On the top of the slide are the logos for the Department of Health & Human Services and the AHRQ logo. The Department of Health & Human Services logo is an artistic image of an eagle with the outlined profile of faces. The AHRQ logo reads, “AHRQ – Agency for Healthcare Research and Quality: Advancing Excellence in Health Care, www.ahrq.gov”
Slide 2
Steps in the ROI calculator
This presentation uses a template with a blue background and a header with the AHRQ and Department of Health & Human Services logos on the left. The header and body of the slide are separated by a light blue horizontal line that traverses 80 percent of the slide from the left.
This slide shows a series of steps in the ROI calculator. The steps include:
- Describe population
- Estimate number of participants
- Estimate baseline utilization or missed work days
- Estimate impact of the asthma program
- Estimate program cost
ROI
User choices about the asthma program are the user data that is used in at all five steps. Meta-analysis occurs at steps 4 and 5.
Slide 3
Data Sources
- Demographics of populations
- Medicaid (CMS 2003)
- Employer sponsored health insurance (CPS 2003-2005)
- State employees (Employees from BLS 2003-2005)
- Large, nationwide, medical claims database (MarketScanTM)
- Prevalence rates
- Utilization and costs for asthma patients
- Literature review
- Impact of asthma care programs
- Cost to implement asthma care programs
Slide 4
Example
- Based on default values of the calculator when calculator is opened
- Asthma care program for children and adults with persistent asthma for Medicaid programs (nationwide)
Slide 5
Population
This slide contains a screen shot of the Population page from AHRQ's Asthma Care ROI calculator. Users are prompted to select the type and geography of the general population (people with and without asthma).
Slide 6
Participants
This slide contains a screen shot of the Participants page from AHRQ's Asthma Care ROI calculator. The screen prompts the user to select the age group and asthma severity to target for a quality improvement program. Next, the user is to review the number of people eligible for the program and the percent expected to participate in the program.
Slide 7
Asthma Definitions
All Asthma
-Patient has at least one claim with asthma as a primary or secondary diagnosis during the year (ICD-9-CM code 493.xx)
Persistent asthma*
-One or more of the following is true using one year of data:
a) ED visit or inpatient admission with asthma diagnosis
b) 4 outpatient visits and at least 2 asthma medication fills
c) 4 asthma medication fills, if all 4 fills for leukotrienes, then must have at least 1 claim with an asthma diagnosis
Persistent asthma* with acute visit
-Met criteria a) for persistent asthma
* Similar to HEDIS definition, differs in that only 1 year of data is used.
Asthma medications include: Antiasthmatic combinations, Bronchodilator combinations, Inhaled anticholingerics, Inhaled coricosteroids, Leukotriene modifiers, Long acting adrenergic bronchodilators, Mast cell stabilizers, Methylxanthines, Short acting adrenergic bronchodilators, Corticosteroid tablets or syrup (oral corticosteroid)
Slide 8
Baseline Data
This slide contains a screen shot of the Baseline Data page from AHRQ's Asthma Care ROI calculator. Two decisions must be made on the page: 1) Select a treatment definition and cost perspective for calculating results, and 2) Review the baseline utilization and cost estimates.
Slide 9
Program Impact
This slide contains a screen shot of the Program Impact page from AHRQ's Asthma Care ROI calculator. The page shows the impact estimates from a meta-analysis of the research literature on asthma quality improvement and disease management. Both healthcare measures, such as program impact on emergency department visits, and productivity measures, such as program impact on missed work days per adult, can be assessed using this tool.
Slide 10
Program Cost
This slide contains a screen shot of the Program Cost page from AHRQ's Asthma Care ROI calculator. The page shows four decisions that will affect calculations of the cost of the program to be implemented:
- Length of operation planned for the program
- Time until the full-impact of program is expected
- Cost of the program per person per year (consider changing based on costs estimates for a specific programs from vendors).
- Discount rate for valuing savings and costs that occur in different years
Slide 11
Results
This slide contains a screen shot of the Results page from AHRQ's Asthma Care ROI calculator. The page shows the impact of the asthma program and summarizes prior assumptions made in the calculator. Two decisions must be made on this page: 1) Whether to include health care savings, productivity gains, or both. 2) Whether to report results per participant or per program.
Slide 12
Undiscounted Results per Person for the User-Specified Program Tabulated by Outcome Measure and Year
This slide contains a screen shot of the Undiscounted Results per Person for the User-Specified Program page from AHRQ's Asthma Care ROI calculator. The page shows the annual utilization and cost per patient for emergency department visits, hospital confinements, outpatient visits, emergency department cost, hospital confinement cost, outpatient cost, asthma-specific ancillary cost, asthma medication cost, missed work days for adults, missed school days for children, productivity cost for adults, and productivity cost for caregivers. The data can be calculated for years 2007 to 2012. Data for 2007 represent the baseline period before the program is implemented.
Slide 13
Literature Review Methods
- Inclusion criteria
- Characteristics of included studies
- Calculation of outcome (impact of the program)
- Analysis
Slide 14
Study Inclusion Criteria
- Studies searched (76 studies met criteria):
- Asthma care quality improvement: Physician & patient training—written asthma action plan, etc. (not drug efficacy)
- U.S. studies: 1995 thru 2006
- Populations: Children and adults under 65
- Studies: Individual interventions (not meta-analyses or editorials)
- Impact period: 6+ months
- Impact: Use or cost of medical care services and productivity (not asthma knowledge or quality of life)
- Insurance: All types
Slide 15
Abstracting literature
Details recorded
- Characteristics of studies and patients (e.g., asthma severity)
- Baseline utilization and cost by patients in the studies
- Impact of program on percent change in visits or days (for default values)
Slide 16
Included studies
The 52 studies report 261 pieces of information
- Related to service utilization and productivity
- For children, adults or both
- With multiple items (e.g., on ED visits, if the study reported results separately for children and adults)
Outcomes (number of related study results)
Emergency department visits (90)
- Hospital stays (75)
- Outpatient visits (57)
- Medication costs (12)
- Cost of ancillary services (3)
- Missed work or school days due to asthma (24)
Slide 17
Study Characteristics
Useable means study had to report average visit rates, missed days, or cost (not just percent with event)
Most useable studies:
- Had a control group (56%); many had randomized controls (38%)
- Involved patient self-management (85%) and regular medical management (58%); many had a written asthma action plan (40%)
- Focused on children only (46%)
- Focused on populations with persistent asthma (55%)
Persistent asthma = subjects met HEDIS criteria OR had 2 or more hospital or ED visits at baseline
- Had mixed insurance coverage (79%)
Slide 18
Included Studies and Patients (includes patients in treatment and control groups)
This slide shows the number of patients and studies for children only, adults only, both, and total. The cost components for each of these groups are ED visits, hospitalizations, outpatient visits, missed work/school days, medication cost, ancillary service cost, total direct cost, and total indirect cost.
These data indicate that more patients and studies on children are included, with the most patients and studies on children only, studying ED visits, hospitalizations, and outpatient visits.
Slide 19
Study Designs
Randomized controlled trial (RCT) studies
- Standard for clinical efficacy
- More likely to be accepted by clinicians—main target of QI programs
Statistically controlled studies
- Much larger samples with greater precision
- Can control for more patient and setting attributes than RCTs
Studies without a control group
- Included for showing importance of the study design in measuring outcomes accurately
- For a preliminary benchmark that can guide a program in its early days about its success or failure
NOTE: Results are available for each design type
Slide 20
Program impact calculations
All studies
- Pre-post treatment comparison
Controlled
- Post treatment-to-control comparison
- Net change pre-post, treatment-to-control comparison
Example calculation
ED visits per person per year
Before intervention
Treatment group: 4
Control group: 4
After intervention
Treatment group: 2
Control group: 3
Pre-post treatment: (2-4) / 4*100 = -50%
Post treatment-to-control: (2-3) / 3*100 = -33%
Net change: [(2-4) / 4*100] - [(3-4) / 4*100] = -50% - (-25%) = -25%
Slide 21
Analysis of Results
Regressions: study-result outcomes regressed on study population and design features
- Ys: ED visits, hospitalizations, outpatient visits,missed work/school days, and medication costs
- Xs: Study population, study design, sample size, length of study, and contact with the physician or patient
- Bs: Average impact of each study feature on Ys, controlling for other Xs
Other issues:
- Standard errors adjusted for multiple results per study
- Studies weighted equally, by using inverse of number of results per study as weight on each study-result observation
- Ancillary services not analyzed in regression context, due to the small number of studies
Slide 22
Selected literature reviews
Bernard-Bonnin, A.-C., S. Stachenko, D. Bonin, C. Charette, and E. Rousseau. 1995. “Self-management teaching programs and morbidity of pediatric asthma: A meta-analysis.” J Allergy Clin Immunol 95(1):34.
Krause, D. D. 2005. “Economic Effectiveness of Disease Management Programs: A Meta-Analysis.” Disease Management 8(2):114-34.
Lee, T. A. and K. B. Weiss. 2002. “An update on the health economics of asthma and allergy.” Current Opinion in Allergy and Clinical Immunology 2(3):195-200.
Sullivan, S. D. and K. Weiss. 2001. “Health economics of asthma and rhinitis. II. Assessing the value of interventions.” Current reviews of allergy and clinical immunology 107(2):203-10.
Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. 2007. “Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies/ Vol 5: Asthma Care.” Technical Review 9 (AHRQ 04(07)-0051-5).
Smith, J. R., M. Mugford, R. Holland, B. Candy, M. J. Noble, B. D. W. Harrison, M. Koutantji, C. Upton, and J. Smith. 2005. “A systematic review to examine the impact of psycho-educational interventions on health outcomes and costs in adults and children with difficult asthma.” Health Technology Assessment 9(23):1
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