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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