Cost-Effectiveness Analysis in Emergency Care

Resident ConferenceJoseph M Reardon, MD

Objectives• Describe the players: the Centers for Disease Control and

Prevention, its interaction with emergency medicine, and opportunities for emergency physicians at CDC and NGOs

• Describe the need for cost-effectiveness analysis• Interpret cost-effectiveness figures in terms of QALYs and

DALYs• Describe applications of cost-effectiveness analysis to ED

and marginalized populations

CDC: Emergency Response & Recovery Branch (ERRB)• Originally the Communicable Disease Center• Now organized into Centers focused on Communicable &

Noncommunicable classes of disease• Center for Global Health at CDC covers diseases outside the

US• ERRB: Addresses needs of acutely displaced populations (refugees and

internally displaced persons)• Collaborates with WHO, UN High Commissioner for Refugees, and NGOs• Data Processor; invited in by partners

The Players

CDC: Epidemic Intelligence Service (EIS)• 2-year, post-residency training program for clinicians• Field epidemiology experience• EIS Officers are assigned to state-level positions or disease-level

positions• EM-relevant skillset: Quick decisions with limited information,

practical questions, at-risk populations [Ebola]• Challenges

• No clinical work

The Players

Additional Post-Residency Opportunities• GRRT: Global Rapid Response Teams at DHHS• STOP: Stop Transmission of Polio field response teams• Médecins Sans Frontières and other partner

organizations

The Players

The Players

Fundamentals of Cost-Effectiveness Analysis

Why Should I Care About Cost-Effectiveness?• Resources are finite• Need to evaluate interventions on a common scale in order to

prioritize funding – globally or locally• Your paycheck will depend on showing the value of your work

BenefitsLife-Years Saved

Disability-Adjusted Life-Years Saved (DALYs)Quality-Adjusted Life-Years Saved (QALYs)

Costs$$$

Fundamentals

Vocabulary• Life-Year: One year of life lived• Quality-Adjusted Life-Year (QALY): Years of life gained by an

intervention, multiplied by a quality of life multiplier (0 to 1)• Disability-Adjusted Life-Year (DALY): Years of life from an

intervention plus years of disabled life multiplied by a disability multiplier (0 to 1), weighted to favor younger age.

WHO Health Statistics Programme

Fundamentals

10 yrs 20 yrs

Fundamentals

Example• In surveys, losing both legs has a DALY weight of 0.5 .

In other words, people think that losing your legs for 2 years is just as bad as dying 1 year earlier.

• Isn’t this ageist, ableist, and otherwise discriminatory?• YES.

Australian Institute of Health & Welfare

Fundamentals

QALYs vs DALYs• Very similar but not interchangeable• DALYs prioritize those interventions that save the lives

of youth more than those interventions that add a few years of life or health to an older person

• DALYs are usually favored

WHO Health Statistics Programme

Fundamentals

Units of Cost-Effectiveness

=__$ Spent__ DALYs Saved

Fundamentals

What determines if something is cost-effective?• It’s cost-effective if you can afford to pay for the years of life saved.• In other words: Cost per DALY saved < Your annual salary

• On a population scale: Cost per DALY saved < Country’s Gross Domestic Product per capita

• In the US, traditionally: Cost per DALY saved < $50,000

Fundamentals

Example: ARDSnet Protocol for ICU

Chest, 2009

Fundamentals

Application: Hepatitis B prevention in refugee camps

Application: Hepatitis B prevention in refugee camps• Hep B is vertically transmitted from mother to child• Administering Hep B vaccine within 24 hours of birth prevents

vertical transmission• Refugee camps have limited budget for food, water, etc• Question: Is it worthwhile to allocate $ from refugee camp budget to

pay for additional vaccination at birth, in addition to routine immunization?

Demotix

Applications

Refugee Camps of InterestApplications

Applications

ResultsApplications

Cost-Effectiveness Modeling in the ED

Cost-Effectiveness Modeling in ED• Example: ProBNP to ID

CHF exacerbation• Saved average of $474

per visit even despite false positives and false negatives

• Cost savings was made up from expensive formal echos that were avoided

Am J Card, 2006

Applications

Cost-effectiveness of ED interventions• Pre-Hospital

• Training people over age 50 in CPR: $23,000 / life-year• Training young people in CPR: $137,000 / life-year

• BLS ambulance defibrillators: $820 / life-year• BLS ambulances for myocardial infarction: $59,000 / life-year• ALS ambulances for myocardial infarction: $159,000 / life-year• LifeFlight for critical care transport: $60,000 / life-year

Prehospital Care, 2004Annals Emerg Med, 1996

Applications

Cost-effectiveness of ED InterventionsThrombosis:• tPA for Stroke: $32,000 / life-year saved• Warfarin for Afib: $8,000 / life-year saved

• Lovenox for DVT: $26,000 / QALY saved• Heparin for DVT: $26,000 / QALY saved• Plavix for ACS: $6,000 / life-year

NEJM, 1995Ann Int Med, 1999Crit Care Med, 2011Europ J Health Econ, 2006

Applications

Cost-effectiveness of ED Interventions• Infectious Disease

• Early goal-directed therapy for sepsis: $6,000 / QALY• HIV prophylaxis after needlestick injury: $41,000 / life-year

• Neurology• Topiramate to prevent migraine: $11,000 / QALY

• Trauma• CT for non-accidental trauma: $1,700 / life-year

Pediatrics, 2007Crit Care Med, 2012Annals of EM, 1997

Applications

Cost-effectiveness applications to global health• WHO: Integrated Management on Emergency and Essential Surgical

Care• Packages of emergency medicine essentials• Tailoring to country level: High-income, middle-income, low-income

• An alternative:• Cost-effectiveness of each intervention established and each country’s gross

domestic product per capita dictates an individualized package of interventions

Applications

Review Questions1. Tommy is lobbying Congress.

[Senator] “Why should I fund emergency care instead of [art program for orphans and widows]?”

A. Because we’re awesomeB. Because we save livesC. Because we save more lives per dollar spentD. Because we save more years of life per dollar spentE. Because we save more years of quality life per dollar spentF. [E] plus a personal anecdote

Review Questions2. As of November 2015, how many countries have active Ebola virus transmission?

A. 1B. 2C. 3D. 4E. 5

Review Questions3. What is CDC capable of doing in an international epidemic?

A. Stopping it by any means possibleB. Caring for patients who are afflicted with an emerging infectious disease

(EID)C. Organizing NGOs to provide clinical careD. Tracking cases and advising governments and NGOs on disease controlE. B, C, and DF. C and D

Review Questions4. What is the primary difference between a QALY and a DALY?

A. No differenceB. QALYs are weighted to favor younger agesC. DALYs are weighted to favor younger agesD. QALYs include subjective weights for the value of life with a particular

condition, while DALYs do notE. DALYs include subjective weights for the value of life with a particular

condition, while QALYs do not

Review Questions5. Jeremy called the ECMO team to save the life of a 50-year-old patient with STEMI and cardiac arrest. The patient was on ECMO for 3 days, had a completely successful cardiac cath, an additional 1-week stay in the ICU and 1-week floor stay. He is now disabled at home and gets around in a wheelchair. Is this cost-effective?

A. YesB. No

ECMO $30,000/day x 3 days + Cath $10,000 + ICU $10,000/day x 7 days + Floor $2,000/day x 7 days = $184,000

Patient may live to age 70. 20 years of life x quality adjustment of 0.5 = 10 QALYs

$184,000 / 10 = $18,400 per QALY

Review Questions6. Cat is treating a non-drinker Somali refugee complaining of

confusion and scleral icterus.

What is the most common route of acquiring viral hepatitis among refugees and immigrants?

Review Questions7. John’s patient has hepatitis B virus, alcoholism, and is newly diagnosed with cirrhosis. What percentage of hepatitis B carriers will go on to develop cirrhosis?

A. 1%B. 5%C. 10%D. 50%E. 90%

Review Questions8. What is the most cost-effective skill for an EMT-Basic to have?

A. CPRB. Bag-valve mask usageC. DefibrillationD. DrivingE. B or C

Review Questions9. True or false, Lovenox is more cost-effective than heparin for acute DVT.

A. TrueB. False