Скачать презентацию Interactive session design cost effectiveness Jan J Скачать презентацию Interactive session design cost effectiveness Jan J

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Interactive session design cost effectiveness • Jan J. v. Busschbach, Ph. D. • Erasmus Interactive session design cost effectiveness • Jan J. v. Busschbach, Ph. D. • Erasmus MC – Institute for Medical Psychology and Psychotherapy PO Box 1738 3000 DR Rotterdam +31 10 4087807 J. [email protected] nl • Psychotherapeutic centre 'De Viersprong’ – PO Box 7 4660 AA Halsteren + 31 164 632200 Jan. [email protected] nl • Presentations can be found at – http: //www. xs 4 all. nl/~jannetvb/busschbach/ 1

Questions to be solved; • Who is the audience? – Who’s perspective? • • Questions to be solved; • Who is the audience? – Who’s perspective? • • Should we evaluated at all? What are the costs? What are the effects? How do effects relate to the costs in practice? – Model • Who to interpret the cost effectiveness ratio? 2

The societal perspective • Standard in health economics • Determine cost (and effects) from The societal perspective • Standard in health economics • Determine cost (and effects) from the societal viewpoint – Resource used by all parties concerned – The cost for society as a whole • No matter who paying • Other perspectives are possible – Insurance, government, hospital, patient, industry, doctor

When to evaluated? When to evaluated?

Tariffs • Cutback operation, correction of anus anterior – Small operation – Halve hour Tariffs • Cutback operation, correction of anus anterior – Small operation – Halve hour – Tariff: 1571 Euro • Posterior Saggital Anorectoplasty (PSARP) – Large operation – 3 to 5 hours – Tariff: 374 Euro

Cost price investigations • Measure only volumes of major costs drivers • Estimated “real Cost price investigations • Measure only volumes of major costs drivers • Estimated “real market prices” – One should include all resources used » The societal perspective – Shadow pricing • Tariffs are only used in health economics – If they are a reasonable accurate indication of the resources used – If they are a small proportion of the total costs – If they volumes do not contribute to the incremental costs » (the difference between to alternative programs)

We are in need of uni-dimensional effects • For instance: – $ 10, 000. We are in need of uni-dimensional effects • For instance: – $ 10, 000. 1 hip transplantation – $ 15, 000 , 1 wheelchair • Costs can be compared – Are uni-dimensionaal • Effects are less easy to compare – Effects are multi-dimensional • How to make the effects also uni-dimensional? 7

How to make the effects unidimensional? • Three methods – Cost Benefit Analysis » How to make the effects unidimensional? • Three methods – Cost Benefit Analysis » Express effects in money – Cost Effectiveness Analysis » Focus on one effect – Cost per QALY Analysis (Utility) » QALY 8

QALY league table 9 QALY league table 9

Visual Analogue Scale • VAS Normal health – Also called category scaling • From Visual Analogue Scale • VAS Normal health – Also called category scaling • From psychological research • “How is your quality of life today ? ” • “X” marks the spot X – Response in centimeters – Rescale to [0. . 1] • Different anchor point possible: – Normal health (1. 0) versus dead (0. 0) – Best imaginable health versus worse imaginable health Dead 10

Time Trade-Off • TTO • Wheelchair – With a life expectancy: 50 years • Time Trade-Off • TTO • Wheelchair – With a life expectancy: 50 years • How many years would you trade-off for a cure? – Max. trade-off is 10 years • QALY(wheel) = QALY(healthy) – Y * V(wheel) = Y * V(healthy) – 50 V(wheel) = 40 * 1 • V(wheel) =. 8 11

The Euro. Qol EQ-5 D • MOBILITY – I have no problems in walking The Euro. Qol EQ-5 D • MOBILITY – I have no problems in walking about – I have some problems in walking about – I am confined to bed • SELF-CARE – I have no problems with self-care – I have some problems washing or dressing myself – I am unable to wash or dress myself • USUAL ACTIVITIES (e. g. work, study, housework family or leisure activities) – I have no problems with performing my usual activities – I have some problems with performing my usual activities – I am unable to perform my usual activities • PAIN/DISCOMFORT – I have no pain or discomfort – I have moderate pain or discomfort – I have extreme pain or discomfort • ANXIETY/DEPRESSION – I am not anxious or depressed – I am moderately anxious or depressed – I am extremely anxious or depressed 12

Validated Questionnaires • Describe health states • Have values from the general public – Validated Questionnaires • Describe health states • Have values from the general public – – – Rosser QWB 15 D HUI Mark 2 HUI Mark 3 Euro. Qol EQ-5 D 13

Patient Perspective 14 Patient Perspective 14

The Societal Perspective 15 The Societal Perspective 15

How to get these societal values? • Patient fills in questionnaire • Choose the How to get these societal values? • Patient fills in questionnaire • Choose the value function from the literature • Calculate societal value COMPUTE MVH_A 1 = 1. VARIABLE LABELS MVH_A 1 'York A 1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ). RECODE MVH_A 1 (1 = SYSMIS). END IF. IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A 1 = MVH_A 1 -. 081. IF (mo = 2) MVH_A 1 = MVH_A 1 -. 069. IF (mo = 3) MVH_A 1 = MVH_A 1 -. 314. IF (sc = 2) MVH_A 1 = MVH_A 1 -. 104. IF (sc = 3) MVH_A 1 = MVH_A 1 -. 214. IF (ua = 2) MVH_A 1 = MVH_A 1 -. 036. IF (ua = 3) MVH_A 1 = MVH_A 1 -. 094. IF (pd = 2) MVH_A 1 = MVH_A 1 -. 123. IF (pd = 3) MVH_A 1 = MVH_A 1 -. 386. IF (ad = 2) MVH_A 1 = MVH_A 1 -. 071. IF (ad = 3) MVH_A 1 = MVH_A 1 -. 236. IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A 1 = MVH_A 1 -. 269. 16

An example of a value function * SPSS syntax Dolan 1997, Medical Care, 1997; An example of a value function * SPSS syntax Dolan 1997, Medical Care, 1997; 35: 1095 -108. * mo = mobility, sc= self care, ua = usual activities, pd = pain & discomfort , ad = anxiety and depression. COMPUTE MVH_A 1 = 1. VARIABLE LABELS MVH_A 1 'York A 1 tariff'. DO IF (NVALID(mo, sc, ua, pd, ad) < 5 ). RECODE MVH_A 1 (1 = SYSMIS). END IF. IF (MAX(mo, sc, ua, pd, ad) > 1) MVH_A 1 = MVH_A 1 -. 081. IF (mo = 2) MVH_A 1 = MVH_A 1 -. 069. IF (mo = 3) MVH_A 1 = MVH_A 1 -. 314. IF (sc = 2) MVH_A 1 = MVH_A 1 -. 104. IF (sc = 3) MVH_A 1 = MVH_A 1 -. 214. IF (ua = 2) MVH_A 1 = MVH_A 1 -. 036. IF (ua = 3) MVH_A 1 = MVH_A 1 -. 094. IF (pd = 2) MVH_A 1 = MVH_A 1 -. 123. IF (pd = 3) MVH_A 1 = MVH_A 1 -. 386. IF (ad = 2) MVH_A 1 = MVH_A 1 -. 071. IF (ad = 3) MVH_A 1 = MVH_A 1 -. 236. IF (MAX(mo, sc, ua, pd, ad) > 2) MVH_A 1 = MVH_A 1 -. 269. 17

Some values • Broken arm • 12211 – – – no problems in walking Some values • Broken arm • 12211 – – – no problems in walking about some problems washing or dressing some problems with performing usual activities no pain or discomfort not anxious or depressed • Societal value = 0. 779 18

Some values • Broken hip • 22222 – – – some problems in walking Some values • Broken hip • 22222 – – – some problems in walking about some problems washing or dressing some problems with performing usual activities moderate pain or discomfort moderately anxious or depressed • Societal value = 0. 516 19

Outcome Research • Clinical research – Does it work? – Efficacy – Perfect patient Outcome Research • Clinical research – Does it work? – Efficacy – Perfect patient » No co morbidity • Outcome research – Does it work in practice – Effectiveness – Every day patient » Normal co morbidity • Randomized Clinical Trial • Trials in a naturalistic setting – Controlled conditions – Real life conditions 20

Trial versus Clinical Practise • • • Subject homogeneity Double blind Placebo comparison Forced Trial versus Clinical Practise • • • Subject homogeneity Double blind Placebo comparison Forced compliance Fixed procedures High motivation • • • Representativeness Open treatment Usual care Real compliance Flexible procedure Daily motivation 21

Trial versus Clinical Practise • Validity – High internal – Low external • Increase Trial versus Clinical Practise • Validity – High internal – Low external • Increase validity by – Search for large deviations of practice – Model outcomes to practice • Modelling – Use trial effect – Add external elements • Validity – Log internal – High external • Increase validity by – Search for causal relations – Model outcomes to new situation • Modelling – Use natural history – Add effect 22

Modelling depression Depressive patient Cure Sex Age Number of relapses suicide Duration of illness Modelling depression Depressive patient Cure Sex Age Number of relapses suicide Duration of illness Natural death Still depressive 23

Books • Oostenbrink, J. B. , M. A. Koopmanschap, et al. – Books • Oostenbrink, J. B. , M. A. Koopmanschap, et al. – "Handleiding voor Kostenonderzoek. Methoden en Richtlijnprijzen voor Economische Evaluaties in de Gezondheidszorg. ” 2000, College voor Zorgverzekeringen • Rutten-van Mölken MPMH, Busschbach JJV, Rutten FFH. – Van Kosten tot Effecten: Een Handleiding voor Evaluatiesstudies in de Gezondheidszorg. Elsevier Gezondheidszorg, Maassen, ISBN: 90 352 2281 4. Zomer 2000 24