Domain 5:
Economic aspects
Kristian Kidholm
Odense University Hospital,
Denmark
Content
1.
Background
2.
Societal level: Economic evaluation
2.1. Estimation of costs
13/04/2015
3.
Institutional level: Business case
4.
Methods for data collection
5.
Sensitivity analysis
6.
Summary
2
Background
Growth in health care expenditure per capita (%)
The economic situation in european health care:
- Health care cost have been rising more than GDP
- New pharmaceutical product (e.g. cancer)
- Financial crisis – reduced growth
- The population is getting older
Growing need for prioritizing:
1.
2.
3
Growth in GDP per capita (%)
Societal level => need for societal economic evaluation
Health care institutions => need for business case (expenditure – revenue)
Source: OECD Health Data 2009
Societal level: Economic evaluation
Economic evaluation:
• Comparative analysis of alternatives in terms of cost and consequences
Costs
Programme A
Consequences
Choice:
Costs
Programme B
Consequences
Types of economic evaluations:
Cost-minimisation analysis (CMA):
Incremental cost of A
Cost-effectiveness analysis (CEA)
Incremental cost of A per extra unit of outcome
Cost-utility analysis (CUA)
Incremental cost of A per extra QALY
Cost-benefit analysis (CBA
Cost-benefit ratio of A?
4
Societal level: Economic evaluation
Economic evaluation:
• Comparative analysis of alternatives in terms of cost and consequences
Costs
Programme A
Consequences
Choice:
Costs
Programme B
Consequences
Based on data from other domains
Types of economic evaluations:
Cost-minimisation analysis (CMA):
Incremental cost of A
Cost-effectiveness analysis (CEA)
Incremental cost of A per extra unit of outcome
Cost-utility analysis (CUA)
Incremental cost of A per extra QALY
Cost-benefit analysis (CBA
Cost-benefit ratio of A?
5
Estimation of costs
Cost
= the value of resources used (when using telemedicine)
=
Quantities of
resources used
*
Prices
What kind of resource use should be included?
6
- Describe the patient pathways:
- Where are resources used?
Prog. A
Prog. B
-
If the perspective is societal: Include all resources used by
• Hospitals
• The municipality
• The patients
• The relatives
Estimation of costs
Topics and outcomes
Resource use related to delivering telemedicine:
• Investments in equipment etc.
• Training of staff
• Maintenance
• Use of staff (time)
Which outcomes to include?
– Medical doctors
– Nurses
– Etc.
•
•
•
•
•
Medication
Utensils
Patients’ use of time
Relatives’ use of time
Transportation
Where do you expect telemedicine
to cause a positive or negative change?
See 78 examples in the appendix of the MAST Manual
Estimation of costs
Topics and outcomes
Resource use related to changes in use of health care:
•
•
•
•
•
•
Primary care
Emergency unit visits
Outpatient visits
Hospitalisation
Bed days
Tertiary care
Which outcomes to include?
Where do you expect telemedicine
to cause a positive or negative change?
Estimation of costs
Hints - Estimation of costs in practise:
Disregard:
- Costs that are similar for programme A and B (e.g. overhead costs per patient)
- Minor costs, that does not change the results
Collect data for use of resources for each patient:
- If costs are expected to vary
- But not for costs that are the same for all patients (fixed costs)
Should investment be included?
- Yes!
- Estimate “equivalent annual costs”
- Divide costs between different programs
Estimation of costs
Prices:
- Should reflect opportunity costs (forgorne beneits)
In practise:
- Use market prices if possible
- The price of patient time: Use average wage rate (e.g. 50% for retired patients)
Presentation of results:
- Prices for each resource should be presented (e.g. in appendix)
- Increases transferability
Reporting of results
Economic evaluation:
1. Average use per patient of resources in programme A and B
2. Average costs per patient for each resources
3. Total costs per patient
4. Incremental analysis of costs and consequences,
e.g. cost-effectiveness ratio
5. Sensitivity analysis
-
Confidence intervals, P-values (statistical significance)
11
Reporting of results
Reporting of costs of using telemedicine and the alternative
Prog. A.
Average
use
Prog. B.
Average
use
Prog. A.
Average
costs
Prog. B.
Average
costs
Investments in equipment etc.
€
€
Training of staff
€
€
Maintenance
€
€
Use of staff (for each of the relevant type of staff)
€
€
Medication
€
€
Utensils
€
€
Patients’ use of time
€
€
Relatives’ use of time
€
€
Transportation
€
€
Total costs
€
€
Reporting of results
Reporting of changes in use of health care resources
Prog. A.
Average
use
Prog. B.
Average
use
Prog. A.
Average
costs
Prog. B.
Average
costs
Primary care
€
€
Emergency unit visits
€
€
Outpatient visits
€
€
Hospitalisation
€
€
Bed days
€
€
Tertiary care
€
€
Total costs
€
€
Business case
Aim: Estimate Return on Investment for the institution using telemedicine
=
Increase in revenue (money gain)
Expenditures (money invested)
Part 1: Expenditures:
- E.g. increase in the hospitals total expenditures of treating the patient group
Estimation:
- E.g. What is the hospital expenditures related to the use of resources?
-
Business case
Part 2: Changes in revenue
• For public financed hospitals: Changes in reimbursement
Estimation for hospitals:
• Change in DRG-rate
• Change in number of patients
• Change in total reimbursement
Notice:
• Does telemedicine change the DRG-rates per patient?
• Will the DRG rate be changed in the future?
Business case
Presentation of results of the business case:
•
Describe data
•
•
•
Estimate change in expenditure per patient
Estimate change in number of patients
Estimate change in total expenditure
•
•
•
Estimate change in revenue per patient
Estimate change in number of patients
Estimate change in total revenue
•
Sensitivity analysis
Notice:
The result of a business case can be very different from the economic evaluation
Methods for data collection
Generally:
– Criteria for quality of data on economic aspects are similar to criteria for
quality of data on clinical effects
Systematic literature review
New studies:
1. Design: RCT, Cluster RCT, controlled studies
2. Methods for data collection:
– CRF: Case Report Form (used by staff)
– Patient diary
– Interview or questionnaire to patients
– Interview or questionnaire to staff
– Data from hospital registers
17
Sensitivity analysis
Sensitivity analysis:
•
How does the costs change by changes in the parameters?
Example: What if the number of patients is changed?
If you have made large investments
Estimate average cost if no. if patients is increased or decreased
Describes also transferability
Cost per patient
120
100
80
60
Serie1
40
20
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
Number of patients ( * 100)
Summary
1.
Include both societal economic evaluation and business case
2.
Economic evaluation:
Estimate differences in use of all kinds of resources (costs)
Present arguments for choice of outcomes
Collect data for each patient (similar to clinical data)
3.
Business case
- Estimate changes in the institutions expenditures and revenues
4.
Assess sensitivity and transferability of the results
Main reference:
Methods for the Economic Evaluation of Health Care Programmes
(Oxford Medical Publications)
M.F. Drummond, M.J. Sculpher, G.W. Torrance, and B.J. O'Brien
Questions?
www.renewinghealth.eu