This document discusses technology assessment, outcomes research, and economic analyses in healthcare. It provides background on rising healthcare costs in the US without clear improvements in health outcomes compared to other countries. The rationale for assessing new technologies and their impact is described. Key aspects of technology assessment are outlined, including technical efficacy, diagnostic accuracy, diagnostic impact, therapeutic impact, patient outcomes, and societal outcomes. Challenges with randomized controlled trials in assessing technologies are reviewed. The National Lung Screening Trial is presented as an example. Finally, computed tomography for appendicitis is analyzed as a hypothetical example of how modeling could be used to assess a technology when a randomized trial may not be feasible.
Predictors of MDT review and the impact on lung cancer survival for HNELHD re...Cancer Institute NSW
Review by a Multidisciplinary Team (MDT) has been shown to lead to increased rates of surgical resection, radiotherapy, chemotherapy and timeliness of care. Most recently, the Victorian lung cancer patterns of care study have found that MDT review is an independent predictor of lung cancer survival.
Introducing VESPIR: a new open-source software to investigate CT ventilation ...Cancer Institute NSW
Computed tomography ventilation imaging (CTVI) is an exciting new functional lung imaging modality enabling functionally adaptive lung cancer radiotherapy treatments. In 2015, this became clinical reality with the first patient treatment performed in the US. Unfortunately the development of new CTVI workflows in the clinic can be challenging, due to the requisite advanced four-dimensional (4D) image processing. To overcome this, we have developed VESPIR (VEntilation via Scripted Pulmonary Image Registration), a user-friendly software toolkit to help streamline the end-to-end validation of CTVI workflows in the clinic.
Defining and assessing a delineation uncertainty margin for modern radiotherapyCancer Institute NSW
The implementation of image-guided technology and progressively conformal techniques in modern radiotherapy for the treatment of cancer, ensure the planned distribution of dose is well matched to the clinician-defined target volume. However, this precision relies on the target volume including all malignant tissue, with delineation uncertainty resulting in potential normal tissue toxicities and insufficient dose to the cancer. Methods need to be implemented to minimise delineation uncertainty, and subsequently improve local control and patient outcomes.
One example of how Clinical Cancer Registry level data can review practice va...Cancer Institute NSW
We examined the possible utility of using Cancer Institute NSW Clinical Cancer Registry data by examining one contentious issue in radiation oncology as an example. Increasing evidence has been published about the safety and efficacy of hypofractionated radiotherapy, in comparison with standard fractionation, in early, node-negative breast cancer.
A distributed data mining network infrastructure for Australian radiotherapy ...Cancer Institute NSW
Routine electronic storage of medical records and imaging is becoming standard practice in radiotherapy. There is immense potential to utilise this increasingly diverse data resource as an evidence base for decision support systems for cancer prognosis and subsequent personalised treatment decisions.
Hydrogel use in prostate cancer radiation therapyMatthew Katz
Hydrogel use represents a technical advance in trying to decrease the risk of treatment toxicity in prostate cancer radiation therapy. I presented this talk at the Fall Conference of the Southern NH chapter of Oncology Nursing Society yesterday.
Predictors of MDT review and the impact on lung cancer survival for HNELHD re...Cancer Institute NSW
Review by a Multidisciplinary Team (MDT) has been shown to lead to increased rates of surgical resection, radiotherapy, chemotherapy and timeliness of care. Most recently, the Victorian lung cancer patterns of care study have found that MDT review is an independent predictor of lung cancer survival.
Introducing VESPIR: a new open-source software to investigate CT ventilation ...Cancer Institute NSW
Computed tomography ventilation imaging (CTVI) is an exciting new functional lung imaging modality enabling functionally adaptive lung cancer radiotherapy treatments. In 2015, this became clinical reality with the first patient treatment performed in the US. Unfortunately the development of new CTVI workflows in the clinic can be challenging, due to the requisite advanced four-dimensional (4D) image processing. To overcome this, we have developed VESPIR (VEntilation via Scripted Pulmonary Image Registration), a user-friendly software toolkit to help streamline the end-to-end validation of CTVI workflows in the clinic.
Defining and assessing a delineation uncertainty margin for modern radiotherapyCancer Institute NSW
The implementation of image-guided technology and progressively conformal techniques in modern radiotherapy for the treatment of cancer, ensure the planned distribution of dose is well matched to the clinician-defined target volume. However, this precision relies on the target volume including all malignant tissue, with delineation uncertainty resulting in potential normal tissue toxicities and insufficient dose to the cancer. Methods need to be implemented to minimise delineation uncertainty, and subsequently improve local control and patient outcomes.
One example of how Clinical Cancer Registry level data can review practice va...Cancer Institute NSW
We examined the possible utility of using Cancer Institute NSW Clinical Cancer Registry data by examining one contentious issue in radiation oncology as an example. Increasing evidence has been published about the safety and efficacy of hypofractionated radiotherapy, in comparison with standard fractionation, in early, node-negative breast cancer.
A distributed data mining network infrastructure for Australian radiotherapy ...Cancer Institute NSW
Routine electronic storage of medical records and imaging is becoming standard practice in radiotherapy. There is immense potential to utilise this increasingly diverse data resource as an evidence base for decision support systems for cancer prognosis and subsequent personalised treatment decisions.
Hydrogel use in prostate cancer radiation therapyMatthew Katz
Hydrogel use represents a technical advance in trying to decrease the risk of treatment toxicity in prostate cancer radiation therapy. I presented this talk at the Fall Conference of the Southern NH chapter of Oncology Nursing Society yesterday.
Stereotactic radiation requires precision and accuracy to treat patients safely. With a couch surface that can tilt in 6 directions, treatment can be given with less difficult, more quickly and more safely.
A charity, Golf Fights Cancer, is generously supporting Lowell General Hospital in making this 6 degree of freedom couch available to help my patients. Thank you to everyone who attended the Good Guys Invitational!
Low Dose Radiation Therapy (LDRT) for COVID-19 PneumoniaMatthew Katz
The COVID-19 pandemic has galvanized research on how to treat people ill enough to be hospitalized with SARS-CoV-2 pneumonia. Radiation therapy is being evaluated in clinical trials as an investigational treatment. This presentation from July was for colleagues at Massachusetts General Hospital to discuss the pros/cons of using radiotherapy for an infectious disease.
ASTUTE: Acute Stroke Telemedicine: Utility Training and Evaluation
Implementing Telemedicine in Acute Stroke and the development of a Standardised Telemedicine Tookit
Lancashire Teaching Hsopitals NHS Foundation Trust
Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013
More information about this event can be found at
http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx
Best Practices for a Data-driven Approach to Test UtilizationViewics
Would you like to learn how data-driven interventions can improve laboratory test utilization in your organization? Would you like to hear about the impact that leading hospitals/health systems and managed care organizations have made through these interventions?
If so, you might be interested in this presentation by utilization management expert Dr. Michael Astion, Medical Director at the Department of Laboratories at Seattle Children’s Hospital and Clinical Professor of Laboratory Medicine at the University of Washington.
In this presentation, Dr. Astion discusses the current state of the misuse of laboratory testing in the United States and some of the interventions that are being implemented to improve it. He covers a number of common areas of unnecessary testing — from pure abuse to tests that could be useful but are ordered inappropriately.
You'll learn about:
• Two areas of laboratory testing where misordering of tests occur frequently
• Three interventions to improve the value of testing for patients
• The role of genetic counselors and other laboratory professionals in improving lab test ordering
• The national endeavor known as PLUGS, the Pediatric Laboratory Utilization Guidance Service
Revolutionizing Renal Care With Predictive Analytics for CKDViewics
Chronic Kidney Disease (CKD) is a common and growing condition, affecting about half of the Medicare population and of diabetics. In the United States, the lifetime risk of CKD for 30-year-olds is now greater than half, and the prevalence of CKD is projected to rise significantly over the next 15 years.
Current methods of predicting which CKD patients will progress to renal failure and require dialysis or transplant have low accuracy rates, causing great anxiety and suboptimal care. Without accurate risk prediction, many patients are over-treated, effectively wasting limited resources and negatively impacting outcomes. Conversely, other patients may receive inadequate treatment, restricting options to only the most costly and least desirable interventions.
Watch this on-demand webinar with Dr. Navdeep Tangri, developer of the Kidney Failure Risk Equation, which revolutionizes the way CKD patients are managed by leveraging laboratory data to accurately predict the risk of kidney failure in patients with CKD.
You’ll learn:
• How CKD is burdening our healthcare system, and the need for better care management tools
• How the Kidney Failure Risk Equation was researched, developed, and validated
• How Viewics is implementing CKD predictive analytics to automatically deliver risk information to clinicians and issue customized, educational reports to patients and clinicians
Implementing American Heart Association Practice Standards for Inpatient ECG ...Allina Health
Implementing American Heart Association Practice Standards for Inpatient ECG Monitoring: An Interventional Study at Abbott Northwestern Hospital presented by Kristin Sandau, PhD, RN
Patient Blood Management: Impact of Quality Data on Patient OutcomesViewics
Patient blood management (PBM) has been proven to improve patient outcomes and save hospitals millions of dollars. Ensuring the quality of your data is central to decision making and critical to having a strong PBM program.
Would you like to learn how your organization can improve patient outcomes by implementing a PBM program based on accurate data?
If so, view this presentation by blood management expert Lance Trewhella. Lance presents how to develop a successful, evidence-based, multidisciplinary PBM program aimed at optimizing the care of patients who might need transfusion.
You’ll learn:
• Current recommendations for blood transfusion utilization
• The impact of quality data on PBM programs
• Best data practices in PBM
Tackling the U.S. Healthcare System’s Infectious Disease Management ProblemViewics
The United States healthcare system has a serious infectious disease management problem. The antibiotic resistance crisis is widespread, serious, costly, and deadly. Delays in pathogen identification lead to poor clinical outcomes, including increased mortality risk. And, optimally managing outbreaks is critical to health systems whose reimbursement is tied to the health of a population, such as ACOs.
Eleanor Herriman, MD, MBA, Chief Medical Informatics Officer at Viewics led an informative panel discussion with industry leaders on the issues surrounding the infectious disease management crisis. Margret Oethinger, MD, Ph.D., Medical Director of Providence Health & Services, and Susan E. Sharp, Ph.D., DABMM, FAAM, Regional Director of Microbiology and the Molecular Infectious Disease Laboratories, Department of Pathology, Kaiser Permanente and President-Elect, American Society for Microbiology cover the current state of infectious disease management in the U.S., and what can be done to improve it.
You’ll learn about:
• The magnitude of the U.S. health system’s infectious disease management problem
• The most serious concerns and trends for healthcare institutions and communities across the nation
• The most promising solutions to health systems’ most urgent infectious disease management challenges
ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.
Assessment & Feedback Literature ReviewMorse Project
Presentation by Dr Ann Ooms and Hendrik van der Sluis, Kingston University, at the "Improving Assessment and Feedback Practices in a Technology-Enhanced Teaching and Learning Environment: Theory and Practice" Event, 19th May 2010 at Kingston University. Part of the "Higher Education Academy : Evidence Based Practice Seminar Series 2010"
The presentation provides an overview of recent literature concerning assessment and feedback
Binary outcome models are widely used in many real world application. We can used Probit and Logit models to analysis this type of data. Specially, dose response data can be analyze using these two models.
Stereotactic radiation requires precision and accuracy to treat patients safely. With a couch surface that can tilt in 6 directions, treatment can be given with less difficult, more quickly and more safely.
A charity, Golf Fights Cancer, is generously supporting Lowell General Hospital in making this 6 degree of freedom couch available to help my patients. Thank you to everyone who attended the Good Guys Invitational!
Low Dose Radiation Therapy (LDRT) for COVID-19 PneumoniaMatthew Katz
The COVID-19 pandemic has galvanized research on how to treat people ill enough to be hospitalized with SARS-CoV-2 pneumonia. Radiation therapy is being evaluated in clinical trials as an investigational treatment. This presentation from July was for colleagues at Massachusetts General Hospital to discuss the pros/cons of using radiotherapy for an infectious disease.
ASTUTE: Acute Stroke Telemedicine: Utility Training and Evaluation
Implementing Telemedicine in Acute Stroke and the development of a Standardised Telemedicine Tookit
Lancashire Teaching Hsopitals NHS Foundation Trust
Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013
More information about this event can be found at
http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx
Best Practices for a Data-driven Approach to Test UtilizationViewics
Would you like to learn how data-driven interventions can improve laboratory test utilization in your organization? Would you like to hear about the impact that leading hospitals/health systems and managed care organizations have made through these interventions?
If so, you might be interested in this presentation by utilization management expert Dr. Michael Astion, Medical Director at the Department of Laboratories at Seattle Children’s Hospital and Clinical Professor of Laboratory Medicine at the University of Washington.
In this presentation, Dr. Astion discusses the current state of the misuse of laboratory testing in the United States and some of the interventions that are being implemented to improve it. He covers a number of common areas of unnecessary testing — from pure abuse to tests that could be useful but are ordered inappropriately.
You'll learn about:
• Two areas of laboratory testing where misordering of tests occur frequently
• Three interventions to improve the value of testing for patients
• The role of genetic counselors and other laboratory professionals in improving lab test ordering
• The national endeavor known as PLUGS, the Pediatric Laboratory Utilization Guidance Service
Revolutionizing Renal Care With Predictive Analytics for CKDViewics
Chronic Kidney Disease (CKD) is a common and growing condition, affecting about half of the Medicare population and of diabetics. In the United States, the lifetime risk of CKD for 30-year-olds is now greater than half, and the prevalence of CKD is projected to rise significantly over the next 15 years.
Current methods of predicting which CKD patients will progress to renal failure and require dialysis or transplant have low accuracy rates, causing great anxiety and suboptimal care. Without accurate risk prediction, many patients are over-treated, effectively wasting limited resources and negatively impacting outcomes. Conversely, other patients may receive inadequate treatment, restricting options to only the most costly and least desirable interventions.
Watch this on-demand webinar with Dr. Navdeep Tangri, developer of the Kidney Failure Risk Equation, which revolutionizes the way CKD patients are managed by leveraging laboratory data to accurately predict the risk of kidney failure in patients with CKD.
You’ll learn:
• How CKD is burdening our healthcare system, and the need for better care management tools
• How the Kidney Failure Risk Equation was researched, developed, and validated
• How Viewics is implementing CKD predictive analytics to automatically deliver risk information to clinicians and issue customized, educational reports to patients and clinicians
Implementing American Heart Association Practice Standards for Inpatient ECG ...Allina Health
Implementing American Heart Association Practice Standards for Inpatient ECG Monitoring: An Interventional Study at Abbott Northwestern Hospital presented by Kristin Sandau, PhD, RN
Patient Blood Management: Impact of Quality Data on Patient OutcomesViewics
Patient blood management (PBM) has been proven to improve patient outcomes and save hospitals millions of dollars. Ensuring the quality of your data is central to decision making and critical to having a strong PBM program.
Would you like to learn how your organization can improve patient outcomes by implementing a PBM program based on accurate data?
If so, view this presentation by blood management expert Lance Trewhella. Lance presents how to develop a successful, evidence-based, multidisciplinary PBM program aimed at optimizing the care of patients who might need transfusion.
You’ll learn:
• Current recommendations for blood transfusion utilization
• The impact of quality data on PBM programs
• Best data practices in PBM
Tackling the U.S. Healthcare System’s Infectious Disease Management ProblemViewics
The United States healthcare system has a serious infectious disease management problem. The antibiotic resistance crisis is widespread, serious, costly, and deadly. Delays in pathogen identification lead to poor clinical outcomes, including increased mortality risk. And, optimally managing outbreaks is critical to health systems whose reimbursement is tied to the health of a population, such as ACOs.
Eleanor Herriman, MD, MBA, Chief Medical Informatics Officer at Viewics led an informative panel discussion with industry leaders on the issues surrounding the infectious disease management crisis. Margret Oethinger, MD, Ph.D., Medical Director of Providence Health & Services, and Susan E. Sharp, Ph.D., DABMM, FAAM, Regional Director of Microbiology and the Molecular Infectious Disease Laboratories, Department of Pathology, Kaiser Permanente and President-Elect, American Society for Microbiology cover the current state of infectious disease management in the U.S., and what can be done to improve it.
You’ll learn about:
• The magnitude of the U.S. health system’s infectious disease management problem
• The most serious concerns and trends for healthcare institutions and communities across the nation
• The most promising solutions to health systems’ most urgent infectious disease management challenges
ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.
Assessment & Feedback Literature ReviewMorse Project
Presentation by Dr Ann Ooms and Hendrik van der Sluis, Kingston University, at the "Improving Assessment and Feedback Practices in a Technology-Enhanced Teaching and Learning Environment: Theory and Practice" Event, 19th May 2010 at Kingston University. Part of the "Higher Education Academy : Evidence Based Practice Seminar Series 2010"
The presentation provides an overview of recent literature concerning assessment and feedback
Binary outcome models are widely used in many real world application. We can used Probit and Logit models to analysis this type of data. Specially, dose response data can be analyze using these two models.
Summarization of Environmental Impact Assessment Methodology by Dr. I.M. Mis...Arvind Kumar
Summarization of Environmental Impact
Assessment Methodology by Dr. I.M. Mishra
Professor, Dept. of Chemical Engineering
Dean, Saharanpur Campus
Indian Institute of Technology, Roorkee
Outcome Measures in Cancer: Do disease specific instruments offer greater sen...Office of Health Economics
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Ομιλία - Παρουσίαση: Prof. Todor (Ted) A. Popov, Professor of Medicine, Medical University in Sofia, Chairman of the Bulgarian Ethics Committee for Multicenter Studies
Τίτλος Παρουσίασης: «Do databases around the world speak the same language?»
Have you ever wondered how search works while visiting an e-commerce site, internal website, or searching through other types of online resources? Look no further than this informative session on the ways that taxonomies help end-users navigate the internet! Hear from taxonomists and other information professionals who have first-hand experience creating and working with taxonomies that aid in navigation, search, and discovery across a range of disciplines.
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f you offer a service on the web, odds are that someone will abuse it. Be it an API, a SaaS, a PaaS, or even a static website, someone somewhere will try to figure out a way to use it to their own needs. In this talk we'll compare measures that are effective against static attackers and how to battle a dynamic attacker who adapts to your counter-measures.
About the Speaker
===============
Diogo Sousa, Engineering Manager @ Canonical
An opinionated individual with an interest in cryptography and its intersection with secure software development.
This presentation, created by Syed Faiz ul Hassan, explores the profound influence of media on public perception and behavior. It delves into the evolution of media from oral traditions to modern digital and social media platforms. Key topics include the role of media in information propagation, socialization, crisis awareness, globalization, and education. The presentation also examines media influence through agenda setting, propaganda, and manipulative techniques used by advertisers and marketers. Furthermore, it highlights the impact of surveillance enabled by media technologies on personal behavior and preferences. Through this comprehensive overview, the presentation aims to shed light on how media shapes collective consciousness and public opinion.
This presentation by Morris Kleiner (University of Minnesota), was made during the discussion “Competition and Regulation in Professions and Occupations” held at the Working Party No. 2 on Competition and Regulation on 10 June 2024. More papers and presentations on the topic can be found out at oe.cd/crps.
This presentation was uploaded with the author’s consent.
Sharpen existing tools or get a new toolbox? Contemporary cluster initiatives...Orkestra
UIIN Conference, Madrid, 27-29 May 2024
James Wilson, Orkestra and Deusto Business School
Emily Wise, Lund University
Madeline Smith, The Glasgow School of Art
2. Rationale
• Cost of medical care increasing faster than
cost of living
• 5.6% of GDP in 1965; 17.6% 2012; 19.8% 2020
• $27.5 B 1960; $2.71 T 2011; $4.64 T 2020
• $8649 per person in 2011; $13,709 2020
• US spends more than 33 others in Organization
for Economic Co-operation and Development
• But fewer MDs, hospital beds per capita
5. 0
2
4
6
8
10
12
14
16
18
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
US (17.1%)
FR (11.6%)
SWE (11.5%)
GER (11.2%)
NETH (11.1%)
SWIZ (11.1%)
DEN (11.1%)
NZ (11.0%)
CAN (10.7%)
JAP (10.2%)
NOR (9.4%)
AUS (9.4%)*
UK (8.8%)
Health Care Spending as Percentage of GDP, 1980–2013
Percent
OECD Health Data 2015
6. Rationale
• Workers now paying at least $1,094 more in
premiums annually for coverage than in 2000
• Still waiting to see what ACA does…
• Despite expenditures, can we document
significant improvement in health status?
• Life expectancy
• Perinatal mortality
9. Our poor health
• Life expectancy 78.8 vs. 81.2 (2013)
• Infant mortality 6.1/1000 vs. 3.5 (2011)
• 68% adults over 65 had at least 2 chronic
conditions (33% UK, 56% Canada; 2014)
• Obesity rate 35.3% (3.7% Japan, 30.6% NZ; 2014)
• Smokers 13.7 (12.8 Australia, 24.1 France; 2013)
10. US does more of…
United States Rank compared
with OECD
countries
OECD median
MRI units 35.5 per 1,000,000 2nd (Japan 1st) 11.4 per 1,000,000
MRI exams 106.9 per 1000 50.6 per 1000
CT units 43.5 per 1,000,000 3rd (Japan 1st,
Australia 2nd)
17.6 per 1,000,000
CT exams 240 per 1000 136 per 1000
Tonsillectomy 254.4 per 100,000 1st 130 per 100,000
Coronary bypass 79.0 per 100,000 3rd 47.3 per 100,000
Knee replacement 226 per 100,000 1st 121.6 per 100,000
Caesarian section 32.9 per 1000 live
births
6th 26.1 per 1000 live births
OECD Health Data 2012 and 2015
11. Why?
• Current payment structure means MDs get
paid more to do more interventions
• ACA has not had effect yet…
• Fear of litigation
• Patients ask for more—and usually do not
pay out of pocket (insurance covers)
12. Why?
• MDs in US paid more but seen less
• 4 visits/year (OECD average 6.5 visits/year)
• US uses more pharmaceuticals
• 2.2 drugs per adult (1.2 Netherlands)
• Cost more (US=100; Australia=49; Germany=95)
• Procedures cost more
• Bypass 75,345 vs. 42,130 in Australia
• Appendectomy 13, 910 vs 4,995 Netherlands
14. Bit of background
• Technology assessment hierarchy
• Based on efficacy (benefit under ideal
circumstances)
• Differs from effectiveness (benefit in real
world)
• Differs from efficiency (sufficient value?
adds economic component)
Fryback D, Thornbury J. The efficacy of diagnostic imaging. Med Dec Making 1991;11:88-94
15. Technology assessment hierarchy
• Technical efficacy
• Diagnostic accuracy
• Diagnostic impact
• Therapeutic impact
• Patient outcomes
• Societal outcomes
Fryback D, Thornbury J. The efficacy of diagnostic imaging. Med Dec Making 1991;11:88-94
16. Technical efficacy
• Ability of technology to produce image
• Measured by image characteristics
• Signal to noise, resolution of line pairs, etc.
• Developmental: prototype and phantom,
safety
• Exploratory: possible use, wide range of
patients, situations, conditions
18. Diagnostic accuracy
• Distinguish between disease, non-disease,
or normal, abnormal
• Establish diagnosis if symptoms
• Screen in asymptomatic patient
• Quantify severity or extent of disease
• Prognostic information (staging)
• Monitor therapy
• Need gold standard; measure of truth
19. Diagnostic accuracy
• Sensitivity, specificity, positive and negative
predictive values
• 2 x 2 table to display comparison to gold
standard or reference
• Area under ROC curve
• Most radiology research falls into this
category
21. Diagnostic impact
• Which imaging tests have greatest impact on
clinical decisions?
• Before test need to know
• Differential diagnosis
• Degree of certainty of diagnoses
• Probability of each consideration
• Reassess after test performed
• Best done prospectively
23. Therapeutic impact
• Which imaging tests have greatest impact on
therapeutic decisions?
• Percent procedures avoided due to imaging
• Percent imaging changed plan
• Retrospectively inferred from records
• Prospectively assessed using clinicians’
stated plans
25. Patient outcomes
• Traditionally, morbidity or mortality
• Change in quality adjusted life years (QALY)
• Can be difficult to prove link as imaging
study several steps removed from patient
outcome
26. Societal outcomes
• Cost analyses from societal perspective
• Usually reported as cost per QALY
• Must be below some threshold to be
accepted (? $50,000/QALY)
• Example, head CT to screen for brain mets
in lung cancer patients or only if
symptomatic?
• $70,000/QALY deemed too high to adopt
28. Outcomes research—goals
• Use imaging wisely
• Avoid over-diagnosis and over-treatment
• Risks of treatment in early or mild disease
may outweigh benefits
• Data that will permit maintenance of quality
at reduced cost
• Increasingly important
• Radiology needs to prove worth
29. Outcomes research—getting started
• Choose technology to be evaluated
• Define specific clinical indication
• Define target population
• Choose alternative techniques for
comparison (may include no imaging)
• Define outcomes affected by technology
30. Randomized controlled trial
• Gold standard of outcomes research
• Patients assigned to different groups based
on imaging (or no imaging) to be performed
• Measure appropriate outcomes
• Confounders and biases accounted for in
design
31. RCT—limitations
• Cost
• Size of population
• Power calculation
• Estimate expected differences
• Time to complete
• Technology obsolete by time outcomes
assessed?
• Technology as moving target
• Results may only apply to narrow spectrum of
patients; issue of generalizeability
32. RCT—unnecessary when?
• Anecdotal evidence of benefit dramatic;
observational studies suffice
• Example: head CT in trauma
• New technology:
• Has same or fewer side effects
• Has same or better accuracy
• Is less expensive
33. RCT—necessary when?
• Really don’t know answer
• New technology:
• More expensive
• May result in more morbidity
• Very controversial
34. ACRIN—NLST
• National Lung cancer Screening Trial
• 25,000 patients randomized; low dose CT vs. CXR
• Baseline, years 1 and 2
• Q6 month health status and medical intervention
questionnaire
• Very detailed description of what constitutes
positive screen and what to do
• Outcomes
• Primary: Lung cancer specific mortality
• Secondary: huge list
35. ACRIN—NLST
• Low dose CT more sensitive than
radiography
• Two annual incidence screenings with low-
dose CT resulted in
• Decrease number of advanced-stage
cancers
• Increase number of early-stage lung
cancers
NEJM 2013;369:920-921
36. Example to work through
• CT for appendicitis: improve outcomes?
• Technology:
37. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT
38. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT (?oral, ?IV, ?rectal)
• Indication:
39. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT (?oral, ?IV, ?rectal)
• Indication: RLQ pain, fever, etc.
• Population:
40. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT (?oral, ?IV, ?rectal)
• Indication: RLQ pain, fever, etc.
• Population: patients presenting to ER
• Alternative:
41. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT (?oral, ?IV, ?rectal)
• Indication: RLQ pain, fever, etc.
• Population: patients presenting to ER
• Alternative: best clinical judgment plus lab
• Outcomes:
42. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT (?oral, ?IV, ?rectal)
• Indication: RLQ pain, fever, etc.
• Population: patients presenting to ER
• Alternative: best clinical judgment plus lab
• Outcomes: morbidity, mortality, perforation rate,
length of hospital stay, surgery rate, % normal
appendices removed, cost to hospital, etc.
43. Example to work through
• CT for appendicitis: improve outcomes?
• Technology: MDCT (?oral, ?IV, ?rectal)
• Indication: RLQ pain, fever, etc.
• Population: patients presenting to ER
• Alternative: best clinical judgment plus lab
• Outcomes: morbidity, mortality, perforation rate,
length of hospital stay, surgery rate, % normal
appendices removed, cost to hospital, etc.
• Is this feasible?
44. What if RCT not feasible?
• Modeling: Use of decision analysis software
• Need information from other studies
• Accuracy, sensitivity, specificity
• Course of disease, natural history
• Effectiveness of therapy
• Patient utilities and costs
• Meta-analyses for combining results of
studies
45. Modeling
• Assumptions about test parameters
(sensitivity, specificity) based on literature
• Then vary assumptions
• Assumptions about frequency of outcomes
based on personal experience or literature
(mortality and morbidity rates, etc.)
• Allows variation of these
47. CT in appendicitis example
• Retrospective study of 651 patients treated before
use of CT for appendicitis (1992-1995)
• 52% went to surgery; 24% for observation then
surgery; 24% observation to discharge
• Initial surgical group, 81% appendicitis
• Observation to surgery group, 80% appendicitis
• Observation to D/C group, assumed no
appendicitis (no returns to their hospital)
Rhea JT et al. AJR 1997;169:113-118
48. CT in appendicitis example
• Apply sensitivity and specificity of CT from
literature to 100 theoretical patients
• Use morbidity, mortality, perforation, correct
diagnosis rates from study of 651 patients
• Model impact of CT on outcomes
• Decrease in nontherapeutic surgery (13
patients), observation days (1 day less on
average), perforation rate, etc.
• Alternative diagnoses also confirmed
Rhea JT et al. AJR 1997;169:113-118
49. Intermediate outcomes
• Choose levels lower in hierarchy
• Diagnostic impact
• Change in diagnostic possibilities
and confidence
• Before and after test ask referring MD:
• Differential diagnosis
• % certainty for each diagnosis
• Degree of satisfaction with test
50. Intermediate outcomes
• Seattle Low Back Pain Imaging Project (SLIP)
• RCT of plain films vs. MR as initial imaging
• Diagnostic impact
• 15% new diagnosis with plain film
• 30% for MRI (spinal stenosis, HNP, etc)
• Change in probability for most likely
diagnosis for HNP (p<.002)
Jarvik JG et al. Radiology 1997;204:447-454
51. Intermediate outcomes
• Therapeutic impact
• Before test, ask MD for treatment plan
• Observe if plan changes after test
• If temporally related, infer causal
relationship between test and plan change
• SLIP: 38% avoided additional test if plain film
first, 64% if MRI first (p<.001)
52. Intermediate outcomes
• Advantages
• Cheaper and easier than full RCT
(RCT may show intermediate outcomes if
assessed as in SLIP)
• No one denied potentially good test
• Works well for “add-on tests”
• Tests that would not necessarily
replace existing work-up
53. Intermediate outcomes
• Disadvantages
• Stated plans do not necessarily equal
clinical action
• If treatment invasive, difficult, expensive
or risky, easier to hypothetically choose
• RCT still better for “replacement test”
54. Patient outcomes
• Reduced mortality
• Reduced morbidity
• Decrease complications from other tests
• Avoid invasive procedures
• Faster return to normal (or pretest) state
55. Patient outcomes
• Quality of life: ability to undertake
rewarding and enjoyable activities
• How person feels, functions
• Quality adjusted life years (QALYs)
• Patient satisfaction, reassurance
• Physiologic marker improvement
• Improved function
56. Functional status
• General and specific measures
• SF-36 (Short Form 36)
• 36 questions, 8 domains
• General health, pain, physical functioning,
social functioning, mental health, etc.
• Roland score (back pain specific index)
• Sciatic frequency index
57. SLIP follow-up
• RCT ultimately enrolled 380 patients
• Roland score at 12 months did not differ between 2
groups (8.75 plain film vs. 9.34 MRI, p = .53)
• p >.75 for all domains of SF-36
• Patient reassurance measure
• 1 month p=.09
• 3 month p=.08
• 12 month p=.002 (58% plain film vs. 74% MRI)
• Increased reassurance with MRI over time
• 10 in MRI vs. 4 in plain film had surgery (p =.09)
Jarvik JG et al. JAMA 2003;289:2810-2818
58. Outcomes research—limitations
• Tenuous link between test and patient outcome
• Test usually steps removed from outcome
• Best situation: proven link between therapy
and outcome link diagnosis to therapy to
outcome
• Example: detection of cerebral aneurysms
with MRA treatment decreases morbidity
and mortality link MRA to reduced
morbidity/mortality
59. Outcomes research—limitations
• If no proven impact on outcome, may be:
• Diagnostic test (inaccurate, insensitive)
• Referring clinician (inappropriate use of
info; info does not reach)
• Therapy (ineffective or unavailable)
• Patient (lack of compliance)
• System (lack of patient access)
60. Alternative outcome
• Therapeutic value of diagnostic test
• Diagnostic test can have direct impact on
quality of life
• Reassurance important to patients and
referring clinicians
• If consider only positive tests fail to consider
that negative test has value
61. Alternative outcome
• Example: nonspecific chest pain
• 176 patients randomized to receive no
studies or EKG and CPK level
• Test group had less short term disability
(20% versus 46%; P=.001)
• Use of diagnostic test independent predictor
of recovery in logistic regression
• Test group felt care “better than usual”
Sox HC, et al. Ann Intern Med 1981;95:680-5
63. Economic evaluations
• Must establish viewpoint of analysis
• Society, insurer, provider, patient
• All have different inputs and outcomes;
different costs to consider
• Example: patient may value increased
quality of life at any cost while HMO
may value decreasing overhead costs
64. Costs
• Value of resources
• Charges as estimate
• Medicare/Medicaid reimbursement as
estimate
• Micro-costing techniques—all resources
identified and quantified
• Consider cost of missed abnormalities and
superfluous work-up of false positives
65. Costs—examples
• Medical
• Diagnostic test and interpretation
• Nursing care
• Nonmedical
• Time (travel, tests and treatment)
• Travel
• Support with daily activities
• Lost productivity
66. Types of economic analyses
• Cost identification or cost minimization
• Compares alternative health care
strategies assumed equally effective
67. Cost identification—example
• CT vs. US plus plain film after ESWL
• 25 patients underwent all 3
• Assumed equal accuracy
• Exams timed; direct technical costs calculated
using procedural-based accounting system
• CT 15.3 minutes; US + plain film 37.2 minutes
• CT $36.86; US + plain film $57.60
• Sensitivity analysis on time; within reasonable
range CT always cost less
Remer EM et al. Radiology 1997;204:33-37
68. Types of economic analyses
• Cost benefit
• Costs and benefits assigned dollar values
• Comparison of different technologies
• Limited use in medicine due to difficulty
assigning monetary values to health states
• Cost effectiveness leaves outcomes in
natural, objective units
• # lives saved, # cancers detected, etc.
69. CEA—example
• What gain from sixth stool guaiac?
• Progression from fifth to sixth stool guaiac
costs $47 million/cancer detected
• Can use intermediate outcomes (length of
stay, readmission rates, number of
unnecessary surgeries prevented)
Neuhauser D, Lewicki AM. N Engl J Med 1975; 293
70. Cost utility analysis
• Similar to CEA but uses subjective outcomes that
explicitly incorporate patient preferences
• QALY: basic outcome measure
• Year of life with significant morbidity less desirable
than year with excellent health
• Full health equals 1
• Death equals 0
• Morbidity somewhere between 0 and 1
• Preferred method for economic evaluations
71. Utility values
• Side effects from interferon—.93
• Mild angina—.90
• Prophylactic mastectomy, oophorectomy—.86
• Moderate angina—.70
• Hospitalization for tuberculosis—.60
• Severe angina—.50
• Moderate to severe stroke—.39
• Recurrent stroke—.12
72. Components of economic analysis
• Most with modeling software
• Reference case (defines typical patient)
• Strategies (set of alternative care pathways)
• Time horizon (period to consider risks and
benefits)
• Perspective (viewpoint of decision maker)
• Effectiveness measure (outcome)
• Decision tree allows varying components
74. Components of economic analysis
• Probabilities (all events in model have one)
• Estimated from historical data; literature, pilot
study or expert opinion
• Utilities (assign utility to every health
condition in model)
• Costs (identify all relevant)
• Assumptions (due to limitations imposed by
available data; must explicitly state)
75. Economic analysis—example
• Whole body CT screening
• Base-case analysis: from cohort of 500,000
50 year old men
• Sex, age varied in analysis
• Benefits of screening assumed due to earlier
detection of disease, improvement in survival
• 8 conditions included in model: ovarian, pancreatic,
lung, liver, kidney and colon cancer; aortic aneurysm,
coronary artery disease
• Costs of screening, follow-up tests, patient care
Beinfeld, M. T. et al. Radiology 2005;234:415-422
76. Beinfeld, M. T. et al. Radiology 2005;234:415-422
Schematic of decision-analytic model with life expectancy
and cost outcomes used in the cost effectiveness analysis
77. Economic analysis—example
• Compared to routine care
• 6 days of life gained at $2513/patient
• Incremental cost: $151,000/life-year gained
• 90.8% had finding; only 2% had disease
• 32.3% of total cost = work-up of FPs
• With favorable assumptions, one time screening not
cost effective; would add burden to healthcare
system
Beinfeld, M. T. et al. Radiology 2005;234:415-422
78. Economic analysis—limitations
• Not all agree with strategies chosen
• Was comparison to standard of care?
• Were all reasonable options considered?
• Was reference case typical of patient population?
• Fears of bias if study funded by drug company or
equipment manufacturer
• If too early, data scant; if late, decisions made and
model obsolete
• Noncontrast CT for renal colic: accepted standard
without study of cost
79. Conclusions
• Need to be familiar with concepts
• Way to inform health care policy makers, guide
research
• Goal to improve quality in rational manner, decrease
waste and unnecessary expenditure
• Enhance Radiology community’s ability to participate
in health care decision-making locally and nationally
• Preserve our specialty!