Health Economics in Clinical Practice

Guidelines: The Know-Do Gap

Ann Scott, Carmen Moga,

Christa Harstall

April 16, 2019

Disclosure

I have no actual or potential conflict of

interest in relation to this topic or

presentation.

The Ambassador Guideline Adaptation and Development Program

• Started in 2004 as a knowledge

translation strategy for promoting

the use of current research evidence

to encourage and support best

practice in pain management across

Alberta

• Program for moving research evidence into practice by:

– Increasing clinician knowledge about best evidence

– Encouraging clinicians to incorporate research evidence into practice

• Evolved into a guideline adaptation program that has since expanded into other areas beyond the original chronic pain remit

Objectives

1. Forecasting economic impact during guideline

construction

– How to incorporate economic information into the construction of

guideline recommendations

– How to forecast the potential economic ramifications of guideline

recommendations

2. Measuring economic impact after guideline

implementation

– Create an inventory of methods for evaluating the economic impact

of guidelines

Outline of Methods

• Forecasting economic impact during guideline construction

– Theoretical frameworks

o Guidance from internationally recognized standards (IOM, GIN, AGREE)

o Literature search

– Practical methods

o Guideline sample from adaptation process for low back pain

o Guideline manuals (CMA, CTFPS, NICE, NHMRC, USPSTF, WHO)

o Literature search

• Measuring economic impact after guideline implementation

– Modeling and “real world” studies

o Literature search

Studies published in 2005, 2007, 2009, 2011, and 2013

Interventions for prevention, diagnosis, and treatment

Results

Forecasting

economic

impact

What we’re supposed to be doing…

Theoretical Frameworks

• AGREE II tool (criterion #20)

– Involve appropriate experts in finding and

analyzing the cost information

– Report economic consequences of implementing

CPG recommendations (if applicable)

– Describe methods by which the cost information

was sought (e.g. inclusion of health economist in

GDG)

– Identify the types of cost information considered

(e.g. economic evaluations, drug acquisition cost)

• G-I-N

– Include information on cost, if possible

– Templates for health economic assessment are

under development

• IOM

– No information available

Results

Forecasting

economic

impact

What we’re supposed to be doing…

Theoretical Frameworks

• Peer reviewed literature (n=6) key themes

– GDG should include a health economist

– Health economist’s role is to analyze and educate

– Discuss economic aspects in parallel not post hoc

– Only include resource aspects when necessary

– Present analyses in natural units (e.g. days in

hospital)

– Patient/carer costs only important with respect to

compliance

– Focus on “barrier” and “balanced” interventions

– Not always necessary in “simple” guidelines

– Published analyses are of limited use

– Keep models simple and transparent

Results

Forecasting

economic impact

What we are doing…

Selected guideline development groups

• Australia (NHMRC), Canada (CMA, CTFPHC), UK

(NICE), USA (USPSTF), international (WHO) main

messages:

– Include economists or experts in health

economics to advise on search strategies,

conduct analyses, and interpret relevant

economic data; include a separate decision

modelling support team; commission the work

if needed

– Conduct full economic evaluation (cost-

effectiveness, cost-utility, cost-benefit

analyses), conduct new modelling studies, or

provide contextual information regarding costs

– Recommend interventions that increase

effectiveness at an acceptable level of

increased cost

– Describe resource implications and economic

consequences of recommended practice

– Use a health care payer or societal perspective

Results

Forecasting

economic

impact

What we are doing…

Peer reviewed literature

• 3 SRs of over 300 CPGs (1985-1998)

– 14% to 30% considered costs

• 1 review of 30 largest US physician

specialty societies (CPGs 2008-2012)

– 57% considered costs, half of which used an

explicit methodology

– Usually for risk factor reduction or preventive care

• 1 SR of over 16 CPGs (2003-2015)

– “Cost effectiveness” mentioned 14 times

– Increasing trend over time

• 1 SR of over 100 most cited CPGs in the

NGC (2014)

– 43% considered costs and utilized only 6% of the

relevant available cost analyses

– Factors likely to increase use: quality,

transparency, direct association of costs to patient

outcomes

Results

Forecasting

economic

impact

What we are doing…

• Seed guidelines from Ambassador Program

Sample of 12 CPGs (1st + 2nd edition LBP

CPG)

– No economic experts were involved in

CPG development

– Narrative synthesis of studies on

economic evaluation in 9 CPGs

– Perspective of analysis was reported in

six CPGs: societal, provider, purchaser

(n=2), health system (n=4)

– Four recommendations on economic

aspects were reported in two CPGs

Results

Measuring

economic

impact

Modeling studies (n=45)

• Majority conducted by non-stakeholders or

guideline developers/implementers (76%)

• Perspective: 3rd party payer (64%), provider

(13%), societal (9%)

• Around half (56%) specified a willingness-to-pay

threshold

• 7% (3 studies) evaluated capacity effects

CEA 20%

Cost Analysis 27%

CEA & Cost Analysis

11%

CEA & Cost Utility 40%

Other 2%

Type of Analysis

Results

Measuring

economic

impact

Mapping studies (n=38)

• Post hoc comparison of guideline practice

• Majority conducted by non-stakeholders or

guideline developers/implementers (79%)

• Perspective: 3rd party payer (63%), provider

(24%), societal (8%)

• 5% specified a willingness-to-pay threshold

• 8% (3 studies) evaluated capacity effects

CEA 8%

Cost Analysis 89%

CEA & Cost Analysis

3%

Type of Analysis

Results

Measuring

economic

impact

“Real world” studies (n=43)

• Majority conducted by non-stakeholders or

guideline developers/implementers (93%)

• Perspective: provider (53%), 3rd party payer

(37%)

• 9% (4 studies) evaluated capacity effects

Retrospective Pre-test/Post-test

42%

Prospective Pre-test/Post-test

25%

Prospective Comparison

21%

Retrospective Comparison

4%

Other 8%

Study Types

CEA 9%

Cost Analysis 72%

CEA & Cost Analysis

2%

CEA & Cost Utility 12%

Other 5%

Type of Analysis

• Use health economic analyses

wisely; focus on “problem”

areas only

• Get help

• Keep it simple

• Use a healthcare payer or

societal perspective

• Don’t forget to consider

capacity effects

• Steer away from published

analyses unless you need

modeling inputs

• There is no “ideal” method for

measuring economic impact

Key Messages

for Guideline Developers

capstone@shaw.ca 1.780.448.4881 www.ihe.ca