Cost effectiveness & evidence-based medicine


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Cost effectiveness & evidence-based medicine

  1. 1. Translang  (cost-­‐effecve)  evidence   into  pracce  in  the  EMR  era   Andrew  D.  Auerbach  MD  MPH   Professor  of  Medicine   UCSF  Department  of  Medicine   Chair,  UCSF  Apex  Clinical  Content  Oversight   CommiKee  
  2. 2. Overview  •  Translaon  and  implementaon  of  evidence  •  Where  to  get  evidence  for  those  who  want   (need)  to  implement   –  Translaonal  issues  in  EMR’s   –  Evidence  Acquision,  implementaon  •  Costs,  value,  and  cost-­‐effecveness  
  3. 3. The  Translaonal  pathwayascade   Improved Bench/ Bench to Clinical Comparative Comparative Implement population health,Biomedical bedside efficacy effectiveness effectiveness practices ImprovedResearch translation knowledge research knowledge effectively healthcare value Determine how patient, provider, and delivery Determine causal Determine associations system changes influence outcomes pathways between treatments and outcomes - Health system redesign Outcomes and health services - Scaling and dissemination of delivery system changes Clinical efficacy trials research - Research in redesign and dissemination
  4. 4. It  takes  a  long  me  to  translate…  •  On  average,  it  takes  16  years  to  move  a   biomedical  innovaon  from  bench  to  bedside  •  It  is  unknown  how  long  it  takes  to  have  a   pracce  used  effecvely  
  5. 5. Why  so  long?     • Unaware  of  a   Cons  of  changing  outweigh  the  pros  at    the  top   Precontemplaon   problem,  not   intending  to  make  a   of  this  cascade   change     • Recognion  of   Contemplaon   problem,  beginning   to  look  at  pros  and   cons  of  change   • People  ready  to  take   Preparaon   acon,  may  require   assistance   • People  have   Acon   modified  behaviors   to  address  problem   • People  able  to   sustain  acon,  The  pros  surpass  the  cons  for  later  stages   Maintenance   working  to  prevent   relapse  ..But  backsliding  can  always  take  place  
  6. 6. Factors  which  speed  adopon  •  Consciousness-­‐Raising   –  Increasing  awareness  via  informaon,  educaon,  and  personal  feedback.  •  Changing  social  norms:   –  What  makes  the  new  behavior  cool  and  the  old  one  uncool?     –  Is  the  preferred  behavior  an  important  part  of  who  we  are  and  want  to  be?   –  Does  the  old  behavior  affect  others  negavely?   –  Are  people  generally  supporve  of  change?  •  Counter-­‐Condioning   –  Substung  healthy  ways  of  acng  and  thinking  for  unhealthy  ways   –  Provide  rewards  for  the  new  behavior,  and  eliminate  rewards  related  to  old  ways  •  Self-­‐Efficacy   –  Believing  in  one’s  ability  to  change  and  making  commitments  to  act  on  that  belief  •  System  change:   –  Make  the  new  behavior  easier  to  carry  out  than  the  old  one   –  Provide  reminders  and  cues  that  encourage  the  new  behavior  
  7. 7. Where  to  get  evidence  •  Local  experts   –  Advantages:  Local  champion,  may  represent  local   priories,  may  have  a  ‘how  to’  component   –  Disadvantages:  May  not  be  truly  evidence-­‐based  o  •  Latest  NEJM  (or  pick  your  journal)   –  Advantages:  High  face  validity   –  Disadvantage:  no  ‘how  to’,  always  another  study   on  the  way  
  8. 8. Where  to  get  evidence  •  Cochrane  database  of  systemac  reviews   –  hKp://­‐reviews   –  Advantage:  Comprehensive  synthesis  of  evidence,   explanaon  of  where  evidence  is  clear/unclear   –  Disadvantage:  No  clear  recommendaons  for  how  to  use   the  evidence  •  Professional  sociees   –  Advantages:  Clear  recommendaons   –  Disadvantages:  Potenal  COI,  variaon  across  compeng   sociees  
  9. 9. Clinical  pracce  guidelines  •  A  specific  subset  of  evidence   –  Considered  a  ‘standard’  source  of  pracce   evidence   –  Recent  controversies  (mammography,  PSA,  CT   Angio,  etc)  prompt  discussion  regarding  what   comprises  a  ‘trustworthy’  clinical  pracce   guideline  (CPG)  
  10. 10. Which  guidelines  should  you  choose?  •   To  be  trustworthy,  guidelines  should:     –  Be  based  on  an  explicit  and  transparent  process  that   minimizes  distorons,  biases,  and  conflicts  of  interest;   –  Be  based  on  a  systemac  review  of  the  exisng  evidence;   –  Be  developed  by  a  knowledgeable,  muldisciplinary  panel   of  experts  and  representaves  from  key  affected  groups;  
  11. 11. Which  guidelines  should  you  choose?  •   To  be  trustworthy,  guidelines  should:     –  Consider  important  paent  subgroups  and  paent   preferences,  as  appropriate;   –  Provide  a  clear  explanaon  of  the  logical  relaonships   between  alternave  care  opons  and  health  outcomes,   and  provide  rangs  of  both  the  quality  of  evidence  and  the   strength  of  recommendaons;  and   –  Be  reconsidered  and  revised  as  appropriate  when   important  new  evidence  warrants  modificaons  of   recommendaons.    
  12. 12. What  should  recommendaons  include  • For  each  recommendaon,  the  following  should  be  provided:   •   Explanaon  of  reasoning  underlying  the  recommendaon,   including:     •  Descripon  of  potenal  benefits  and  harms.     •  Summary  of  available  evidence  (and  gaps),  descripon   of  the  quality  (including  applicability),  quanty   (including  completeness),  and  consistency  of  evidence.   •  An  explanaon  of  the  part  played  by  values,  opinion,   theory,  and  clinical  experience  in  deriving  the   recommendaon.    
  13. 13. What  should  the  recommendaons   include  • For  each  recommendaon,  the  following  should  be  provided:   • A  rang  of  the  level  of  confidence  in  (certainty  regarding)   the  evidence  underpinning  the  recommendaon.   • A  rang  of  the  strength  of  the  recommendaon  .     • A  descripon  and  explanaon  of  any  differences  of  opinion   regarding  the  recommendaon.  
  14. 14. What  the  IOM  did  not  talk  about  • How  to  translate  guidelines  into  EMR  decision  support  or  ordersets   –   LiKle  informaon  on  how  to  implement  CPG’s  in  a   way  that  is  concordant  with  core  recommendaons   •   Most  likely  affects  complex  algorithmic  decision  support,   such  as  early  warning  systems   – ‘Atomizaon’  of  evidence/decision  making  in   EMR’s   • The  workflow  in  EMR’s  is  usually  fundamentally  different   than  that  envisioned  by  a  CPG.  
  15. 15. EMR’s  provide  the  needed  connecons   All  these  connecons  can  be  made  by  the   EMR,  but  are  selected  by  people    
  16. 16. Humbling  evidence  •  EMR’s  for  improving  health  quality:   –  Small  to  moderate  sized  improvement  in  acute   care  process  measures,  no  impact  on  outcomes  in   36  published  studies*  (Sahota,  Implementaon  Science  2011)   –  Heterogeneous  impact  on  management/screening   of  chronic  condions  (Roshanov,  Implementaon  Science  2011)   *Don’t  feel  badly,  most  of  QI  is  in  the  same  boat  
  17. 17. Costs  Value–  the  next  froner  •  To  increase  value  you  must  tackle  costs   –  “Approval  driven”  approaches   •  P&T  CommiKees,  anmicrobial  stewardship   –  System  redesign   •  Six  Sigma/Lean  Sigma   –  Some  quesons  for  the  future  
  18. 18. Obligatory  “costs  are  rising”  slide  
  19. 19. 50,000 Some  diseases  have  goKen  more  costly  faster   45,000 40,000 35,000 MIHospital Charges ($) 30,000 CHF CAP 25,000 COPD UTI CVA 20,000 Sepsis 15,000 10,000 5,000 0 1993 1995 1997 1999 2001 2003 Year Rothberg  M,  Health  Aff  (Millwood).  2010  Aug;29(8):1523-­‐31.  
  20. 20. 20% What  are  we  gerng  for  our  money?   18% 16% 14%In Hospital Mortality 12% MI CHF CAP 10% COPD UTI CVA 8% Sepsis 6% 4% 2% 0% 1993 1995 1997 1999 2001 2003 Year Rothberg  M,  Health  Aff  (Millwood).  2010  Aug;29(8):1523-­‐31.  
  21. 21. Where  are  the  cost  reducon  opportunies?   Missed  Prev  Opps,     Prices  That  Are   Fraud,     $55     Too  High,    $105     $75     Inefficiently  Delivered  Services,     $130     Excessive   Administrave   Costs,    $190     Unnecessary   Services,    $210     Non-­‐Wasteful   Spending,    $1,735     Low  hanging  fruit  of   inefficient  and  wasteful  care   are  present,  but  larger   benefit  may  be  elsewhere  
  22. 22. Cost  types  in  healthcare  •  Fixed  costs   –  Costs  that  do  not  vary  over  ranges  of  output.   •  Buildings/Equipment  –  Paid  for  once   •  Salaried  personnel  –  paying  for  anyway   –  For  example:     •  A  PET  scanner  is  expensive,  but  it  is  paid  for  once   •  The  cost  of  upkeep,  space,  and  the  PET  technician  don’t   vary  substanally  as  more  people  use  it  
  23. 23. Point  of  clarificaon  •  Where  do  guidelines/pathways  fit  in  this  talk?   –  Lots  of  studies  on  guidelines,  pathways   –  Minority  report  costs  as  an  outcome   –  Few  used  guidelines/pathways  with  the  aim  of   reducing  costs/ulizaon  (and  few  succeeded).  
  24. 24. Cost  types  in  healthcare  •  Variable  costs   –  Costs  that  change  as  the  volume  of  services   increases   •  Some  medicaons,  material  costs   –  For  example:   •  Reducing  the  number  of  CT  scans  may  reduce  the  amount   of  contrast  purchased  and  used.  
  25. 25. Cost  types  in  healthcare  •  Marginal  costs   –  Elsewhere  in  the  world:   •  Costs  to  produce  an  addional  product  decrease  with   each  addional  unit   –  In  healthcare:  Not  usually  the  case   •  Cost  per  unit  output  fixed  (See  Fixed  costs)  unl   maximal  capacity  reached   •  Addional  PET  scanner  or  PET  scan  not  priced  lower   than  the  first  one.   •  Replacement  opons  generally  not  of  lower  cost  (think   Xa  inhibitor  vs.  warfarin)  
  26. 26. Why  is  Econ  101  in  an  EMR  talk?    •  Vast  majority,  70-­‐80%  -­‐  maybe  as  high  as  84%  of  costs  in  health   care  are  fixed  costs   –  Building  upkeep,  equipment,  personnel  occupy  bulk  of  costs   –  Variable  salaries  and  discreonary  items  (e.g.  drugs,  materials)   represent  a  small  proporon   –  EMR’s  •  Implicaons  over  the  short  term:   –  Reducing  variably  costed  items  will  have  limited  impact   –  Efforts  to  reduce  ulizaon  of  costly  items  oxen  offset  by   compensatory  efforts  to  maintain  revenue  to  subsidize  fixed  costs   –  Goal  will  need  to  focus  on  reducing  fixed  and  variable  costs  in  tandem   Roberts  R  JAMA,  February  17,  1999—Vol  281,  No.  7  
  27. 27. Why  is  Econ  101  in  an  EMR  talk?    •  Implicaons  over  the  longer  term:   –  EMR’s  used  to  automate  human  tasks   –  EMR’s  used  to  eliminate  need  for  fixed  cost  items   –  Must  provide  clear  cost  and  ulizaon  data   –  Overcome  barriers  or  innovate  on  old  models   •  Physician  awareness   •  Health  technology  acquision  commiKees   •  P&T   •  Anmicrobial  stewardship  cmte   •  Pathways   Roberts  R  JAMA,  February  17,  1999—Vol  281,  No.  7  
  28. 28. Physician-­‐targeted  cost  reducon   efforts  •  Speaker’s  prerogave  –  High  level  summary:   -­‐  A  reasonable  number  studies  of  physician-­‐ targeted  intervenons  cost  and  ulizaon  exist.   -­‐  Example:   -­‐  Provision  of  cost  informaon  for  common  primary  care   medicaons  increased  the  likelihood  that  lower  cost   alternaves  would  be  chosen  (Frazier  LM,  Ann  Intern  Med   1991;115:116-­‐21.)   -­‐  Recent  arcle  suggests  we  add  a  ‘check  out’  cart  for   what  we  order  (Brook,  JAMA  2012)    
  29. 29. Physician-­‐targeted  cost  reducon   efforts  -­‐  In  general:     -­‐  Educaonal  in  nature   -­‐  Slight  decrease  in  ulizaon  paKerns,  effect  did  not   differ  whether  IT-­‐based  or  not   -­‐  No  informaon  as  to  whether  appropriateness   increased   -­‐  Limited  persistence  of  intervenon  effect   -­‐  Focus  on  variable  costs  (e.g.  lab,  some  drug  tests)  
  30. 30. Health  systems  •  Health  Technology  Assessment  CommiKees  •  P&T  •  Anmicrobial  stewardship  •  Pathways  
  31. 31. Health  Technology  Assessment   CommiKees  •  Similar  to  pharmacy  and  therapeucs  commiKee   –  In  existence  for  at  least  20  years   –  Limited  data  on  their  prevalence,  but  appear  most   common  in  integrated  health  systems  •  General  characteriscs   –  Broad  based  membership,  includes  C-­‐suite   –  Physician  led  and  championed   –  Most  commonly  focus  on  surgical  technologies,   capital  expenditures  –  not  implants,  etc.   Fine  A  Healthc  Financ  Manage.  2003  May;57(5):84-­‐7  
  32. 32. Health  Technology  Assessment   CommiKees  •  Few  (?No?)  data  on  their  effecveness  in   constraining  costs   –  In  general,  capital/technology  expenditures   represent  marketplace  differenators  and  are   hard  to  deny  •  UCSF  HTAC   –  In  existence  since  2006   –  24  approvals,  13  provisional  approvals,  4  declined   Gutowski  C  Health  Technology  Assessment  at  the  University  of  California–San  Francisco.  Journal  of  Healthcare       Management  56:1  January/February  2011  
  33. 33. P&T  and  cost  •  A  closed  formulary  may  produce  lower  pharmacy   costs   –  Not  clear  whether  it  slows  pharmacy  cost  rises   –  More  restricve  formulary  pracces  may  have   adverse  effects  (Horn  SD,  Formulary  limitaons  and  the  elderly:  Results  from   the  Managed  Care  Outcomes  Project  AJMC  1198:  4;  1105-­‐1113)  •  No  data  on  whether  specific  P&T  structures  or   acvies  are  more  effecve  than  others  at   restraining  cost.  •  No  data  on  the  ‘return  on  investment’  of  P&T  
  34. 34. Anmicrobial  stewardship  •  Subtype  of  P&T  •  Generally  narrower  focus  on  selected  set  of   medicaons  •  Able  to  link  choice  of  medicaons  to  specific  clinical   situaons  (and  microbes)   –  Oxen  include  clear  clinical  guidelines     –  Pre-­‐approval  via  consultaon  in  many  programs  
  35. 35. Anmicrobial  stewardship  •  Highly  effecve  at  increasing  appropriateness  of   anmicrobial  use   –  Can  produce  both  reducons  in  direct  costs  of  medicaons   and  reduced  downstream  events   –  Most  effecve  programs  include  physician  outreach/ approval  component  with  ered  approach    •  Limited  data  on  their  cost  to  benefit  rao   –  One  study  esmated  1M/year  direct  cost  savings   –  No  esmates  of  the  program  cost     Standiford  HC.  Anmicrobial  stewardship  at  a  large  terary  care  academic  medical  center:  cost  analysis  before,  during,  and   axer  a  7-­‐year  program.  Infect  Control  Hosp  Epidemiol  2012;33:338-­‐45.  
  36. 36. Health  systems  •  Anmicrobial  stewardship  models  include   concepts  that  may  be  useful  elsewhere   –  Physician  detailing     –  Tiered  restricon  process   –  Understanding  that  restricng  anmicrobials  has   real  benefits   •  ASM’s  also  –  target  acute  care  medicaons.  
  37. 37. Pathways  •  Where  do  guidelines/pathways  fit  in  this  talk?   –  Lots  of  studies  on  guidelines,  pathways   –  Minority  report  costs  as  an  outcome   –  Few  used  guidelines/pathways  with  the  aim  of   reducing  costs/ulizaon  (and  few  succeeded).  
  38. 38. How  can  EMR’s  innovate  over  old   models  •  HTAC,  P&T,  AMS,  and  Pathways   –  Can  provide  decision  support  over  paper  models.   –  Flexibly  catch  people  ‘off  path’   –  Set  firm(ish)  guardrails  around  unwanted   pracces   –  Actually  measure  what  the  pathway  is  doing  and   give  clear  feedback  
  39. 39. A  few  closing  quesons  
  40. 40. Queson  1:    Can  physicians  embrace  limitaons  stewardship   as  a  professional  standard?  
  41. 41. We  have  to  •  Growing  recognion  that  costs  are  important  •  EMR’s  can  help  reinforce  posive  behavior,   discourage  unwanted  behavior  
  42. 42. Queson  2:    Will  physicians  allow  themselves  to  be   stewarded  by  EMR’s  (or  anyone)?  
  43. 43. The  pizalls  of  greater  choice   Physicians   want  this   The  future   needs    this  
  44. 44. Find  ‘Model  T’  systems  •  What  would  your  company  look  like  if  it  produced   just  one  product?   –  1908  Ford  Model  T     –  Single  model  from  which  others  arose  •  More  modern  examples:   –  Starbucks:  Medium  Coffee   –  In  And  Out  Burger:  Cheeseburger  +  fries   –  Bank  of  America:  Base  checking  account    
  45. 45. Translate  this  to  healthcare  workflows  •  Potenal  examples  of  Model  T  workflows   –  Inpaent  Model  T:  What  if  all  we  did  as  an  instuon  was   treat  pneumonia?   –  Ambulatory  Model  T:  What  if  all  we  did  was  see  paents   for  hypertension?  •  Use  these  models  to  define  workflows,  clinic  visit   structure,  etc.  for  most  common  paent  flows   –  Add  ‘modules’  on  to  allow  customizaon  around  core   funcons.   –  Can  then  create  single  entry  points  an  economies  of  scale   –  Can  EMR’s  do  this?    
  46. 46. Translate  to  therapeuc  choices  •  Complexity  in  treatment  choices   –  Within  these  groups,  what  20%  of  drugs  account   for  80%  of  paents   •  What  20%  of  devices  account  for  80%  of  paents?   •  Can  we  make  those  the  defaults?   •  Can  this  approach  the  be  used  to  set  ers  of  ‘approval’   or  decision  support?   –  Top  80%  easily  available   –  Next  10%  require  aKestaon  as  to  choice   –  Next  10%  require  more  in-­‐depth  approval?  
  47. 47. Queson  3:  Can  health  IT  really  solve   everything  (including  costs)?  
  48. 48. Health  informaon  systems  and  cost   reducon  •  HIT  is  thought  to  be  a  key  route  reducing  costs   –  Reduced  redundancy  through  sharing  of   informaon   –  Ability  to  provide  decision  support       –  Few  studies  have  demonstrated  cost  reducons*   •  Maybe  cost  increases??    
  49. 49. Health  IT  •  Why  it  might  be  old  wine  in  new  boKles   –  Using  Health  IT  as….   •  A  more  efficient  way  to  warehouse  as  broad  a  selecon  of   treatments/algorithms  as  possible.   •  A  more  efficient  way  to  present  all  possible  treatment/ tesng  choices   –  We  don’t  improve  on  exisng  systems  and   organizaonal  structures  to  help  define  appropriate   choices     •  P&T,  Anmicrobial       “Culture  eats  technology  for  lunch”  
  50. 50. Health  IT  •  Why  it  can  get  us  to  the  place  we  want  to  be   –  IT  does  force  workflow  standardizaon   –  More  sophiscated  use  of  formulary  materials   limits   •  Decision  support   •  Automated  ‘academic  detailing’   –  Data  about  producon  processes    
  51. 51. Conclusions  •  Translang  evidence  into  pracce  is  hard,  but   crical   –  EMR’s  can  help  by  providing  easy  access  to  the   best  therapies  and  tests  •  Reducing  costs  in  EMR’s  is  a  crical  goal   –  Automate  and  smooth  workflows  to  target  fixed   costs   –  Innovate  and  partner  with  exisng  organizaonal   funcons  to  speed  adopon  
  52. 52. Conclusions  •  Can  we  find  answers  to  the  key  quesons?   –  The  culture  of  healthcare  is  changing   –  Perhaps  instead  of  culture  eang  technology  for   lunch  (at  least  insofar  as  cost  and  quality  is   concerned),  culture  can  make  the  meal  more   appealing.