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