The Research Initiative in Clinical Economics (RICE) comprises research and activities arelated to cost-effectiveness analysis, cost-benefit analysis, and similar methods for estimating the value of health care interventions at the Agency for Healthcare Research and Quality. The projects that follow are all currently funded studies in clinical economics or a related component.
* Projects on which RICE members serve in an advisory role are indicated by an asterisk.
Principal Investigator: Angus, Derek C.
Title: Economic Analysis of Pulmonary Artery Catheter Use
Institution: University of Pittsburgh
Project Period: 2001-2005
Grant Number: R01 HS11620
Project Officer: Chiang, Yen-Pin
The pulmonary artery catheter (PAC) is a commonly used device that provides hemodynamic data to guide care of the critically ill, such as patients with acute respiratory distress syndrome (ARDS/ALI). Clinicians believe PAC use improves patient outcomes, but evidence is lacking and data suggest the PAC may increase deaths as well as considerably increase costs. The National Heart, Lung, and Blood Institute (NHLBI) funded a large multicenter trial (Fluid And Catheter Treatment Trial (FACTT)) where ARDS/ALI patients who receive a PAC will be compared to those who receive a less invasive procedure. The researchers proposed to complement FACTT with a concurrent economic analysis of the PAC. Their aims are to compare differences between study arms regarding long-term survival, quality of life, and quality-adjusted survival, acute care, and long-term costs. They will also calculate the cost-efficacy of PAC use, estimate cost-effectiveness under more "real-world" conditions, and produce life-time cost-effectiveness ratios to facilitate comparison of results to other cost-effectiveness analyses.
Principal Investigator: Asarnow, Joan R.
Title: Youth Partners in Care: Depression & Quality Improvement
Institution: University of California, Los Angeles CA
Project Period: 1998-2003
Grant Number: R01 HS09908-01
Project Officer: Mullican, Charlotte A.
The proposed study is an effectiveness trial of a quality improvement intervention for the treatment of adolescent and young adult depression within managed primary care setting under "usual care" conditions. Depression in youth interferes with functioning during a critical developmental period and is associated with adverse outcomes, such as suicide, risk for drug and alcohol problems, and adult depression. Does improving rates of use of efficacious treatment improve outcomes, and at what costs? To address this question, we propose a randomized trial at the clinic level to evaluate an intervention featuring patient and primary care-provider education about treatment for depression, coupled with clinic resources that facilitate initiation and provision of appropriate care, whether medication management or full-course Cognitive Behavioral Therapy. We assess intervention effects, compared to care as usual, on quality of care, satisfaction with care, clinical symptoms and daily functioning, service use and costs, and indirect costs and parental psychological distress.
This proposal is a unique opportunity to extend Partners in Care (PIC), an AHCPR PORT-II on the cost-effectiveness of quality improvement interventions for adult depressed patients in primary care. This proposal uses PIC intervention materials and study measures. Patients identified as depressed in intervention and control clinics will be evaluated at baseline, 6-months, 12 months, and 18 months. We hypothesize that the intervention will improve quality of care, and through quality of care, improve clinical and functioning outcomes for depressed youths and reduce family burden. The study has an interdisciplinary team including psychiatrists, psychologists, nurses, primary care clinicians, statisticians, sociologists, and economists.
Principal Investigator: Clarke, Gregory N.
Title: HMO Collaborative Care Treatment for Depressed Youth
Institution: Kaiser Foundation Research Institute
Project Period: 1999-2003
Grant Number: R01 HS10535
Project Officer: Mullican, Charlotte A.
* Principal Investigator:
Coons, Stephen Joel
Title: U.S. Valuation of the EuroQol EQ-5D Health States
Institution: University of Arizona
Project Period: 2001-2003
Grant Number: R01 HS10243
Project Officer: Chiang, Yen-Pin
The measurement of self-reported health status is becoming an increasingly common activity among health care systems. Self-reported health status can be used in evaluative studies and policy research. The EuroQol Group's EQ-5D is a preference-based health status measure that is gaining popularity in the United States. However, the EQ-5D health state values have not been established for a representative U.S. population sample or for minority groups in the United States. The researchers propose to (1) to establish population-based preference values for the EQ-5D's 243 health states for use in the United States and (2) to compare EQ-5D health state values of the general population with those measured in the two largest minority populations in the US: Hispanics and non-Hispanic blacks.
Principal Investigator: Gardiner, Joseph
Title: Statistical Inference for Cost-effectiveness Analysis
Institution: Michigan State University, East Lansing, MI
Project Period: 1997-2003
Grant Number: R01 HS09514-04
Project Officer: Henderson, Melford J
Motivated by the need for new techniques for analyses of health care costs from clinical and epidemiological studies, the goal of this study is to develop statistical techniques that fill methodological gaps in current cost-effectiveness analysis (CEA) models. When a health care intervention is deployed, cost are engendered though the use of resources. These occur in random amounts at random times that might differ by patient attributes, clinical and intervention characteristics. Study design and sampling may lead to incomplete observation of key outcomes in some patients. Incorporating these components into statistical models that accurately reflect the experience of patients as their health histories manifest over time permits consideration of health outcomes and costs jointly. This study proposes statistical models of costs and patient outcomes that incorporate the temporal dynamics that generate these data and the availability of concomitant exogenous information. They propose to use a Markovian regime to model the dynamics of movement of patients through different health states, with costs incurred at transitions between states and sojourns within states. Applying a constant discount rate where appropriate, they will estimate summary health outcome measures (e.g., life expectancy, quality-adjusted life years, net present value, net health cost and benefit, cost-effectiveness ratios). They will assess the impact of exogenous factors on these parameters and provide a unified framework for statistical inference and then test the performance and sensitivity of the procedures with real and simulated data.
They propose applications of the methods to several peer-reviewed investigations. (1) They will assess the determinants of total health care costs and the use and cost of pharmacologic treatments in a longitudinal study of quality and continuity of care to 9,000 Medicaid recipients with a diagnosis of attention deficit hyperactivity disorder. (2) They will estimate cost of hospitalization in relation to co-morbidity, patient demographic, and clinical attributes in a retrospective study of cardiac procedures performed in two cohorts of patients with myocardial infarction. (3) From the Multicenter Automatic Defibrillator Implantation Trial (MADIT), they will assess resource utilization and and survival in patients at high risk for ventricular arrhythmia, and re-examine the cost-effectiveness of the defibrillator compared to conventional therapy. (4) They will assess (relative to usual care) incremental costs, net health benefit and net cost measures in a trial of an intervention designed to improve mental health and physical health functioning and life course development in low-income pregnant women. (5) They will assess the determinants of cost by providing treatment in a study of stage of diagnosis, treatment, and survival in patients with cancer in Medicaid. In summary, by developing and testing new methods for cost-effectiveness studies, and demonstrating their application in several ongoing clinical studies, this study not only offers an array of promising techniques, but also bridges the gap between methodological development and implementation.Principal Investigator: Groff, Janet Y.
Title: Treatment Outcomes for Abused Women in Public Clinics
Institution: University of Texas Health Sciences Center Houston; Houston, TX
Project Period: 2000-2004
Grant Number: R01 HS11079-01
Project Officer: Mullican, Charlotte A.
This 4-year randomized controlled trial will design, implement, and test the efficacy of nurse case management and group education for African-American, Hispanic, and white abused women attending inner-city primary care clinics. These clinics are part of a county-wide system that maintains a computerized information system of inpatient and outpatient encounters. The theoretically-based intervention will build on empirically tested components designed to: increase safety planning behaviors; increase self-efficacy for safety behaviors; decrease frequency and severity of abuse; improve physical emotional and social well-being; decrease unscheduled medical care utilization; and increase work productivity. An additional objective is to evaluate the impact of the interventions on the health and functional status and medical utilization of abused women's children. Consecutive sampling of women 18-44 years of age presenting for medical care will be screened for domestic violence until a sample of 400 abused women is obtained. Participants will be randomized to one of four treatment cells in a factorial design: referral card, referral card + group education, referral card + case management, referral card + group education + case management. Nurse case management will include education on safety planning, crisis management, supportive care, anticipatory guidance, and referrals. Group education will consist of sessions conducted by local legal, social, and educational agencies for abused women. The factorial study design will allow testing the main effects of group education and nurse case management and the interaction of group education and case management on safety behaviors, health outcomes in the women and their children, and medical care utilization. Measures will be collected at baseline and every 6 months for 3 years after randomization. An economic evaluation of the program will be conducted using cost benefit analyses of the four alternative treatments from both societal and health care system perspectives.
Principal Investigator: Jarvik, Jeffrey G.
Title: Rapid MR vs. X-Ray: Randomized Outcome Trial for Back Pain
Institution: University of Washington; Seattle WA
Project Period: 1998-2002
Grant Number: R01 HS09499-01A2
Project Officer: Cummings, Mary A.
The researchers have developed a rapid magnetic resonance imaging (NM) study of the lumbar spine that can be performed using nearly all clinical NM scanners. Because the total imaging time is only approximately 2 minutes, the rapid NM is cost competitive with plain films and may play a major role in the diagnosis and treatment of patients with low back pain. Using a rapid NM early in the care of patients with low back pain might benefit patients by: (1) providing a more rapid definitive diagnosis; (2) obviating further imaging or referral; and (3) reassuring both patient and physician that there is no serious disease. There is a risk that the incidental abnormalities commonly seen on lumbar spine NM might lead to unnecessary diagnostic and therapeutic interventions that otherwise would not have been performed, resulting in worse patient outcomes and higher costs. The researchers will examine the consequences of substituting the rapid magnetic resonance (NM) scan for plain film x-rays as the initial imaging examination in patients with low back pain. They will test the hypothesis that substituting a rapid NM for plain films will not only result in better patient outcomes, but will also be more cost-effective. The researchers will follow the patients for 12 months to ascertain clinical outcome and patient satisfaction, impact on diagnostic and therapeutic decisionmaking, and utilization of resources. Estimates of the total annual direct and indirect costs attributable to low back pain in the U.S. approach $50 billion. Even if the rapid NM saves only 1% of only the direct medical costs, this translates into $240 million/year. The researchers will evaluate the practical consequences of replacing lumbar spine x-rays with this promising new technology. See also minority supplement addressing cost-effectiveness.
Principal Investigator: Johnson-Masotti, Ana P.
Title: Bayesian Cost-Effectiveness Analysis of HIV Prevention
Institution: Medical College of Wisconsin
Project Period: 2001-2002
Grant Number: R03 HS11364
Project Officer: Chiang, Yen-Pin
Costs and effectiveness are seldom known with certainty. What is needed is a method that simultaneously addresses the uncertainty that comes from not knowing the correct parameters and from sampling variations. The researchers aim to develop a method using the Bayesian framework that simultaneously tackles both of these types of uncertainty. They will develop a Bayesian method for computing confidence intervals around the cost-effectiveness ratio for HIV prevention interventions and apply the method to a cost-effectiveness analysis of a randomized trial comparing three HIV prevention interventions for the seriously mentally ill. This more inclusive approach to estimating the cost-effectiveness of HIV prevention should produce more accurate estimates for use in policy analyses and resource allocation decisionmaking.
Principal Investigator: Langfitt, John T.
Title: Cost-Effectiveness Analysis of Surgery in Epilepsy-CEASE
Institution: University of Rochester
Project Period: 1998-2002
Grant Number: R01 HS09986
Project Officer: Chiang, Yen-Pin
Epilepsy is a significant public health problem. Most of the medical, social and economic burden falls on those with medically intractable epilepsy (MIE). The researchers goal is to identify, improve and disseminate cost-effective technologies for treating MIE. The primary aim of the study is to constrain previous estimates of the cost-effectiveness of epilepsy surgery. The researchers will also describe the influence of site of care and patient characteristics on variations in overall cost-effectiveness and compare validity and responsiveness of generic, preference-based measures of quality of life in this population. This study will provide policymakers with a more valid and generalizable assessment of the value of epilepsy surgery. Identifying patient characteristics associated with lower costs and better outcomes will lead to improvements in quality of care. Furthermore, identifying the most valid and responsive preference assessment methods will help future investigators make informed, data-based choices of measures for outcomes studies in patients with epilepsy and other chronic, neurologic diseases.
Principal Investigator: Laxminarayan, Ramanan
Title: Conference on Economics of Antibiotic Resistance
Institution: Resources for the Future
Project Period: 2001-2002
Grant Number: R13 HS10943
Project Officer: Baine, William
Principal Investigator: Mandelblatt, Jeanne S.
Title: Care, Costs and Outcomes of Local Breast Cancer
Institution: Georgetown University
Project Period: 1994-2000
Grant Number: R01 HS08395
Project Officer: Cummings, Mary A.
Principal Investigator: McCloskey, Laura
Title: The costs and benefits of intervening: Battered Women's Mental and Physical Health Over Time
Institution: Harvard University
Project Period: 2000-2005
Grant Number: R01 HS11088
Project Officer: Mullican, Charlotte A.
Violence against women in the United States poses a serious public health hazard, potentially leading to psychological harm, physical injury, and death. Some hospitals have responded to this threat by investing in staff training or in-house service programs in order to identify, refer or treat women who come to the hospital. The aim of this research project is to compare the impact of these interventions on the mental and physical health of abused women. The long-term health care utilization of the women will be regularly assessed. The actual cost of these hospital programs, and the estimated cost of further services gleaned from other spheres, will be contrasted to the cost of violence to women's long-term mental and physical health, accumulated quality years of life, economic productivity and social capital. Although the survivor shoulders the greatest burden, the cost of relationship violence to society has yet to be fully weighed. Medical costs surface as the most salient to the health care community, however, there are many related costs that should be taken into account. The findings will offer new information on the cost effectiveness of a variety of hospital-based interventions, leading to specific recommendations.
Principal Investigator: Meenan, Richard T.
Title: Application of Conjoint Analysis to Preferences of Low Back Pain Patients
Institution: Kaiser Foundation Research Institute
Project Period: 09/30/2001-03/31/2003
Grant Number: R03 HS11726
Project Officer: Chiang, Yen-Pin
Like standard gamble (SG) and time-trade-off (TTO), conjoint analysis (CA) refers to a set of techniques used for estimating individual's stated preferences. It generally involves the decomposition of individual evaluations of a designed set of multi-attribute alternatives into separate components of utilities or preference weights. As such, conjoint analysis is often used to establish the relative importance of different attributes of a good or service, and to assess the ipportunity cost and tradeoffs between attributes. When cost is included as one of the attributes to be assessed, conjoint analysis can be used to assess willingness to pay (WTP). The proposed study is aimed to apply the CA techniques in the context of complementary and alternative medicine (CAM), where many have suggested that patients who seek and use CAM derive theraputic benefits from the process attributes of CAM beyond the direct health outcomes. Conjoint analysis' potential in producing utility estimates that incorporate preference over process attributes as well as outcomes attributes makes it a unique technique for the economic assessment of CAM.
* Principal Investigator: Neumann, Peter J.
Title: A Comprehensive Database of Cost-Effectiveness Analyses
Institution: Harvard University
Project Period: 2001-2004
Grant Number: R01 HS10919
Project Officer: Chiang, Yen-Pin
The investigators have previously developed a database of 228 original cost-utility analyses and 700 cost-utility ratios through 1997. The proposed study would expand the database to include cost-utility analyses through the year 2001, and adding to the database all cost-effectiveness analyses that use life-years as a measure of effectiveness. In addition, the investigators will examine whether key technology assessment decisions and recommendations on medical interventions made by different health care organizations reflect cost-effective practices. All pertinent data elements concerning the published studies will be placed online for easy access to researchers and to broaden their potential impact.
Principal Investigator: Ramsey, Scott D.
Title: Cost-Effectiveness Analysis of Lung Volume Reduction Surgery for Severe Emphysema
Agreement Number: NHLBI/AHCPR IAA Agreement #00-230F-97
Project Officers: Weinman, Gail (NHBLI); Clancy, Carolyn (AHRQ)
The National Emphysema Treatment Trial (NETT) is a multi-center, randomized controlled trial of lung volume reduction surgery (LVRS) verses maximal medical therapy (MMT) for patients with severe emphysema. The study is powered for survival outcomes (absolute mortality difference is assumed to be 4 percent) with a sample size of 4,700 to be randomized into two groups: MMT only or LVRS (via either median sternotomy—MS—or video-assisted thoracoscopic surgery—VATS) plus MMT over 5 years with a common closeout date set at January 2003.
Through an IAA with NHLBI and the Health Care Financing Administration (HCFA), the Agency is sponsoring a cost-effectiveness study to be conducted alongside the clinical trial. The cost-effectiveness study started in May 1998. The primary objective of the cost-effectiveness study is to estimate, for Medicare beneficiaries enrolled in the NETT, the incremental cost-effectiveness of LVRS plus MMT compared to MMT only for patients with sever emphysema. The Quality of Well-Being (QWB) questionnaire will be used to ascertain quality-adjusted life years (QALYs) as the measure of effectiveness. All medical and non-medical costs will be estimated from both the societal and the payers (health insurers) perspective. Study components include: (1) the identification and valuation of relevant costs and consequences associated with alternative interventions; (2) the determinants of cost-effectiveness attributable to LVRS; (3) the analysis of uncertainty around the cost-effectiveness ratios. (Further description of the study methods is available in the literature Ramsey et al., Economic analysis of lung volume reduction surgery as part of the National Emphysema Treatment Trial. Ann. Thorac. Surg 2001;71:995-1002).
To the extent that economic considerations are to be incorporated into macro-level health care decisions, cost-effectiveness analysis provides an explicit framework for policy makers (as well as citizens in an open society) to assess alternative courses of medical interventions in terms of their effects on health resources and health benefits. LVRS, as an expensive new medical technology that presumably will enhance patient functioning but at an increased cost, could serve as a good model for critically examining such trade-offs between competing values. Although virtually no public or private policy maker would suggest the use of cost-effectiveness analysis as the sole criterion for adopting new medical technologies, findings from this study along with other considerations, shall no doubt serve to inform HCFA in formulating its coverage decision for the costly procedure.
This study can also serve as a case study in critically assessing the promises and challenges of the RCT-based CEA paradigm. Conducting the cost-effectiveness analysis prospectively alongside the randomized clinical trial should bring the advantages of efficiency and enhanced scientific validity for CEA results. On the other hand, the artificial and restrictive nature of RCTs and the relatively limited study time frame argue against the applicability and generalizability of such CEA findings.
Principal Investigator: Sainfort, Francois
Title: Preferences for Short-Term Health States in Radiology
Institution: University of Wisconsin
Project Period: 1999-2001
Grant Number: R01 HS10277
Project Officer: Chiang, Yen-Pin
Principal Investigator: Sherman, Kenneth E.
Title: Health Utilities in Hepatitis C Infected Patients
Institution: University of Cincinnati
Project Period: 1999-2000
Grant Number: R03 HS10366
Project Officer: Baine, William B.
In this project, investigators plan to examine the preferences (utilities) of hepatitis C patients for different health states and develop a predictive model and seek to develop a conceptual model of utilities. The investigators will use different methods in order to derive utilities, correlate them to responses to a disease-specific health status instrument, and use the Beck Depression Inventory to assess the role of depression on utilities. They will be able to develop a predictive model of utilities of infected patients. The researchers also plan to validate the measure by conducting intensive interviews with patients in order to better understand how people understand utility questions and arrive at their responses.
Principal Investigator: Weiss, Kevin B.
Title: Pediatric Asthma Care PORT II
Institution: Rush-Presbyterian-St. Luke's Medical Center
Project Period: 1996-2001
Grant Number: R01 HS08368
Project Officer: Bosco, Lynn A.
Asthma remains one of the key causes of morbidity in children. National practice guidelines for asthma have been proposed as a source of goals for improving asthma care. Yet there remains a lack of valid and reliable outcome measures to use in researching new strategies for improving asthma care for children. The Pediatric Asthma Care Patient Outcome Research Team (PAC PORT) was designed to both (1) design and validate asthma outcomes tools for the pediatric population and subsequently (2) test the cost-effectiveness of the asthma guidelines as implemented via two alternative methods. As part of the original scope of work for the PAC PORT II, several new outcome assessment instruments were tested, including several individual patient measures such as: a parent reported 14 day asthma symptom day count, a quality of life instrument (the Children's Health Survey for Asthma (CHSA)), and the Pediatric Asthma Care Experience (PACE) to examine patients experience with asthma care. An Asthma Prescription Measure of compliance with pharmacologic therapy was also designed to evaluate how well pediatric populations met expected asthma guideline prescribing goals. The purpose of this proposed 1-year competitive renewal is to: (1) advance our knowledge of the performance of these outcomes assessment instruments, (2) increase the availability of these instruments through Spanish translation, and (3) in the specific case of the CHSA, derive a tool that may be used in clinical practice.
Principal Investigator: Wells, Kenneth B.
Title: Improving the Cost-Effectiveness of Care for Depression
Institution: Rand Corporation
Project Period: 1995-2001
Grant Number: R01 HS08349
Project Officer: Mullican, Charlotte A.
Continuing the work of the previously funded Patient Outcomes Research Team study, this study will evaluate the cost-effectiveness of alternative approaches to improving care for depression in prepaid group practices and to obtain information on the linkages between processes of care and patient outcomes in primary care settings. Major depression and chronic depression are common in health care settings, strongly affect functioning, and have high social and economic costs. Efficacious treatments for depression exist, but are often not applied, especially in general medical settings. To address these issues, the investigators will implement and evaluate interventions designed to increase the exposure of patients to two treatments: appropriate antidepressant medication and interpersonal or group cognitive therapy. They will assess intervention effects, compared to care as usual, on quality of care, patient clinical and functioning outcomes and satisfaction with care, use of services, direct and indirect costs, and cost effectiveness of care and cost-utilities.
Current as of May 2002
Internet Citation:
Currently Funded Studies in Clinical Economics. May 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/coer/ricefund.htm