cost effectiveness in radiology - by jeffrey shyu
TRANSCRIPT
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Cost-Effectiveness in Radiology
Jeffrey Shyu
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Cost-Effectiveness in Radiology
OIG analysis of Part B data, 2007
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Cost-Effectiveness in Radiology
http://www.ifhp.com/
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Cost Effectiveness in Radiology
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Cost Effectiveness in Radiology
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NLST
• Methods– Three strategies: screening with CT,
screening with XR, no screening– QALY, ICER, cost per person estimates
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NLST
• Results (CT compared to no screening)• Per person:
– Additional $1631– Additional 0.0316 life-years– Additional 0.0201 QALYs– ICERs
• $52,000 per life-year gained• $81,000 per QALY gained
– Wide variability
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Lung Cancer Screening
• McMahon 2011– Up to $169,000/QALY
• Pyenson 2012– Less than $19,000 per life-year saved
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Decision Analysis
• Identify and bound decision problem• Create decision tree• Fill in the tree
– Data collection, expert opinions• Calculate expected value• Sensitivity analysis
– Evaluate uncertainty and test conclusions
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Cost
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Cost Analysis• Direct Costs
– Decision leads to resource utilization directly– CT, staff costs, physician payments, additional workup for
positive results, lung cancer treatment• Medicare Physician Fee Schedule
• Indirect Costs– Changes in resource use leading to increased or decreased
productivity– Opportunity costs (time, etc.)
• BLS data
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSLookup/index.html?redirect=/pfslookup/02_PFSsearch.asphttp://www.bls.gov/news.release/archives/ecec_03102010.pdf
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Cost Analysis
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Effectiveness
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QALYs
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Expected Value• Weighted average of possible values of a random
variable
• Bet on a horse– Probability of winning: 10%– Potential net winnings: $1000– Costs $200 to play
• E(b) = $1000*0.1 - $200*0.9 = - $80
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Expected Value
• Expected value for two different treatment regimens
• Surgery + Medical Treatment• Medical treatment alone
• E(x) = 0.6*40 + 0.3*25 + 0.1*0 = 31.5 QALYs gained• E(y) = 0.7*40 + 0.15*20 + 0.15*0 = 31 QALYs gained
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Standard Gamble
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Time Trade Off
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Measuring and Valuing Outcomes
• Perspectives– Patient– Society
• Health state classification systems– e.g. EQ-5D
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ICER
• Net increase in cost / Net gain in effectiveness
• Additional cost per unit increase in effect• Measure of value of resources• Willingness to pay threshold
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NLST
• Results (CT compared to no screening)• Per person:
– Additional $1631– Additional 0.0316 life-years– Additional 0.0201 QALYs– ICERs
• $52,000 per life-year gained• $81,000 per QALY gained
– Wide variability
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Willingness to Pay Threshold
• $25K per QALY gained?• $50K?• $100K?• $150K?
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Two Kinds of Decisions
• Ultrasound• XR• CT• MRI• PET/CT• PET/MRI
• 81 mg aspirin• 325 mg aspirin• 20 mg statin• 81 mg aspirin +
statin• 325 mg aspirin +
statin
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Shopping Spree
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Competing Choice
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Decision Analysis
• Identify and bound decision problem• Create decision tree• Fill in the tree• Calculate expected value• Sensitivity analysis
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Decision Analysis
• Identify and bound decision problem• Create decision tree• Fill in the tree• Calculate expected value• Sensitivity analysis
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Modeling
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Markov Model
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Markov Model
• Mutually exclusive, collectively exhaustive health states
• Transition probabilities govern movement among states
• Fixed cycle length• Health states with utility value and/or costs
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Decision Analysis
• Identify and bound decision problem• Create decision tree• Fill in the tree• Calculate expected value• Sensitivity analysis
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Case
• Data Search– Probabilities
• Percentage of CTs that find liver masses• True cancer rate• True benign finding (cyst)• False negative rate• False positive rate• Etc…
– Data Quality/Missing Data– Expert Opinion
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Decision Analysis
• Identify and bound decision problem• Create decision tree• Fill in the tree• Calculate expected value• Sensitivity analysis
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Sensitivity Analysis
• How high a false negative rate can you tolerate for this test to be cost-effective?
• How many screening CTs can you perform for this test to be cost-effective?
• What complication rates can you tolerate for ablation to be more cost-effective than nephrectomy for treating RCC?
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Sensitivity Analysis
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Health Care Rationing?
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Health Care Rationing?• (c)(1) The Secretary shall not use evidence or findings from comparative
clinical effectiveness research conducted under section 1181 in determining coverage, reimbursement, or incentive programs under title XVIII in a manner that treats extending the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.
• (e) The Patient-Centered Outcomes Research Institute established under section 1181(b)(1) shall not develop or employ a dollars-per-quality adjusted life year (or similar measure that discounts the value of a life because of an individual’s disability) as a threshold to establish what type of health care is cost effective or recommended. The Secretary shall not utilize such an adjusted life year (or such a similar measure) as a threshold to determine coverage, reimbursement, or incentive programs under title XVIII.
http://www.ssa.gov/OP_Home/ssact/title11/1182.htm
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Challenges
• Variation and uncertainty• Data lacking• Cost estimates challenging• Lack of methodological uniformity• Politically controversial