Economische evaluatie: toepassing op

klinische paden

Luk Bruyneel

Leuvens Instituut voor Gezondheidszorgbeleid

CONTENTS

1. Business, social or economic case for quality? Leatherman et al. 2003

2. Economic evaluation of ERP for colorectal surgery Lee et al. 2014

3. Deviation-based cost modeling for clinical pathways Vanounou et al. 2007

4. Developing a business case for quality Reiter et al. 2007

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1. Business, social or economic case for quality?

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1. Business, social or economic case for quality?

First key question

Does improved quality increase or reduce margins or provide a return on investment

in a defined time frame?

Second key question

What entity realizes a financial benefit from a specific quality improvement?

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1. Business, social or economic case for quality?

Business case

If the entity that invests in the intervention realizes a financial return on its

investment in a reasonable time frame, using a reasonable rate of discounting.

Financial return=“bankable dollars” (profit), a reduction in losses for a given

program or population, or avoided costs.

Philanthropic motives regulations professional ethics

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1. Business, social or economic case for quality?

1. How much would it cost to increase nurse staffing?

2. Would these costs be offset by cost savings from reduced length of stay and complications?

3. Would the hospital realize these cost savings, or, because of how the hospital is paid, would

these savings be captured by payers?

4. Can the hospital attract additional profitable patients on the basis of its nurse staffing?

5. Are there cost savings other than those achieved via better patient care that might also be

realized if nurse staffing is increased?

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Needleman 2008

1. Business, social or economic case for quality?

Economic case

If discounted financial benefits exceed discounted costs, whether they accrue to

patients, employers, providers or payers, or some other segment of society.

Social case

The benefit fo the indvidual (patient) or to society of improved health status and

productivity, regardless of cost.

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1. Business, social or economic case for quality?

The misalignment of financial incentives creates a formidable obstacle to the

adoption of quality interventions. A quality improvement may be desirable for its

positive impact on patients, for its ability to improve efficiency (save money), or both.

However, health care organizations may be reluctant to implement improvements if

better quality is not accompanied by better payment or improved margins, or at least

equal compensation.

8Needleman 2008

Hospitals that increase nurse staffing in light of research demonstrating an association of improved

outcomes with such increases will likely lose money as a result.

2. Economic evaluation of ERP for colorectal surgery

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2. Economic evaluation of ERP for colorectal surgery

To perform a systematic review and quality assessment

of all economic evaluations

comparing enhanced recovery pathways (ERP) and perioperative conventional care (CC)

in patients undergoing elective colorectal surgery.

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2. Economic evaluation of ERP for colorectal surgery

Clinical pathways were considered ERP if they included:

1. Patient information

2. Preservation of GI function

3. Minimization of organ dysfunction

4. Active pain control

5. Promotion of patient autonomy

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2. Economic evaluation of ERP for colorectal surgery

Quality of studies evaluated using Consensus on Health Economic Criteria (CHEC)

1. Is the study population clearly described?

2. Are competing alternatives clearly described?

3. Is a well-defined research question posed in answerable form?

4. Is the economic study design appropriate to the stated objective?

4. Is the chosen time horizon appropriate in order to include relevant

costs and consequences?

6. Is the actual perspective chosen appropriate?

7. Are all important and relevant costs for each alternative identified?

8. Are all costs measured appropriately in physical units?

9. Are costs valued appropriately?

10. Are all important and relevant outcomes for each alternative

identified?

11. Are all outcomes measured appropriately?

12. Are outcomes valued appropriately?

13. Is an incremental analysis of costs and outcomes of

alternatives performed?

14. Are all future costs and outcomes discounted appropriately?

14. Are all important variables, whose values are uncertain,

appropriately subjected to sensitivity analysis?

16. Do the conclusions follow from the data reported?

17. Does the study discuss the generalizability of the results to

other settings and patient/client groups?

18. Does the article indicate that there is no potential conflict of

interest of study researcher(s) and funder(s)?

19. Are ethical and distributional issues discussed appropriately?

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2. Economic evaluation of ERP for colorectal surgery

10 articles met inclusion criteria

5 studies before and after design (prospective ERP cohort compared with

historical cohorts)

2 studies where both groups were studied prospectively

1 study where both groups were studied retrospectively

2 randomized controlled trials

(only 2 studies performed economic evaluation as a primary study objective)

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2. Economic evaluation of ERP for colorectal surgery

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2. Economic evaluation of ERP for colorectal surgery

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2. Economic evaluation of ERP for colorectal surgery

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Only study to include

implementation and

maintenance cost of ERP

Only study to include overhead costs,

but method of allocation not specified

Median costs

vs

mean costs

Very poor study

quality

2. Economic evaluation of ERP for colorectal surgery

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None of the studies

originally calculated ICER

2. Economic evaluation of ERP for colorectal surgery

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Green et al. 2014

3. Deviation-based cost modeling

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3. Deviation-based cost modeling

Two limitations of traditional analyses

1. Current analyses do not expalin why clinical pathways decrese length of stay

and reduce hospital costs.

2. Fails to differentiate between effects of clinical pathways and impact of secular

trends.

DBCM

provides the ability to analyze the impact of secular trends and to delineate

pathway-attributable gains.20

3. Deviation-based cost modeling

209 panceaticoduodenectomies over 5-year period

64 prepathway patients

145 postpathway patients

Guide for preoperative planning, thromboembolic and antibiotic prophylaxis, perioperative

pain management, and removal of central venous catheteers, nasogastric tubes, urinarary

cateheters, and intera-abdominal drains.

Standardized patient perioperiative fluid resuscitation, alimentation, and diagnostic testing.

Several patient-centered inititatives, psychosocial and geriatric consultation, and early

rehabilitation planning.21

3. Deviation-based cost modeling

Comparison prepathway vs postpathway:

Rates of complications

Hospital duration

ICU transfers

Patient discharge disposition

Reoperation

Hospital readmission

30-day or in-hospital mortality

Total hospital costs

Detailed cost analysis for each patient individually. DBCM was

specifically designed to reflect both the clinical impact of

complications and their economic consequences.

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3. Deviation-based cost modeling

LOS categories derived

from first random half

of patientsClavien classifcation of

surgical complications

Validated on second

random half of patients

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3. Deviation-based cost modeling

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3. Deviation-based cost modeling

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3. Deviation-based cost modeling

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4. Developing a business case for quality?

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4. Developing a business case for quality?

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4. Developing a business case for quality?

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4. Developing a business case for quality?

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