1 econoqualimetrics edward broughton, phd., mph senior economic analyst, usaid health care...

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EconoqualimetricsEdward Broughton, PhD., MPH

Senior Economic Analyst, USAID Health Care Improvement Project, EnCompass,

USAID HEALTH CARE IMPROVEMENT PROJECT

Objectives

• What are the quality improvement interventions that we evaluate?

• What is cost-effectiveness analysis?

• Why do we do CEAs on QI interventions?

• How do you do CEAs of QI interventions?

• How do you interpret the results?

• What do you do with the results of a CEA?


What are the quality improvement interventions that we evaluate?

• Improvement collaboratives

• Standards-based management

• Client-oriented, provider-efficient (COPE)

• Continuous quality improvement

• others


EONC QI intervention in Niger

• Essential Obstetric and newborn care

• Program to address poor birth outcomes for mothers and children

• Coordinated and supported multiple facility-based teams to overcome barriers to implementation of interventions to reduce PPH and maternal and newborn mortality

• Teams worked on common set of evidence-based care practices, monitored indicators, and met regularly to share successful changes

• Active management of the third stage of labor (AMTSL) and immediate essential newborn care (ENC)

• 25 reference hospitals in 7 of Niger’s 8 regions in 2006. Expanded to 8 primary care maternities.


What is cost-effectiveness analysis?

• A way to measure efficiency of an intervention

• Cost-effectiveness = costs ÷ effects

• Cost-effectiveness ANALYSIS is the cost-effectiveness of one intervention relative to a baseline

• One of many forms of economic analysis. Others include cost-minimization, cost-utility analysis and cost-benefit analysis


Why do cost-effectiveness analysis of QI programs?

• Compare the QI intervention to doing nothing

• Compare one QI intervention to another

• Compare a QI intervention to another health intervention

• Determine what the biggest contribution to the cost-effectiveness of a program is

• Determine whether a program is affordable / sustainable


How to do a CEA

• There is a flu epidemic at and there is a 100% certainty that you will contract the disease

• Cost of the flu vaccine (100% effective) is $15

• Treatment of a case of flu costs $10

• Cost of flu vaccine strategy is:

$15 - $10 = $ 5


Is it cost-effective?

• Incremental cost-effectiveness ratio (ICER) = difference in costs / difference in effects

• ICER = ($ 15 – 10) / (1 – 0)

= $5 / flu case averted

• What if the flu vaccine cost $ 5 ?

• ICER = ($ 5 – 10) / (1 – 0) = – $ 5 /per flu case averted


CEA of EONC QI intervention in Niger

• Answers the question of what are the effects of the intervention on mothers and newborns

• Cost-effectiveness = Cost of the intervention per outcome (birth)

• CEA is cost-effectiveness after the intervention relative to the cost-effectiveness before the intervention

• Active management of the third stage of labor (AMTSL) and immediate essential newborn care (ENC)

• 25 reference hospitals in 7 of Niger’s 8 regions in 2006. Expanded to 8 primary care maternities.


Defining the study

• What is the specific question we are asking?

• From whose perspective are we asking it?

• What is the time-frame?

• What are the outcomes we are considering?


Data

• Costs– Costs of the intervention: HCI/USAID, MOH, (patients)– Change in costs of services (deliveries)– (costs to the MOH if they were doing the intervention)

• Effectiveness– Process measures

• Compliance with treatment standards

– Patient outcomes• PPH, deaths averted

– Composite measures• DALYs, QALYs


Models


Key results: : Cost effectiveness analysis of the EONC QI intervention in Niger

Therefore the MOH implementing the improvement collaborative improves service delivery and maternal outcomes AND saves money

Total cost of QI intervention w HCI and MOH: $ 843,000 or $ 9.45 per deliveryIncremental total cost: $ 217,000 or $ 2.43 per delivery

Total cost of MOH alone: $ 404,000 or $ 4.50 per deliveryIncremental cost: -$ 152,000 or -$ 1.70 per delivery

Average cost per delivery: Before QI: $ 35 After QI: $ 28

Incremental cost-effectiveness

With MoH & HCI & development costs

W. costs for MoH to implement program

Estimate ($) Estimate ($)

Per PPH averted 147 -101

Per additional mother receiving AMTSL 3.48 -2.43

Per child receiving essential neonatal care 3.13 -2.07

Per DALY averted 3.17 -2.23


Cost effectiveness plane

14

Higher cost

Lower cost

More effective

Less effective

Willingness-to-pay threshold

$3.17

-$2.23


Willingness to pay

• For the individual: how much would you be willing to pay for good health / avoid bad health?

• For society: how much have decisionmakers decided to pay for good health / avoid bad health?– UK threshold approx £35,000 (US$55,650)– Australia and NZ about the same– Developing countries: ? Affordability– Use of league tables


Cost effectiveness plane

16

Higher cost

Lower cost

More effective

Less effective

Willingness-to-pay threshold

Accept

Reject

Accept

Reject

Reject

Accept (?)


Interpretation of results

• Intervention cost $843,000 but saved $626,000 therefore the net cost was $217,000 (or $2.43/delivery)

• The relative cost-effectiveness (ICER) is $ 3.17 per DALY averted if HCI does the intervention or …

• …about —$2.23 per DALY averted if MOH does the intervention


But…..

• Efficiency is only one criteria for health resource allocation decisions

• We should consider equity

• We should consider affordability

• We should consider sustainability


Mini-Exam

• Which of the following is true?:A. 0.1 QALYs is better health than 0.1 DALYs

B. 0.1 DALYs is better health than 0.1 QALYs

C. 0.1 QALYs is roughly equivalent health to 0.1 DALYs

D. Not enough information to decide

• If comparing your health program to a baseline, which of the following is true?:A. negative incremental cost-effectiveness ratio is better than positive

B. Positive incremental cost-effectiveness ratio is better than negative

C. The sign on an incremental cost-effectiveness ratio is irrelevant

D. Not enough information to decide


Mini-Exam

• Which of the following is true?:

B. 0.1 DALYs is better health than 0.1 QALYs

• If comparing your health program to a baseline, which of the following is true?:A. negative incremental cost-effectiveness ratio is better than positive

1 econoqualimetrics edward broughton, phd., mph senior economic analyst, usaid health care...

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