assessing health and economic outcomes for diagnostic imaging william c. black, m.d....

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

http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage

US Health Care Expenditures

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

Year

Tri

llio

ns

Health Expenditures by Country2006

Life Expectancy by CountryCountry Life Exp Rank

Macau 84.4 1

Japan 82.1 3

Canada 81.2 7

United Kingdom 79.0 36

Bosnia 78.5 43

United States 78.1 49

Mexico 76.1 71

China 73.5 108

Iraq 70.0 145

Angola 38.2 224

Factors Increasing Spending

Congressional Budge Office. Nov 2007

• New medical technology & services

• Increases in income and insurance

• Aging population

Growth in physician services

Imaging Boom1997-2006Washington 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, 2008. 27(6): p. 1491-502.

“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

Disease

PLE D + B

No disease

1-PLE N -C

Treat

Test positive

SELE D + B

Test negative

1-SELE D

Disease

P

Test positive

1-SPLE N -C

Test negative

SPLE N

No disease

1-P

Test

Disease

PLE D

No disease

1-PLE N

No Treat

CHOOSE

Baseline Values

P 0.5

B, C 1.0

LEN 2.0

LED 0.0

SE, SP 0.8

Baseline Analysis

Treat 1.0

Test 1.3

No Treat 1.0

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 0-1.0

• Can be assessed directly or derived

from health survey, e.g., SF-36

Quality Adjusted Life Year

Quality Adjusted Life Years

0 0.5 1.0

0.5

1.0

Quantity of Life

Qua

lity

of L

ife

QALY = 0.5+0.25 = 0.75

QALYs

Methods of Cost Analysis

• Cost Minimization Analysis (CMA)

• Cost Effectiveness Analysis (CEA)

• Cost Benefit Analysis (CBE)

Methods of Cost Analysis

Method Costs Health

CMA Dollars None

CEA Dollars LYs, QALYs

CBA NMB NMB

Cost PerspectiveRad Dept Radiologists, technologists,

technology (payment)

Hospital Other physicians, nurses, technicians, technology (payment)

Payer Plus outpatient costs

Societal Plus other public agencies, patients, family

Tarride et al. J Am Coll Radiol, 2009. 6(5): 307-16.

CER =∆COSTS∆QALYS

Comparison

Do Nothing

Do Something

STRATEGY COST QALYS CER

0

$100,000

0

4

NA

$25,000

c

e

II I ?

Cost-Effective

III ?

NotCost-Effective

IV

Black. Med Decis Making 1990. 10(3): 212-4.

c

e

II IB

IV

IIIA

IA

IIIB

K

Black. Med Decis Making 1990. 10(3): 212-4.

Incremental vs Average CE

1

2

3

STRAT COST QALYS AVG CER ICER

-$250,000

$250,000

$750,000

5

20

25

-$50,000

$12,500

$30,000

$33,333

$100,000

$THOUS$THOUS

QALYSQALYS

1010

1010

1515

-5 0 5 10 15 20 25-400

-200

0

200

400

600

800

11

22

33

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

• Questionnaires @ 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 (SF-36) @ BL, 12 mos

• Angina Status

– CCS @ BL, 6, 12, 18, & 24 mos

– SAQ @ 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 SF-36 @ 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

• Discounting @ 3%

• Sensitivity analysis

• ICER with 95% CI

– nonparametric bootstrapping

Base Case

Strategy Cost QALYs 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 1970-2005

Sensitivity Analysis

• Bootstrap methods

• 1-way sensitivity analysis

• Prob sensitivity analysis