Potential Impact of Implementing Research Findings: Modeling Approach Implementing PCOR Results to Inform Choices and ANIRBAN BASU Improve Healthcare Delivery basua@uw.edu Monday, June 25 th @basucally Academy Health, Seattle 2018
Acknowledgements Joint work by Blythe Adamson, Ph.D. & Anirban Basu, in collaboration with PCORI research staff, Joanna Siegel and William Lawrence Funded by PCORI Work carried out under Salutis Consulting LLC
Goal Understanding the Potential Benefits of Implementing Research Findings
Key features of demonstration > Common modeling framework across multiple disease conditions and interventions > Impact estimates for different stakeholders > Not a conversation about value… but enumerating costs and consequences
Four Studies (Selected by PCORI) 1. ANTIBIOTIC STUDY ( Keren et al. JAMA Ped 2015 ): Antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally for post-discharge treatment of children with acute osteomyelitis or complicated pneumonia using 2. STROKE STUDY ( Xian et al. BMJ 2015 ): Warfarin versus to anticoagulation among anticoagulation naïve elderly acute ischemic stroke patients, who are discharged alive with documented persistent or paroxysmal atrial fibrillation/flutter 3. DIABETES STUDY ( Young et al. JAMA Int Med 2017 ) Use of self- monitor blood glucose (SMBG) for non-insulin-treated patients with type 2 diabetes 4. CHEST PAIN STUDY ( Hess et al. BMJ 2016 ): Shared decision-making using a decision aid with usual care in the choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome
A COMMON MODEL US population for whom Patient ‐ comparative ‐ effectiveness centered results are generalizable outcomes* Time horizon of 5 years (no discounting) Outcome X Treatment 1 % currently used No X Year 1 Year 2 Year 3 Year 4 Year 5 Current Practice Outcome X Treatment 2 Incident Cohort 1 % currently used No X Cohort 2 Cohort Outcome X Cohort 3 Treatment 1 100% No X Implementation Cohort 4 Model Outcome X Cohort 5 Treatment 2 0% No X Immediate, complete uptake Outcomes limited to of PCORI study length of study follow ‐ up findings *Focus of impacts on overall health sector, private payer, public payer and patients
A COMMON MODEL US population for whom Patient ‐ comparative ‐ effectiveness centered results are generalizable outcomes* Time horizon of 5 years (no discounting) Outcome X Treatment 1 % currently used No X Year 1 Year 2 Year 3 Year 4 Year 5 Current Practice Outcome X Treatment 2 Incident Cohort 1 % currently used No X Cohort 2 Cohort Outcome X Cohort 3 Treatment 1 100% No X Implementation Cohort 4 Model Outcome X Cohort 5 Treatment 2 0% No X Immediate, complete uptake Outcomes limited to of PCORI study length of study follow ‐ up findings *Focus of impacts on overall health sector, private payer, public payer and patients
Target Population & Current Practice Acute Osteomyelitis Complicated Pneumonia PROJECT 1 73,673,073 73,673,073 Number of children in the United States Annual incidence of hospitalization, per 13 20 100,000 children Percentage of hospitalized population the 43% 59% findings would be applicable to based on study inclusion/exclusion criteria Annual number of index hospitalizations 4,090 8,857 Total number of children impacted over 5 20,448 44,283 years PROJECT 2 Persons in the United States ≥ 65 years (n = 40,267,984) Who experience non ‐ valvular acute ischemic stroke each year (n = 299,270) Stroke patients with atrial fibrillation (n = 77,536) Cohort* in Analysis • Discharged on warfarin (n = 17,388) (n=19,759) • No anticoagulation (n=2,371)
Target Population & Current Practice PROJECT 3 PROJECT 4 ED visits each year Time Patients with ED Patients not Type 2 Diabetes patients in x = x for the principle horizon visit for chest pain excluded from the United States (n = 26,338,269) reason of chest pain years that could study participation and related symptoms potentially benefit (not referable to from decision aid in body systems) 5 years Using insulin or no Age ≥ 30 years and medication (43%) Non ‐ insulin treated Excluded from study 6,642,000 visits x x = (1 – 71.8% excluded) 5 years 9,369,818 (531/1032 = 51.4%) Eligible for study Not using SMBG (112/450 = 24.9%) Impact Model Cohort of Non ‐ Insulin Treated Type 2 Diabetes Patients Using SMBG (n = 7,091,977)
Chest Pain Study Hess 2016
Decision stress test 74% Admit to observation unit 52.1% no stress test Model 26% Current Practice Outpatient follow ‐ up stress test 1 7 % visit within 30 days 98.8% no stress test 8 3 % Do not admit 47.9% ED visit for chest pain at low risk for acute No follow ‐ up visit within 30 days 1.2% coronary syndrome stress test 74% Admit to observation unit 37.3% no stress test 26% Implementation Model: Using Decision Aid Outpatient follow ‐ up stress test Limitation: There was some 1 7 % visit within 30 days (8%) loss to follow ‐ up in the 98.8% no stress test study; of 70 people lost, 68 8 3 % were confirmed alive at 45 Do not admit 62.7% days (Hess 2016). Slightly more people were lost ‐ to ‐ follow up under the “Using No follow ‐ up within 30 days Decision Aid” arm as fewer 1.2% were admitted to hospital. *Between study arms, there was no difference in stress test type, CCTA performed within 30 days, coronary revascularization, admittance to hospital from ED observation unit, repeated ED visit, readmission to the hospital, outpatient clinic difference, or cardiac events. These outcomes were not included in the final model because they are not changed with use of the decision aid. 11
Model Inputs Parameter Value (Range) Source Number of ED visits for the principal reason of chest 6,642,000 Calculated from Rui et al. 2014 pain and related symptoms (not related to body Table 10 (5,175,920 ‐ 8,108,080) systems), total per year Hess et al. 2016 Excluded from participation in the study* 71.8% 2323/3236 Hess et al. 2016 Probability of admission for observation with usual care 52.1% (49.8 ‐ 54.4%) 225/447 Probability of outpatient visit within 30 days if not Calculated from Hess et al. 2016 98.8% (98.7 ‐ 98.9%) admitted with usual care (203+275)/(52+100+55+101+138+38) Calculated from Hess et al. 2016 Probability of stress test if admitted to hospital 74.1% (72.2 ‐ 76.0%) (169+120)/(225+165) Calculated from Hess et al. 2016 Probability of stress test at outpatient follow ‐ up visit 17.0% (15.6 ‐ 18.3%) 35/(55+100+52) Risk difference for admission using decision aid 14.8% (8.4 ‐ 21.2%) Hess et al. 2016 *Patients were excluded from randomization to usual care or the decision aid for several reasons. The most common reasons were (1) known coronary artery disease, (2) acute ischemia on initial electrocardiogram (ECG), and (3) they were unable to use decision aid (for example a learning barrier or dementia). ED = emergency department 12
Population Size Calculation ED visits each year Time Patients with ED Patients not x = x for the principle horizon visit for chest pain excluded from reason of chest pain years that could study participation and related symptoms potentially benefit Hess et al (2016) (not referable to from decision aid in body systems) 5 years Rui et al (2014) 6,642,000 visits x x = (1 – 71.8% excluded) 5 years 9,369,818 ED = emergency department 13
Cost Inputs Cost Value (Range) Source Hospital admission for observation and testing Cost of hospital admission for $3,313 Mallidi et al. 2013 observation and stress testing (3,136 ‐ 3,490) Assumed near the upper range of outpatient stress $500 testing cost (below), with probabilistic draws based on Cost of inpatient stress testing standard deviation. One ‐ way sensitivity analysis uses (SD = 26.75, 448 ‐ 1,867) upper range of $1,867 from Mallidi et al. 2013. Outpatient follow ‐ up visit with cardiologist or primary care provider Cost of outpatient follow ‐ up visit $198 (186 ‐ 210) MEPS 2014 Average cost of outpatient stress test $244 (234 ‐ 255) CMS Physician Fee Schedule Search, General stress testing $77.52 weighted by frequency of test type Echo stress testing $274.51 Nuclear stress testing $494.55 The cost of hospital admission and cost of outpatient visit exclude the cost of the stress test. Some patients who are admitted for stress testing do not receive a stress test and some patients who follow ‐ up within 30 days do not receive a stress test at the follow ‐ up visit. 14
Results
$18,000 $16,000 Outpatient $14,000 Total Cost (Millions $) Inpatient $12,000 $10,000 Using Decision Aid $8,000 $6,000 Usual Care $4,000 $2,000 $0 Public Private Out ‐ of ‐ Pocket Millions $ $608 $133 $4,100 Savings
$18,000 $16,000 Outpatient $14,000 Total Cost (Millions $) Inpatient $12,000 $10,000 Using Decision Aid $8,000 $6,000 Usual Care $4,000 $2,000 $0 Public Private Out ‐ of ‐ Pocket Millions $ $608 $133 $4,100 Savings
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