Economic evaluation in primary care and

chronic disease management

Braden Manns

Svare Chair, Health Economics

Outline:

1. Economic evaluation in primary care

• Case study

• Basic principles of economic evaluation

• Is health economics relevant to primary care?

• An example of economic evaluation within diabetes care

• How to engage health care providers in taking costs into account?

2. Blended capitation – improving accountability for care that provides good value for money

3. Exercise: Incorporating costs into policy making.

Objectives:

Is health economics relevant to primary care?

Case study

Basic Principles of economic evaluation

How to engage health care providers in

taking costs into account?

An example of economic evaluation within

diabetes care

Case study

Glucose testing strips in diabetes

67 year old woman, with Type 2 Diabetes and

Albuminuria.

Follow-up of blood pressure and kidney disease.

Medications; metformin (500 mg bid), glyburide (2.5

mg bid) and Ramipril (5 mg daily).

No hypoglycemic episodes, BP 126/80.

HbA1c high (8.6%): You recommend watching diet,

exercise and increasing glyburide to 5 mg bid.

You request she monitor her blood sugar intermittently

during the day and request follow-up in few months.

You also wonder if she would benefit from a nurse

case manager?

Basic principles of

economic evaluation

What is economic evaluation?

Comparative analysis of alternative

courses of action in terms of both their

costs and consequences.

Opportunity cost, scarcity of resources,

and choice.

Funding diabetes nurses or a foot screening

program in people with diabetes?

Diabetes nurses help with blood sugar

control.

Reduces eye and kidney complications.

Annual costs $150,000 per clinic.

Foot screening program in high-risk

diabetes: Reduces amputation.

Set up cost $100,000

Annual costs $100,000

3 types of economic evaluation:

Cost- effectiveness analysis.

Cost- utility analysis.

Cost- benefit.

What is the role of economic

evaluation within health care

priority setting ?

Why use economic evaluation?

Improved clinical

outcomes Increased costs

How to interpret a cost-effectiveness ratio:

Cost/QALY ratio Recommendation

<$20,000 Strong evidence for adoption and appropriate utilization.

$20,000-100,000 Moderate evidence for adoption and appropriate utilization.

>$100,000 Weak evidence for adoption.

Other Important factors to consider

when setting priorities

Life saving intervention versus gain in life expectancy.

Impact on quality of life.

Is the treatment for a large or small number of people?

Is the treatment for older or younger patients?

Is the treatment for those with good or poor baseline health?

What is the budget impact?

Equality of access to therapy.

Is it a priority for government / the health care system?

Is health economics

relevant to primary care?

Is health economics relevant to

primary care?

What is the goal of health care providers?

What is the goal of health care-policy makers?

“I will apply, for the benefit

of the sick, all measures

which are required”

An example of economic

evaluation within

diabetes care

Glucose testing

strips in diabetes

Cost-effectiveness of self-

monitoring of blood glucose in

patients with type 2 diabetes

mellitus managed without insulin

CMAJ, Jan. 12, 2010, 182(1)

C. Cameron, D. Coyle, E. Ur, S. Klarenbach

Self-monitoring for patients with Type 2 Diabetes (not using insulin)

Background:

• self-monitoring of blood glucose is recommended for patients who are not using insulin (CDA guidelines).

• $350 million per year in Canada.

• In 2010, cost of strips exceeded those for all oral anti-diabetes drugs combined.

• ~ 50% of the total expenditure on blood glucose test strips is for patients with type 2 diabetes who are not using insulin.

Effectiveness:

• 7 randomized trials, enrolling 2270 patients with type 2 diabetes managed with oral antidiabetesagents or lifestyle measures.

• All trials compared self-monitoring of blood glucose (and education) with no self-monitoring.

• Average number of tests 1.29 per day ($0.73 per test strip).

• The pooled difference in HbA1C was in favour of self-monitoring (weighted mean difference –0.25%, 95% CI –0.36% to –0.15%).

Self-monitoring for patients with Type 2 Diabetes

(not using insulin)

Table: Cumulative incidence of diabetes-related complications over 40 years

Overall %

(95% CI)

1 Chronic Condition

Only % (95% CI)

2+ Chronic Conditions

% (95% CI)Comparison

Cumulative incidence %

ConditionNo self-

monitoringSelf-monitoring

Absolute risk

reduction, %

Number needed to

treat

Myocardial infarction 36.58 36.21 0.38 266

Heart failure 17.64 17.20 0.44 228

Stroke 16.34 16.14 0.20 500

End-stage renal disease 2.29 2.21 0.08 1299

Self-monitoring for patients with type 2 diabetes not using insulinImpact on clinical outcomes:

How do you interpret the results?

High quality systematic review shows small changes in HbA1C,

which translate into small changes in clinical events noted in the

economic evaluation

Improvements in clinical outcomes are uncertain

Baseline cost per QALY ~$110,000 – higher than most

interventions we pay for in Canadian health care

- though health care providers are the gatekeeper

- governments have created funding policies using this data

Message for primary care

Don’t prescribe self-monitoring in stable

patients except when

• changes to therapy are being made

• patients who are prone to

hypoglycemia.

Self-monitoring in patients with diabetes

managed without insulin provides VERY

small (and uncertain) improvements,

and money would be better invested

elsewhere

How to engage health

care providers in taking

costs into account?

Getting physicians to be stewards of resources?

• Education

• Key performance indicators

• New payment models – blended capitation

1. Education: Balancing the patient in front of you with the

patients in your waiting room: Answer 3 Questions

Does the intervention you’re considering really work?

What are the resource implications of the new treatment?

Should you say “no” based on cost-effectiveness?

The uncomfortable truth.

Resources are limited / choices must be made.

Obligation to patient vs. obligation to society.

Goal of health care system is to maximize the health of

all its population under the constraint of a fixed budget -

considering cost- effectiveness is a reasonable tool to

help make these choices.

Saying “No” based on cost-effectiveness

Clinical practice guidelines should take cost

into account.

Formularies that consider costs can help you

care for your patients in a cost-conscious

manner, while still providing the vast majority

of “effective” therapies.

Developing local guidelines which your care

can be consistent with (i.e. guidelines for your

specialty clinic, or ward).

Helping health care providers say “NO”

Returning to Hippocrates:

• I will apply, for the benefit of the sick, all

measures which are required, avoiding those

twin traps of overtreatment and therapeutic

nihilism.

• I will remember that I do not treat a fever chart,

a cancerous growth, but a sick human being,

whose illness may affect the person’s family

and economic stability. My responsibility

includes these related problems, if I am to care

adequately for the sick

• I will remember that I remain a member of

society, with special obligations to all my fellow

human beings.

• I will remember that there is art to medicine as

well as science, and that warmth, sympathy

and understanding may outweigh the

surgeon’s knife or the chemist’s drug.

Importance of following established processes

Valid data sources

Indicators should represent high-value care

Issues: Targets / Physician buy-in and ownership critical / Enforcement

Role for SCNs

2. Key performance indicators?

Indicators of high value Kidney Care in Alberta: Examples

1. Use of home dialysis: Proportion of new dialysis patients being

treated with peritoneal dialysis within 180 days after initiating

dialysis

2. Pre-emptive kidney transplantation: Proportion of new kidney

failure patients who are potential transplant candidates (<60 yrs

old; with no heart disease or cancer) who receive a transplant

rather than dialysis

3. Documentation of level of care: Goals of Care Designation Order

signed for all patients on dialysis.

The goal of the new compensation model is to provide:

• Albertans – with increased access to primary health care, through strong relationships to their primary care physicians and improved continuity of care.

• Physicians – with the flexibility to provide services in different ways so they can spend more time with patients and deliver comprehensive care that encourages health promotion, wellness and enhanced collaborative care.

• Government – with a more sustainable health system with better accountability, stability and budget predictability.

3. Blended Capitation payment model for primary care

• Includes a mix of patient-based (capitation) payments (85%) and volume-based payments through fee-for-service (15%).

• Capitated payments for each rostered patient

• A basket of medically insured services has been developed to reflect the typical activities of a non-specialized general practitioner in an office-based setting.

• The capitation amount is estimated on the average use of the basket of services based on a patient’s age, sex and risk status.

Compensation

Comprehensive evaluation planned (led by IHE):

Cost and cost-effectiveness embedded in many domains

Data sources:

• Panel/Roster analysis (demographic, chronic disease, continuity)

• Patient Experience Survey (HQCA)

• Quality Indicators (ASaP, NICE)

• Team Based Surveys

• Qualitative Interviews

• System Utilization Baseline (ED, Hospital, etc.)

Domains:

• Access to care

• Continuity of care

• Quality, comprehensiveness, efficiency of care

• Patient experience

• Team-based care

• Patient-centred care

• Complex patients receiving multi-disciplinary care

• Referral rate to specialty care

• Health are costs

Care Domain Patient Eligibility Indicator Source

Colorectal Cancer

Screening

50 – 74 years

Completed fecal immunochemical test (2

years), sigmoidoscopy (<5 years),

colonoscopy (<10 years)

AHS administrative data

EMR

Breast Cancer Screening Females 50 – 74 years Completed mammogram (2 years) AHS administrative data

EMR

Cervical Cancer Screening Females 25 – 69 years Completed pap test (3 years) AHS administrative data

EMR

Cardiovascular Disease

Risk Assessment

50 – 74 years

Measurement of CVD Risk using a calculator

and/or counselling or

Lipid panel (<3 years)

AHS administrative data

EMR

Hypertension Assessment >18 years Completed blood pressure measurement

(<1 year)

EMR

Obesity Screening >18 years Completed BMI (<2 year) EMR

Tobacco Use Cessation >18 years Identified patients as tobacco user

or non-user

AHS administrative data

EMR

Diabetes Screening >40 years Completed Fasting Glucose

or HgA1C (5 years)

AHS administrative data

EMR

Indicators – High Value Preventive care

Care Domain Patient Eligibility Indicator Source

Congestive Heart Failure

>18 years with CHF % of patients with

ACE/ARB prescriptions

AHS administrative data

EMR

Diabetes

>18 years with diabetes % patients with

ACR and HgA1C (1 year) or

Retinopathy (<2 years)

AHS administrative data

EMR

>18 years with diabetes and

ACR>30mg/g (or >3mg/mmol)

% of patients with

ACE/ARB prescriptions AHS administrative data

Chronic Kidney Disease >18 years with GFR <60/mls/min

(<2years)

% patients with ACR or PCR (<3years)

AHS administrative data

EMR

>18 years with GFR <60/mls/min and

ACR >3mg/mmol or PCR>15mg/mmol

or Urinalysis protein 1+ or greater

% of patients with

ACE/ARB prescriptions

Cardiovascular Disease >18 years with a CVD Risk >20 or prior

MI or stroke or diabetic

% patients on a statin (<3 years) AHS administrative data

EMR

Indicators – High Value chronic disease care

Open discussion – incorporating costs into policy making in

primary care

The Mosaic PCN has a surplus of $800,000 for the next 3 years.

They have placed a priority on care of vulnerable patients with

chronic diseases including diabetes, and heart disease. They are

considering hiring nurse clinicians to assist patients with self-

management, funding additional enhancements to their electronic

medical record (to facilitate reminders, clinician prompts), or

establishing a comprehensive audit and feedback system. What

factors should they be considering in their decision making?

Evaluation

Question

Intended

Outcome

Indicator Data

Source

High Level

Impact/Value

Can patients access

the care they need,

when they need it?

Same day access to the physician and team

Third Next Available appointment with

Physician and Team Alberta AIM

website

Timely AccessContinuity

Patients are satisfied with their ability to

access their regular primary care provider

% of patients reporting desirable access to

their provider on patient experience

questionnaire

HQCA Patient

Experience

Patients decrease their activity within the

emergency department for conditions best

treated in primary care

% of patients who accessed the emergency

department for family practice/ambulatory

care sensitive conditions

AHS

Administrative

Data

Patients decrease their hospitalizations for

conditions best treated in primary care

% of patients with a reported in-patient

stay for ambulatory care sensitive

conditions

AHS

Administrative

Data

Patients discharged from hospital have

timely follow up with physician/team

% of patients with a visit to primary care

after discharge from hospital

AHS

Administrative

Data

How often do

patients see their

own physician in

their medical home?

Patients have more visits to their own

physician or to other members of the

medical home consistent with their needs

% of patients with visits to their own

physician or to other physicians within the

medical home

Clinic EMR

AHS

Administrative

DataTimely Access

Continuity

% of patients with visits to other physicians

outside their medical home

Patients report being able to regularly see

their own physician or team within their

medical home consistent with their needs

% of patients reporting consistent access

to their own provider on patient

experience questionnaire Q16

HQCA Patient

Experience

Evaluation

Question

Intended

Outcome

Indicator Data

Source

High Level

Impact/Value

Are patients receiving

quality, comprehensive care

when they access their

physician or medical home?

Patients receive appropriate

preventative care and chronic disease

management according to clinical

practice guidelines and in alignment

with Choosing Wisely

recommendations

% of patients are screened according

to Alberta Screening and Prevention

maneuvers (appendix B)

Clinic EMR

AHS

Administrative

Data

Comprehensive

Care

Team based Care

Continuity

% of patients with chronic disease are

managed appropriately according to

UK Quality & Outcomes Framework

/National Institute for Health and

Care Excellence guidelines (appendix

B)Patients with chronic disease have a

care plan to assist with management

of their conditions

% of patients with chronic disease

who have an care plan in place with

their own provider/team

Clinic EMR

AHS

Administrative

DataPatients reporting feeling satisfied

with the quality of care received.

% of patients who feel they are

receiving comprehensive care on

patient experience questionnaire

HQCA Patient

Experience

Are patients’ expressed

needs, values and

preferences around their

care being met in a

respectful and responsive

manner?

Patients report feeling respected and

involved in the decisions around their

health care

% of patients with a patient

experience questionnaire feeling

satisfied with their own involvement

in decisions around their care.

HQCA Patient

ExperiencePatient Centred

Patients have been asked about their

current health care state and ability to

manage their own care

% of patients with an EQ-5D indicating

maintaining or improving functional

health status.

Evaluation

Question

Intended

Outcome

Indicator Data

Source

High Level

Impact/Value

To what extent have

patients accessed team-

based care for their

desired health care needs?

Patients access a variety of

health care professionals at

their medical home that

meet their needs

% of patients with a visit to an

interdisciplinary team member

Clinic EMR

AHS Administrative

Data

Team-Based Care

Continuity

Timely Access

% of patients with >1 visit to an

interdisciplinary team member

% of patients with visits to >1

interdisciplinary team member

Do the providers feel

satisfied and supported in

their goal to deliver

quality, comprehensive

patient centred care?

Providers report greater

satisfaction around in their

perceived care delivery

% of providers with a completed Health

Team Effectiveness survey reporting high

general work satisfaction

Health Care Team

Effectiveness SurveyTeam-Based Care

Patient Centred

Have patients with more

complex needs been

formally rostered to the

program and are they

receiving the care

coordination they require?

Patients with complex

needs are identified within

their medical home and are

linked with the services

they need within their

medical neighbourhood

% of complex needs patients rostered to the

BCM programClinic EMR

AH Administrative Data

Timely Access

Team Based Care

Comprehensive

Care

Care Coordination

System Support

% of complex needs patients with an action

plan for their care% of complex needs patients with a

community care referral

Patients with chronic

disease or complex

conditions have a lower

number of hospital

admissions and emergency

departments

% of emergency department visits and

hospital admissions/readmissions in patients

with chronic or complex conditions post-

implementation (for chronic disease and all

cause)

Evaluation

Question

Intended

Outcome

Indicator Data

Source

High Level

Impact/Value

What is the level of consensus

in the team around the clinics’

engaged leadership, capacity

for improvement and

approach to panel and

continuity?

All staff consistently champion quality

improvement in care and have clear

understanding around accountability

related to their roles.

% of ‘Level A’ items endorsed by physicians and teams in the Phase 1 Medical home assessment

Medical

Home

Assessment

Survey

System Support

Comprehensive Care

Team Based Care

Patient Centred

Clinic supports a culture of continuous

quality improvement that includes

comprehensive measures that involve

all team members and patients

Panel and disease registries for chronic

disease are maintained to manage care

for the practice population and used for

proactive care

Has the referral rate to

specialty care been affected by

the change in physician

remuneration?

Referral rates are lower after switching

from fee-for-service to a blended

capitated model.

% of patients with specialty

care visit

Clinic EMR

AHS

Administrativ

e Data

System Support

Comprehensive Care

Team Based CareHas there been a shift in

ordering patterns (labs,

diagnostic imaging, and

prescriptions) after the change

in physician remuneration?

The change to blended capitation does

not result in an increase in ordering

behaviour activity.

% of laboratory, diagnostic imaging and prescriptions ordered by physicians post implementation