the methods section – would it be possible to repeat the study? How was the diet measured? How were the outcomes measures? What were the main findings? What are the strengths and weaknesses of the conclusions? Cost-Effectiveness Concept Checks

27. League Tables progressive listing of costs per unit of effectiveness/outcome Unit of Outcome: Cost per Life Year Saved  Hypertension screening 40 year male$ 9,800/LY 40 year female$ 45,869/LY  Mammography 55-65yr women$ 44,550/LY  Pap screening (Pap Net) 20-65y$122,888/LY  Exercise ECG 40 yr male$135,116/LY  Exercise ECG 40 yr female$364,170/LY Judith Barr, ScD; Director, National Education and Research Center for Outcomes; Assessment in Healthcare; Northeastern University, Boston MA Cost-Effectiveness League Tables

28. Activities on CE Lewin Study A study at Group Health Cooperative in Puget Sound Area Covered dietitian services as a supplemental benefit for Medicare enrollees covered under risk contract Examined use and costs over time of services in this Medicare population with diabetes and CVD who did and did not use RD services Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare; Northeastern University, Boston MA

29. Lewin Study For DM patients using RD services hospital admissions were reduced by 9.5% and MD visits by 23.5% For CVD the use of RD services was associated with an 8.6% decrease in hospital utilization and a 16.9% decrease in MD visits. Judith Barr, ScD; Director, National Education and Research Center for Outcomes Assessment in Healthcare Northeastern University, Boston MA Activities on CE

30. Maciosek article (’06) Summarize the purpose of the review Define the ‘Clinically preventable burden’ What was the inclusion criteria for the review? Summarize the findings for nutrition related services. Do you think there is additional evidence that would alter the conclusions? What types of studies are necessary to provide evidence of effectiveness? The authors describe the limitations of their work – do you think aspects of this report should be reflected in public health policy? ‘Effective’ Clinical Services Concept Checks

31. What do you define as a limitation in demonstrating the cost- effectiveness of nutrition services  In clinical care  In prevention / PH

32. Risk Management / CQI

33. Objectives: Review issues on patient safety Characterize ‘risk’ situations in health care Identify components of quality assurance processes

34. TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM Health care in the United States is not as safe as it should be--and can be At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies I N S T I T U T E O F M E D I C I N E Shaping the Future for Health November 1999

35. Patient Safety 2005 proposed budget for patient safety is $84 million. The Centers for Medicare & Medicaid Services (CMS) has made it clear that patient safety is indistinguishable from quality of care.

36. Rodham Clinton - Obama What do the authors pose as the potential benefit of a National Medical Error Disclosure and Compensation Bill (MEDiC Bill)? Compare their proposal to patient safety initiatives that stress a change in the culture of patient safety. Patient Safety Concept Checks

37. Risk Management / CQI What are Medical Errors? Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place Where do they happen: Medical errors can occur anywhere in the health care system: HospitalsClinics Outpatient Surgery CentersDoctors' Offices Nursing Homes Pharmacies Patients' Homes http://www ahrq gov/consumer/20tips htm

39. Risk Management / CQI Clinical Nutrition and Food Service Systems

40. Risk Management / CQI Clinical Nutrition and Food Service Systems  High risk areas * Equipment - knives / blades * Wet floors * Cleaning solutions * High turnover in personnel

41. Risk Management / CQI Risk Management Risk Management Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself

42. Concept Discussion: Other safety issues in a health care facility. What are high risk areas in food service? How can a culture of a safety be applied to staff training

43. Risk Management / CQI Clinical Nutrition and Food Service Systems High risk areas

44. Risk Management / CQI Clinical Nutrition and Food Service Systems

45. Glabman What are some of the ‘proven methods’ to reduce medical error the author refers to from the medical literature? What are the ’10 most common causes of medical malpractice’ according to the author? What do you think about using robots to fill prescription orders? How can dietitians, as members of the health care team, address these common causes? Risk Management Concept Checks

46. Risk Management / CQI Quality Assurance is a dynamic, systematic process that assures the delivery of high- quality care to clients

47. Risk Management / CQI QA Process Identify or define the problem Establish a method to evaluate the problem Set a timeline for data collection Collect the data Analyze the results Discuss the findings and make conclusions Suggest alternatives to rectify the problem Try a solution – evaluate Develop a system to monitor the success Implement a system to reevaluate the plan with set time criteria

48. Risk Management / CQI Clinical Indicators Clinical Indicators:  Measurement tool used to monitor and evaluate quality Process indictor Outcome indicator Rate-based indicator

49. Risk Management / CQI Process Indicator - measures an activity  Easy to Measure  May not directly impact safetyExamples  Volume Indicators / Service Trends  Screening  Patient Satisfaction

50. Risk Management / CQI Outcome Indicator  Measures what happens after an activity Examples: Weight loss Infection Infection

51. Risk Management / CQI Rate-based indicator: Assesses an event for which a certain proportion of the events that occur are expected Example: Proportion of patients NPO 24 hours after surgery

52. Prevention Quality Indicators: The PQIs are a set of measures that can be used with hospital inpatient discharge data to identify "ambulatory care sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease.

53. Prevention Quality Indicators: AR = admission rate Prevention Quality Indicators: developed by Stanford University under a contract with the (AHRQ) Diabetes short-term complication ARCongestive heart failure AR Perforated appendix ARDehydration AR Diabetes long-term complication ARBacterial pneumonia AR Pediatric asthma ARUrinary tract infection AR Chronic obstructive pulmonary disease Angina admission without procedure Pediatric gastroenteritisUncontrolled diabetes AR Low birth weight rateAdult asthma AR Hypertension ARRate of lower-extremity amputation among patients with diabetes

54. In-Patient Quality Indicators Complications of AnesthesiaBirth Trauma – Injury to Neonate Death in Low-Mortality DRGsPostoperative Sepsis Decubitus UlcerPostoperative Wound Dehiscence Failure to RescueAccidental Puncture or Laceration Foreign Body Left During ProcedureTransfusion Reaction Iatrogenic PneumothoraxPostoperative Physiologic and Metabolic Derangements Selected Infections due to Medical CarePostoperative Pulmonary Embolism or Deep Vein Thrombosis Postoperative Hip FracturePostoperative Hemorrhage or Hematoma Postoperative Respiratory FailureObstetric Trauma with or without 3rd Degree Lacerations–

55. Larson article What is the mission of the ADA Quality Initiative? Why do you think this effort is being undertaken? What are the potential advantages? Do you agree with the statement on page 1071 – beginning of the second paragraph “Every dietetics professional ….” In your opinion, is this a good use of members resources (dues)? ‘Effective’ Clinical Services Concept Checks

56. Risk Management / CQI Elements of successful CQI projects Team effort in design Employee involvement at all levels Quality is part of job description Safety in participation Continuous effort