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PART I Value Added Care: Definitions and Choosing Wisely Dmitry Dukhovny, MD MPH Instructor PART I Value Added Care: Definitions and Choosing Wisely Dmitry Dukhovny, MD MPH Instructor in Pediatrics, Harvard Medical School Neonatologist, Beth Israel Deaconess Medical Center QI/Teaching Value Curriculum November 27, 2012

Acknowledgment n Carl J. Shapiro Institute for Education and Research at BIDMC n John Acknowledgment n Carl J. Shapiro Institute for Education and Research at BIDMC n John Zupancic n De. Wayne Purlsey n Jane Smallcomb n EPIC – Economics in Perinatalogy Investigators’ Collaborative

Conflicts of Interest n. I have no conflicts of interest Conflicts of Interest n. I have no conflicts of interest

Objectives 1. To understand the rationale for and approaches to studying costs in pediatrics Objectives 1. To understand the rationale for and approaches to studying costs in pediatrics 2. To understand the key definitions of economic analyses 3. To “choose wisely”

Agenda n PART I November 27 th, 2012 – Basics and Definitions of Cost-Effectiveness Agenda n PART I November 27 th, 2012 – Basics and Definitions of Cost-Effectiveness Analysis – Choosing Wisely Approach n PART II February 12 th, 2013 – Costs and Charges: Where to Begin? – Case discussions

Development and Implementation of “Choosing Wisely”: A Practical, Multidisciplinary Approach Development and Implementation of “Choosing Wisely”: A Practical, Multidisciplinary Approach

What is it? n Teaching Value Added Care n Multidisciplinary n Fellow Approach at What is it? n Teaching Value Added Care n Multidisciplinary n Fellow Approach at BIDMC NICU Education and Involvement

Fellow Opportunities n Adding a value component to the QI Curriculum n Starting project Fellow Opportunities n Adding a value component to the QI Curriculum n Starting project in projects/adding value to QI n Opportunity to work with the BIDMC NICU Group on a project n Opportunity to start or continue current project you are working on

Why Now? n Part of ACGME Next Accreditation System (NAS) – to be initiated Why Now? n Part of ACGME Next Accreditation System (NAS) – to be initiated July 2013 (probably later) – … “physicians demonstrate competence in efficient and costeffective health care” n Critical time in health care

Big Picture n Goal: not to make you a health economist, BUT to help Big Picture n Goal: not to make you a health economist, BUT to help increase and enhance understanding about healthcare costs n Individualize it to the fellows interests n Make it practical: – You can actually do a project (either now or as an attending in your first job) – Understand the published literature in health economics that pertains to the NICU

Time Line n 11 month cycle Nov 2012 – October 2013 – But hope Time Line n 11 month cycle Nov 2012 – October 2013 – But hope to continue beyond n 2 Part Workshop in Nov-Feb n Pre-implementation Survey n Development of Value Audits n Decide on 2 tests/procedures in the BIDMC NICU to reduce waste (Feb-July)

Cost of Health Care Figure 1 from Davis K. N Engl J Med 2008; Cost of Health Care Figure 1 from Davis K. N Engl J Med 2008; 359: 1751 -1755

Relatively speaking… Image from http: //www. takepart. com/blog/2009/10/09/how-the-american-health-care-system-stacks-up/ Relatively speaking… Image from http: //www. takepart. com/blog/2009/10/09/how-the-american-health-care-system-stacks-up/

Projected US Health Care Truffer, et al. Health Affairs, March 2010 Projected US Health Care Truffer, et al. Health Affairs, March 2010

U. S. Per Capita Health Expenditures: 1950– 2007 Fuchs VR. N Engl J Med U. S. Per Capita Health Expenditures: 1950– 2007 Fuchs VR. N Engl J Med 2012; 366: 973 -977.

International Health Care Spending: 1980 -2007 Note: $US PPP = purchasing power parity. Source: International Health Care Spending: 1980 -2007 Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009) (from the Commonwealth Fund: “Mirror on the Wall” June 2010 Report).

Commonwealth Fund 2010 Report Commonwealth Fund 2010 Report

Average Annual Per Capita Spending for Patients with Different Numbers of Chronic Conditions (United Average Annual Per Capita Spending for Patients with Different Numbers of Chronic Conditions (United States) Bodenheimer T, et al. NEJM 2009; 361: 1521 -1523 Schmidt B, et al. . JAMA 2003; 289(9): 1124 -9

Potential Approach Figure 1 from Drummond, et al. Int J Technol Assess Health Care. Potential Approach Figure 1 from Drummond, et al. Int J Technol Assess Health Care. 2008; 24(3).

The Rationale SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic The Rationale SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

What Factors Affect Health? Organism ? Health Environment ? Access SPR Workshop: Dollars and What Factors Affect Health? Organism ? Health Environment ? Access SPR Workshop: Dollars and Sense Delivery of ? Technology Efficacy of ? Medical Technology Funding © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

What Factors Affect Health? Organism Health Environment Access SPR Workshop: Dollars and Sense Delivery What Factors Affect Health? Organism Health Environment Access SPR Workshop: Dollars and Sense Delivery of Technology Efficacy of Medical Technology Funding © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Beyond the Limits to Health? Organism Health Environment Access SPR Workshop: Dollars and Sense Beyond the Limits to Health? Organism Health Environment Access SPR Workshop: Dollars and Sense Delivery of Technology Efficacy of Medical Technology Funding © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Beyond the Limits to Health? Organism ? ? ? Health Environment Government Efficacy of Beyond the Limits to Health? Organism ? ? ? Health Environment Government Efficacy of Medical Technology Public Health Imagineering Hospital EBM Access Reallocate between individuals SPR Workshop: Dollars and Sense Delivery of Technology Funding Increase premiums, taxes Improve efficiency © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Expenditure Units ($) Efficiency 1. 50 0. 25 1. 50 0. 50 2. 25 Expenditure Units ($) Efficiency 1. 50 0. 25 1. 50 0. 50 2. 25 1. 50 1. 00 Health Units 4. 50 Other social goals 1. 75 2. 25 4. 50 3. 50 OR 0. 75 1. 50 SPR Workshop: Dollars and Sense 2. 25 1. 75 © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Framing and the Analytic Approach SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Framing and the Analytic Approach SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Framing: Type of Analysis CONSEQUENCE SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Framing: Type of Analysis CONSEQUENCE SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Framing: Type of Analysis COST CONSEQUENCE SPR Workshop: Dollars and Sense © 2012 Dukhovny, Framing: Type of Analysis COST CONSEQUENCE SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

What does it mean for something to be “Cost Effective” ? What does it mean for something to be “Cost Effective” ?

Definitions n “economical in terms of tangible benefits produced by money spent” n “cost Definitions n “economical in terms of tangible benefits produced by money spent” n “cost effective describes something that is a good value, where the benefits and usage are worth at least what is paid for them”

Cost-Effective ≠Cost-Saving Cost-Effective ≠Cost-Saving

Framing: Type of Analysis n Costing “Incomplete” Economic Evaluations n Cost-minimization n Cost-effectiveness n Framing: Type of Analysis n Costing “Incomplete” Economic Evaluations n Cost-minimization n Cost-effectiveness n Cost-utility “Complete” Economic Evaluations n Cost-benefit SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Cost-Effectiveness Analysis n Cost-effectiveness study – COST: § Intervention – CONSEQUENCE: § Quantifiable outcome Cost-Effectiveness Analysis n Cost-effectiveness study – COST: § Intervention – CONSEQUENCE: § Quantifiable outcome – Lives saved, life years saved, BP points reduced, hours of crying – OUTCOME MEASURE: § Cost per consequence (cost per life saved, etc. ) – PROBLEM: § How to compare different outcomes for different interventions? SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

Cost-Effectiveness Study Costs of Treatment A – Costs of Treatment B Cost-Effectiveness = SPR Cost-Effectiveness Study Costs of Treatment A – Costs of Treatment B Cost-Effectiveness = SPR Workshop: Dollars and Sense Effects of Treatment A – Effects of Treatment B © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

The Cost-Effectiveness Plane Diff in Cost + - + Diff in Effectiveness - SPR The Cost-Effectiveness Plane Diff in Cost + - + Diff in Effectiveness - SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

The Cost-Effectiveness Plane Diff in Cost * Dominated + - + Diff in Effectiveness The Cost-Effectiveness Plane Diff in Cost * Dominated + - + Diff in Effectiveness - SPR Workshop: Dollars and Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

The Cost-Effectiveness Plane Diff in Cost * Dominated + - + Diff in Effectiveness The Cost-Effectiveness Plane Diff in Cost * Dominated + - + Diff in Effectiveness - SPR Workshop: Dollars and Sense Dominant * © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

The Cost-Effectiveness Plane Diff in Cost * Dominated + * * *+ Diff in The Cost-Effectiveness Plane Diff in Cost * Dominated + * * *+ Diff in Effectiveness - SPR Workshop: Dollars and Sense Dominant * © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

The Cost-Effectiveness Plane Diff in Cost * Dominated + * * *+ Diff in The Cost-Effectiveness Plane Diff in Cost * Dominated + * * *+ Diff in Effectiveness - SPR Workshop: Dollars and Sense Dominant * © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

i. CER Plot: Postpartum Depression 95% * i. CER Plot: Postpartum Depression 95% *

Choosing Wisely n Initiative of ABIM Foundation (Advancing Medical Professionalism to Improve Health Care) Choosing Wisely n Initiative of ABIM Foundation (Advancing Medical Professionalism to Improve Health Care) n Encourages physicians, patients and other stakeholders to think about unnecessary tests and procedures n “Five Things Physician and Patients Should Question” http: //choosingwisely. org/

Next Steps n Break up into groups n Identify 1 to 2 items AND/OR Next Steps n Break up into groups n Identify 1 to 2 items AND/OR n Think about a value component to your QI project

Criteria – There is evidence in the literature that the test does not improve Criteria – There is evidence in the literature that the test does not improve patient outcome – There is insufficient evidence that the test improves patient outcome – The test unnecessarily utilizes staffing or material resources (i. e. , the test is a waste of staff time or resources)

Small Groups n Choose 1 – 2 items n Answer the following questions: – Small Groups n Choose 1 – 2 items n Answer the following questions: – WHY – POTENTIAL HARM – POTENTIAL BARRIERS – HOW

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