Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services

Pham, Clarabelle T.; Caffrey, Orla; Ben-Tovim, David I.; Hakendorf, Paul; Crotty, Maria; Karnon, Jonathan

doi:10.1186/1472-6963-12-266

Cited by 8 publications

(10 citation statements)

References 13 publications

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“…6 Although economic analyses have shown HF clinics to be a cost-effective means of disease management, it is not known which specific structure and process measures are most important to reduce health care costs. [16][17][18] Previous investigators have focused on drivers of HF-related costs at the end of life 19,20 ; however, guidelines suggest that referrals to HF clinics should occur early after a HF hospitalization, a period that represents a distinct phase of HF-related costs. [16][17][18] Previous investigators have focused on drivers of HF-related costs at the end of life 19,20 ; however, guidelines suggest that referrals to HF clinics should occur early after a HF hospitalization, a period that represents a distinct phase of HF-related costs.…”

mentioning

confidence: 99%

The Effect of Multidisciplinary Heart Failure Clinic Characteristics on 1-Year Postdischarge Health Care Costs

Wijeysundera

Austin²,

Wang³

et al. 2014

Medical Care

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mentioning

confidence: 99%

The Effect of Multidisciplinary Heart Failure Clinic Characteristics on 1-Year Postdischarge Health Care Costs

Wijeysundera

Austin²,

Wang³

et al. 2014

Medical Care

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“…The cost-effectiveness of clinical interventions (e.g., diagnostic tests, therapies or medicines) is normally assessed using current clinical care as a comparator, with national guidelines as a proxy for current care [ 1 , 2 ]. However, this comparison with guidelines is inadequate when clinical practice differs significantly from guidelines and is particularly problematic when clinical practice differs between hospitals.…”

Section: Introductionmentioning

confidence: 99%

“…However, both documents pay little attention to clinical practice variation and its consequences when performing relevant cost-effectiveness analyses (CEAs). In practice, most cost-effectiveness studies do not take into account possible causes and consequences of clinical practice variation [ 1 , 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…A few studies have used large databases to investigate practice variation and the impact it has on costs and effects [ 1 , 2 ]. However, their approach is different from ours since we aim to illustrate the importance of investigating possible clinical practice variation and deviation from national guidelines, and the need to perform hospital-level CEAs, which incorporate local hospital conditions when important clinical practice variation exists.…”

Section: Introductionmentioning

confidence: 99%

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Clinical Practice Variation Needs to be Considered in Cost-Effectiveness Analyses: A Case Study of Patients with a Recent Transient Ischemic Attack or Minor Ischemic Stroke

Buisman

Rijnsburger

Hertog

et al. 2015

Appl Health Econ Health Policy

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Background and ObjectiveThe cost-effectiveness of clinical interventions is often assessed using current care as the comparator, with national guidelines as a proxy. However, this comparison is inadequate when clinical practice differs from guidelines, or when clinical practice differs between hospitals. We examined the degree of variation in the way patients with a recent transient ischemic attack (TIA) or minor ischemic stroke are assessed and used the results to illustrate the importance of investigating possible clinical practice variation, and the need to perform hospital-level cost-effectiveness analyses (CEAs) when variation exists.MethodsSemi-structured interviews were conducted with 16 vascular neurologists in hospitals throughout the Netherlands. Questions were asked about the use of initial and confirmatory diagnostic imaging tests to assess carotid stenosis in patients with a recent TIA or minor ischemic stroke, criteria to perform confirmatory tests, and criteria for treatment. We also performed hospital-level CEAs to illustrate the consequences of the observed diagnostic strategies in which the diagnostic test costs, sensitivity and specified were varied according to the local hospital conditions.Results56 % (9/16) of the emergency units and 63 % (10/16) of the outpatient clinics use the initial and confirmatory diagnostic tests to assess carotid stenosis in accordance with the national guidelines. Of the hospitals studied, only one uses the recommended criteria for use of a confirmatory test, 38 % (6/16) follow the guidelines for treatment. The most cost-effective diagnostic test strategy differs between hospitals.ConclusionsIf important practice variation exists, hospital-level CEAs should be performed. These CEAs should include an assessment of the feasibility and costs of switching to a different strategy.Electronic supplementary materialThe online version of this article (doi:10.1007/s40258-015-0167-4) contains supplementary material, which is available to authorized users.

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“…In a RAC‐E analysis, comparison groups are not imposed, but are based on observed characteristics that are relevant to the policy question being addressed. Previous applications have compared services provided for specific diagnoses at alternative hospitals (13, 14).…”

Section: Introductionmentioning

confidence: 99%

A risk adjusted cost‐effectiveness analysis of alternative models of nurse involvement in obesity management in primary care

Karnon

Afzali

Gray

et al. 2013

Obesity

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Objective: Controlled evaluations are subject to uncertainty regarding their replication in the real world, particularly around systems of service provision. Using routinely collected data, we undertook a risk adjusted cost-effectiveness (RAC-E) analysis of alternative applied models of primary health care for the management of obese adult patients. Models were based on the reported level of involvement of practice nurses (registered or enrolled nurses working in general practice) in the provision of clinicalbased activities. Design and Methods: Linked, routinely collected clinical data describing clinical outcomes (weight, BMI, and obesity-related complications) and resource use (primary care, pharmaceutical, and hospital resource use) were collected. Potential confounders were controlled for using propensity weighted regression analyses. Results: Relative to low level involvement of practice nurses in the provision of clinical-based activities to obese patients, high level involvement was associated with lower costs and better outcomes (more patients losing weight, and larger mean reductions in BMI). Excluding hospital costs, high level practice nurse involvement was associated with slightly higher costs. Incrementally, the high level model gets one additional obese patient to lose weight at an additional cost of $6,741, and reduces mean BMI by an additional one point at an additional cost of $563 (upper 95% confidence interval $1,547). Conclusion: Converted to quality adjusted life year (QALY) gains, the results provide a strong indication that increased involvement of practice nurses in clinical activities is associated with additional health benefits that are achieved at reasonable additional cost. Dissemination activities and incentives are required to encourage general practices to better integrate practice nurses in the active provision of clinical services.

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Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services

Cited by 8 publications

References 13 publications

The Effect of Multidisciplinary Heart Failure Clinic Characteristics on 1-Year Postdischarge Health Care Costs

The Effect of Multidisciplinary Heart Failure Clinic Characteristics on 1-Year Postdischarge Health Care Costs

Clinical Practice Variation Needs to be Considered in Cost-Effectiveness Analyses: A Case Study of Patients with a Recent Transient Ischemic Attack or Minor Ischemic Stroke

A risk adjusted cost‐effectiveness analysis of alternative models of nurse involvement in obesity management in primary care

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