Estimating the cost-effectiveness of quality-improving interventions in oral anticoagulation management within general practice

OBJECTIVES

A clinical trial, "Belgian Improvement Study on Oral Anticoagulation Therapy (BISOAT)," significantly improved the quality after implementing four different quality-improving interventions in four randomly divided groups of general practitioners (GPs). The quality-improving interventions consisted of multifaceted education with or without feedback reports on their performance, international normalized ratio (INR) testing by the GP with a CoaguChek device or computer-assisted advice for adapting oral anticoagulation therapy. The quality improvement in INR control versus baseline was similar in the four groups. The aim of the current study was to calculate the cost-effectiveness and influencing factors of the four quality-improving interventions compared with usual care.

METHODS

Activity-based costing techniques with questionnaires were used to determine the global costs per patient per month in the different intervention groups. Effectiveness data were obtained from the BISOAT study. Cost-effectiveness was expressed as cost per additional day within a 0.5 range from INR target.

RESULTS

The one-time cost of multifaceted education was 49,997 euro for the whole study. Monthly continuous costs per intervention ranged between 37 euro and 54 euro per patient. Using the CoaguChek in combination with the multifaceted education was associated with net savings and quality improvement, hence dominated usual care. Sensitivity analyses showed improved cost-effectiveness with extended duration and with increased program size.

CONCLUSION

Implementation of the combination multifaceted education with the use of the CoaguChek is a cost-effective new organizational model of oral anticoagulation management in general practice.

Counter sampling combined with medical provider education: do they alter prescribing behavior?

OBJECTIVE

To observe if medical providers alter their prescribing patterns of three relatively expensive categories of medications provided as samples by manufacturers (focus medications) when they receive additional education from pharmacists concerning the appropriate use of lower cost alternatives (counter samples) that are made available to dispense.

DESIGN

Pretest, post-test with a control group.

SETTING

Two rural, private care clinics in southeastern Idaho providing immediate care services.

PARTICIPANTS

Eight medical providers at a clinic where interventions were employed (active intervention group) and seven medical providers in a clinic where no interventions occurred (control group).

INTERVENTIONS

Medical providers in the active intervention group had: 1) education from pharmacists concerning the appropriate use of lower-cost alternatives compared with expensive focus medications 2) counter samples and patient sample handouts available to dispense to patients at their own discretion.

MAIN OUTCOME MEASURES

The percentage of the total yearly prescriptions for nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, and acid-relief medications that consisted of focus-COX-2 NSAIDs, nonsedating antihistamines, and proton pump inhibitors (PPIs), respectively.

RESULTS

The prescribing behavior of medical providers in the active intervention and control groups were significantly different at baseline in all three categories of focus medications. This suggested that the results should focus on changes across the two years of the study within the intervention and control groups rather than across the two groups. Medical providers in the intervention group significantly decreased the use of COX-2 NSAID prescriptions relative to total NSAID prescriptions following active intervention (38.9% in year 1 versus 23.7% in year 2, P < 0.05). Over the same two time periods, a nonstatistically significant decrease in COX-2 NSAID prescribing was seen at the control site (67.5% versus 62%, P > 0.05). Education and counter sampling did not stop medical providers from significantly increasing the total yearly prescriptions for antihistamines and acid-relief medications that consisted of focus-nonsedating antihistamines (86.7% versus 93.1%, P < 0.05) and PPIs (68.9% versus 86.2%, P < 0.05). Statistically significant increases in the prescribing of focus-nonsedating antihistamines (77.9% versus 98.3%, P < 0.05) and PPIs (77.5% versus 91.4%, P < 0.05) were also observed in the control group.

CONCLUSIONS

Education by pharmacists, combined with access to counter samples, may or may not have an effect on medical provider prescribing, depending on the category of medication targeted for cost control.

Enquête nationale sur la formation médicale continue des anesthésistes–réanimateurs

STUDY DESIGN

The aim of this study was to assess how French anaesthesiologists perform continuing medical education (CME).

METHODS

A 73 items survey was mailed to 1,000 anaesthesiologists (11% of anaesthesiologists population) of geographic, gender and institution representative of national anaesthesiologist demography. A second mail was sent to non-responders, 6 weeks later.

RESULTS

The answer rate was 40.8% and the sample of responders appeared to match the French anaesthesiologist population. Seventy-two percent of surveyed anaesthesiologists were affiliated to the French society of anaesthesia-intensive care and 24% to other medical societies. Attendance to French congresses was 81% and miscellaneous congresses were equally appreciated in terms of quality. Only 17% of surveyed anaesthesiologists attended international congresses. Multi-thematic congresses were preferred by 67%. The annual time devoted to congresses was 6 days (median) with additional 4 days (median) reserved for practical courses. French medical journals and international journals had a reading rate of 89 and 37%, respectively. For 61% of responders CME was funded by institutional grants. Internet CME use was found in 73% of anaesthesiologists. Time and money were the two most frequent reasons invoked for CME restriction.

CONCLUSION

CME is a broadly shared activity, which still remains focussed on national resources.

Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews

OBJECTIVES

The objective of physician continuing medical education (CME) is to help them keep abreast of advances in patient care, to accept new more-beneficial care, and discontinue use of existing lower-benefit diagnostic and therapeutic interventions. The goal of this review was to examine effectiveness of current CME tools and techniques in changing physician clinical practices and improving patient health outcomes.

METHODS

Results of published systematic reviews were examined to determine the spectrum from most- to least-effective CME techniques. We searched multiple databases, from 1 January 1984 to 30 October 2004, for English-language, peer-reviewed meta-analyses and other systematic reviews of CME programs that alter physician behavior and/or patient outcomes.

RESULTS

Twenty-six reviews met inclusion criteria, that is, were either formal meta-analyses or other systematic reviews. Interactive techniques (audit/feedback, academic detailing/outreach, and reminders) are the most effective at simultaneously changing physician care and patient outcomes. Clinical practice guidelines and opinion leaders are less effective. Didactic presentations and distributing printed information only have little or no beneficial effect in changing physician practice.

CONCLUSIONS

Even though the most-effective CME techniques have been proven, use of least-effective ones predominates. Such use of ineffective CME likely reduces patient care quality and raises costs for all, the worst of both worlds.

Modelling the costs and outcomes of changing rates of screening for alcohol misuse by GPs in the Australian context

AIM

To assess the relative cost effectiveness of four strategies (academic detailing, computerised reminder systems, target payments and interactive continuing medical education) to increase the provision of screening and brief interventions by Australian GPs with the ultimate goal of decreasing risky alcohol consumption among their patients.

METHODS

This project used a modelling approach to combine information on the effectiveness and costs of four separate strategies to change GP behaviours to estimate their relative cost effectiveness.

RESULTS

The computerised reminder system and academic detailing appear most effective in achieving a decrease in the number of standard drinks consumed by risky drinkers.

CONCLUSION

Regardless of the assumptions made, the targeted payment strategy appeared to be the least cost-effective method to achieve a decrease in risky alcohol consumption while the other three strategies appear reasonably comparable.

Educational governance for the regulation of industry sponsored continuing medical education in interventional and device based therapies

The relationship between industry and clinicians in educational programmes needs to be regulated. Industry may be best placed to deliver educational programmes in "craft" related specialties and particularly in areas where device implantation/technology based therapy has a major clinical role. The authors supervise industry sponsored clinical teaching at a purpose built independent teaching facility, and have developed the concept of educational governance to regulate their relationship with their industry sponsor and that concept is presented.

How Much Does It Cost to Change the Behavior of Health Professionals? A Mathematical Model and an Application to Academic Detailing

Several strategies have shown to be effective at enhancing the implementation of research findings in daily practice. These implementation strategies improve the delivery of preventive or therapeutic care by successfully educating health professionals. On the other hand, little is known about the costs of these implementation strategies. The goal of this article is to present a mathematical model that predicts implementation costs by using published data. As an important feature, the model portrays the relationship between the degree of treatment underuse and implementation costs. Two application examples of outreach programs for the prevention of stroke and coronary disease analyze the relevance of implementation costs with respect to the cost-effectiveness ratio and total costs. They demonstrate that implementation costs may have little impact on the cost-effectiveness ratio but may nevertheless be relevant to a 3rd-party payer who needs to stay within the budget and ensure that care is provided to a large underserved population. The model and its consideration of implementation costs may contribute to a more efficient use of health care resources.

A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care: cost-effectiveness analysis of the Pediatric Asthma Care Patient Outcomes Research Team II (PAC-PORT II)

BACKGROUND

A decision to implement innovative disease management interventions in health plans often requires evidence of clinical benefit and financial impact. The Pediatric Asthma Care Patient Outcomes Research Team II trial evaluated 2 asthma care strategies: a peer leader-based physician behavior change intervention (PLE) and a practice-based redesign called the planned asthma care intervention (PACI).

OBJECTIVE

To estimate the cost-effectiveness of the interventions.

METHODS

This was a 3-arm, cluster randomized trial conducted in 42 primary care practices. A total of 638 children (age range, 3-17 years) with mild to moderate persistent asthma were followed up for 2 years. Practices were randomized to PLE (n = 226), PACI (n = 213), or usual care (n = 199). The primary outcome was symptom-free days (SFDs). Costs included asthma-related health care utilization and intervention costs.

RESULTS

Annual costs per patient were as follows: PACI, USD 1292; PLE, USD 504; and usual care, USD 385. The difference in annual SFDs was 6.5 days (95% confidence interval [CI], -3.6 to 16.9 days) for PLE vs usual care and 13.3 days (95% CI, 2.1-24.7 days) for PACI vs usual care. Compared with usual care, the incremental cost-effectiveness ratio was USD 18 per SFD gained for PLE (95% CI, USD 5.21-dominated) and USD 68 per SFD gained for PACI (95% CI, USD 37.36-361.16).

CONCLUSIONS

Results of this study show that it is possible to increase SFDs in children and move organizations toward guideline recommendations on asthma control in settings where most children are receiving controller medications at baseline. However, the improvements were realized with an increase in the costs associated with asthma care.

[Demand for extramural funding in German hospitals]

Medical progress is based on scientific research and continuing medical education (CME). Because of the tight financial situation in German hospitals, however, it is becoming increasingly difficult to provide the monetary resources for research and education. Therefore, acquisition of extramural grants has become indispensable for German medical research. Nonetheless, time and again the medical professionals have to face public accusations of unlawful earnings through industry funds. Even though these accusations prove wrong in most cases, they harm the reputation of the medical profession. Thus, guidelines are needed that guarantee both the independence of medical decision making and a productive cooperation with industry sponsors. At their annual meeting in 2003, the elected representatives of the medical profession of Germany ("Deutscher Arztetag") have passed an amendment of the code of conduct for physicians concerning the cooperation of physicians and industry partners. The goal is to organize the cooperation in a way that the independence of the physicians remains unquestionable The following principles are now included in the code of conduct: Transparency of funding; separation of funding and decisions on buying medical products; equivalence of service and payment; and documentation of the cooperation within the framework of occupational law.

Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis

Background

Outreach facilitation has been proven successful in improving the adoption of clinical preventive care guidelines in primary care practice. The net costs and savings of delivering such an intensive intervention need to be understood. We wanted to estimate the proportion of a facilitation intervention cost that is offset and the potential for savings by reducing inappropriate screening tests and increasing appropriate screening tests in 22 intervention primary care practices affecting a population of 90,283 patients.

Methods

A cost-consequences analysis of one successful outreach facilitation intervention was done, taking into account the estimated cost savings to the health system of reducing five inappropriate tests and increasing seven appropriate tests. Multiple data sources were used to calculate costs and cost savings to the government. The cost of the intervention and costs of performing appropriate testing were calculated. Costs averted were calculated by multiplying the number of tests not performed as a result of the intervention. Further downstream cost savings were determined by calculating the direct costs associated with the number of false positive test follow-ups avoided. Treatment costs averted as a result of increasing appropriate testing were similarly calculated.

Results

The total cost of the intervention over 12 months was $238,388 and the cost of increasing the delivery of appropriate care was $192,912 for a total cost of $431,300. The savings from reduction in inappropriate testing were $148,568 and from avoiding treatment costs as a result of appropriate testing were $455,464 for a total savings of $604,032. On a yearly basis the net cost saving to the government is $191,733 per year (2003 $Can) equating to $3,687 per physician or $63,911 per facilitator, an estimated return on intervention investment and delivery of appropriate preventive care of 40%.

Conclusion

Outreach facilitation is more expensive but more effective than other attempts to modify primary care practice and all of its costs can be offset through the reduction of inappropriate testing and increasing appropriate testing. Our calculations are based on conservative assumptions. The potential for savings is likely considerably higher.

Cost of lipid lowering in patients with coronary artery disease by case method learning

OBJECTIVES

This investigation was undertaken to study the costs of a Case Method Learning (CML)-supported lipid-lowering strategy in secondary prevention of coronary artery disease (CAD) in primary care.

METHODS

This prospective randomized controlled trial in primary care with an additional external specialist control group in Södertälje, Stockholm County, Sweden, included 255 consecutive patients with CAD. Guidelines were mailed to all general practitioners (GPs; n=54) and presented at a common lecture. GPs who were randomized to the intervention group participated in recurrent CML dialogues at their primary health-care centers during a 2-year period. A locally well-known cardiologist served as a facilitator. Assessment of low-density lipoprotein (LDL) cholesterol was performed at baseline and after 2 years. Analysis according to intention-to-treat-intervention and control groups (n=88)--was based on group affiliation at baseline. The marginal cost of lipid lowering comprised increased cost of lipid-lowering drugs in the intervention group compared with the primary care control group, cost of attendance of the GP's in the intervention group, and cost of time for preparation, travel, and seminars of the facilitator. Costs are as of 2002 with an exchange rate 1 U.S. dollar = 9.5 SEK (Swedish Crowns).

RESULTS

Patients in the primary care intervention group had their LDL cholesterol reduced by 0.5 (confidence interval [CI], 0.1-0.9) mmol/L compared with the primary care control group (p < .05). No change occurred in controls. LDL cholesterol in the external specialist control group decreased by 0.6 (CI, 0.4-0.8) mmol/L. The cost of the educational intervention represented only 2 percent of the drug cost. The cost of lipid lowering in the intervention group, including the cost of the educational intervention, was actually lower than that of patients treated at the specialist clinic--106 U.S. dollar per mmol decrease in LDL cholesterol in the intervention group and 153 U.S. dollar per mmol decrease in LDL cholesterol in the specialist group. EuroQol 5D Index, which gives an estimate of global health-related quality of life, was 0.80 (CI, 0.75-0.85) in the present cohort.

CONCLUSIONS

The additional cost of CML was only 2 percent of the drug cost. Assuming the same gain in life expectancy per millimole decrease in LDL cholesterol as in the 4S-study gives a cost per gained quality-adjusted life year of U.S. dollar 24,000. This finding indicates that the CML-supported lipid-lowering strategy is cost-effective. The low cost of CML in primary care should probably warrant its use in the improvement of the quality of care in other major chronic diseases.

The costs of implementing the 1999 Canadian Asthma Consensus Guidelines recommendation of asthma education and spirometry for the family physician

BACKGROUND

National and international asthma guidelines recommend that patients with asthma be provided with asthma education and spirometry as a component of enhanced asthma care. The cost of implementing these interventions in family physician practices is not known.

OBJECTIVE

The objective of the present study was to determine the cost of providing recommended asthma care to adult patients in the family practice setting.

METHODS

The present study was conducted using three scenarios of care in family practice. Small, medium and large asthmatic patient populations were used. The incremental costs of implementing enhanced asthma care based on the Canadian Asthma Consensus Guidelines, including the provision of spirometry and asthma education in both group and individual sessions, and the resources required for these interventions were calculated for each scenario.

RESULTS

For a physician with 50 asthmatic patients, the cost of providing enhanced asthma care with spirometry and group education sessions was approximately 78 dollars per patient in the first year of implementation. For individual sessions, the cost increased to 100 dollars per patient for the first year. If the physician had 100 asthmatic patients, the per patient cost would decrease; however, the overall cost of the program would be 7,000 dollars.

CONCLUSIONS

The costs of providing enhanced asthma care are significant. In most cases, physicians are inadequately reimbursed (or not reimbursed) for these interventions. In light of the evidence of the effectiveness of these interventions, health insurance plans should consider adding these services to fee schedules.

Critical appraisal skills training for health care professionals: a randomized controlled trial [ISRCTN46272378]

INTRODUCTION

Critical appraisal skills are believed to play a central role in an evidence-based approach to health practice. The aim of this study was to evaluate the effectiveness and costs of a critical appraisal skills educational intervention aimed at health care professionals.

METHODS

This prospective controlled trial randomized 145 self-selected general practitioners, hospital physicians, professions allied to medicine, and healthcare managers/administrators from the South West of England to a half-day critical appraisal skills training workshop (based on the model of problem-based small group learning) or waiting list control. The following outcomes were assessed at 6-months follow up: knowledge of the principles necessary for appraising evidence; attitudes towards the use of evidence about healthcare; evidence seeking behaviour; perceived confidence in appraising evidence; and ability to critically appraise a systematic review article.

RESULTS

At follow up overall knowledge score [mean difference: 2.6 (95% CI: 0.6 to 4.6)] and ability to appraise the results of a systematic review [mean difference: 1.2 (95% CI: 0.01 to 2.4)] were higher in the critical skills training group compared to control. No statistical significant differences in overall attitude towards evidence, evidence seeking behaviour, perceived confidence, and other areas of critical appraisal skills ability (methodology or generalizability) were observed between groups. Taking into account the workshop provision costs and costs of participants time and expenses of participants, the average cost of providing the critical appraisal workshops was approximately pound 250 per person.

CONCLUSIONS

The findings of this study challenge the policy of funding 'one-off' educational interventions aimed at enhancing the evidence-based practice of health care professionals. Future evaluations of evidence-based practice interventions need to take in account this trial's negative findings and methodological difficulties.

[Physicians and drug industry: attitudes and practice]

BACKGROUND

There is a need for more knowledge on how doctors assess the relationship between the pharmaceutical industry and the medical profession.

METHOD

Postal questionnaires survey in 2002 among a representative sample of 1606 Norwegian doctors. The response rate was 73%.

RESULTS

70% of the respondents indicated that continued medical education would suffer without participation from the pharmaceutical industry, and 40 % that the industry was important for their own updating of skills. 52% agreed that doctors were influenced by the pharmaceutical industry, but 40% claimed that this was not the case for them personally. Specialists in internal medicine, surgery and family medicine were more likely to travel abroad sponsored by the pharmaceutical industry, whereas specialists in family medicine and internal medicine more often attended industry-sponsored meetings in Norway. Psychiatrists were more likely to see the relationship between doctors and industry as too regulated. Young doctors were more sceptical towards the pharmaceutical industry than their older colleagues.

INTERPRETATION

Norwegian doctors find that the pharmaceutical industry is important to their own professional development and this may complicate attempts to regulate this relationship. It is, moreover, a problem that doctors probably underestimate the influence of the industry.

Improving physician attendance at educational seminars sponsored by Managed Care Organizations

PURPOSE

To enhance primary care provider participation in a multi-faceted interactive asthma teaching program sponsored by managed care organizations.

DESIGN

Case series of six MCO-sponsored continuing medical education (CME) sessions.

METHODOLOGY

MCOs were provided with a standard set of recruitment materials. The MCO disease management divisions invited pediatric primary care providers of several types to attend the asthma teaching sessions and tracked the type of contacts employed and the success rate. Participants were awarded CME and were provided with a meal to encourage attendance. The faculty included a local physician-leader and a regional asthma expert. The sessions were scheduled by the MCO, but were given by the study group using a previously developed curriculum that emphasized material endorsed by the National Heart Lung and Blood Institute. Direct costs were tracked.

PRINCIPAL FINDINGS

Overall, 53 of 299 (18 percent) providers participated in the two-part asthma CME sessions. Recruitment was significantly more successful when a physician leader participated in solicitation of providers (P < .01). Successful recruitment generally necessitated two points of contact, and phone contact appeared to yield greater success than e-mail. Scheduling conflicts and inconvenient location were the most common reasons given for not attending the seminars. Ninety percent of providers who attended the first session completed the program. The average direct cost per provider was dollar 370.

CONCLUSION

Even when offering primary care providers a multifaceted interactive asthma-teaching program, physician recruitment necessitates personal and multiple contacts, and careful planning in terms of seminar location, time, and content. Interactive physician education seminars necessitate a large investment of resources but may be cost-effective if care is improved.