Person:

Garber, Alan

Many health plans apply evidence-based approaches to coverage decisions. The foundation of such approaches is the systematic review of information about the effectiveness of medical interventions. This paper discusses the principles underlying evidence-based coverage policy and how they are applied by two major programs: the Technology Evaluation Center of the Blue Cross Blue Shield Association and the Medicare Coverage Advisory Committee. Although such policies likely have limited effects on spending, they can help to direct medical resources toward effective care.

Context: Installation of automated external defibrillators (AEDs) on passenger aircraft has been shown to improve survival of cardiac arrest in that setting, but the cost-effectiveness of such measures has not been proven.

Objective: To examine the costs and effectiveness of several different options for AED deployment in the US commercial air transportation system.

Design, Setting, and Subjects: Decision and cost-effectiveness analysis of a strategy of full deployment on all aircraft as well as several strategies of partial deployment only on larger aircraft, compared with a baseline strategy of no AEDs on aircraft (but training flight attendants in basic life support) for a hypothetical cohort of persons experiencing cardiac arrest aboard US commercial aircraft. Estimates for costs and outcomes were obtained from the medical literature, the Federal Aviation Administration, the Air Transport Association of America, a population-based cohort of Medicare patients, AED manufacturers, and the Bureau of Labor Statistics.

Main Outcome: Measures Quality-adjusted survival after cardiac arrest; costs of AED deployment on aircraft and of medical care for cardiac arrest survivors.

Results: Adding AEDs on passenger aircraft with more than 200 passengers would cost $35 300 per quality-adjusted life-year (QALY) gained. Additional AEDs on aircraft with capacities between 100 and 200 persons would cost an additional $40 800 per added QALY compared with deployment on large-capacity aircraft only, and full deployment on all passenger aircraft would cost an additional $94 700 per QALY gained compared with limited deployment on aircraft with capacity greater than 100. Sensitivity analyses indicated that the quality of life, annual mortality rate, and the effectiveness of AEDs in improving survival were the most influential factors in the model. In 85% of Monte Carlo simulations, AED placement on large-capacity aircraft produced cost-effectiveness ratios of less than $50 000 per QALY.

Conclusion: The cost-effectiveness of placing AEDs on commercial aircraft compares favorably with the cost-effectiveness of widely accepted medical interventions and health policy regulations, but is critically dependent on the passenger capacity of the aircraft. Placing AEDs on most US commercial aircraft would meet conventional standards of cost-effectiveness.

Stanford's two decades of success in linking medical informatics and health services research in both training and investigational activities reflects advantageous geography and history as well as natural synergies in the two areas. Health services research and medical informatics at Stanford have long shared a quantitative, analytic orientation, along with linked administration, curriculum, and clinical activities. Both the medical informatics and the health services research curricula draw on diverse course offerings throughout the university, and both the training and research overlap in such areas as outcomes research, large database analysis, and decision analysis/decision support. The Stanford experience suggests that successful integration of programs in medical informatics and health services research requires areas of overlapping or synergistic interest and activity among the involved faculty and, hence, in time, among the students. This is enhanced by a mixture of casual and structured contact among students from both disciplines, including social interactions. The challenges to integration are how to overcome any geographic separation that may exist in a given institution; the proper management of relationships with those sub-areas of medical informatics that have less overlap with health services research; and the need to determine how best to exploit opportunities for collaboration that naturally occur.

Functional status as measured by dependencies in the Activities of Daily Living (ADLs) is an important indicator of overall health for older adults. Methodologies for outcomes-based medical-decision-making for public policy, such as decision modeling and cost-effectiveness analysis, require utilities for outcome health states. Utilities have been reported for many disease states, but have not been indexed by functional status, which is a strong predictor of outcome in geriatrics. We describe here a utility elicitation program developed specifically for use with computer-inexperienced older adults: Functional Limitation And Independence Rating (FLAIR1). FLAIR1 design features address common physical problems of the aged and computer attitudes of inexperienced users that could impede computer acceptance. We interviewed 400 adults ages 65 years and older with FLAIR1. In exit interviews with 154 respondents, 118 (76%) found FLAIR1 easy to use. Design features in FLAIR1 can be applied to other software for older adults

Background— It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long-term survival after cardiac arrest.

Methods and Results— A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Association’s annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverter-defibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD.

Conclusions— There is racial disparity in long-term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life-saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients.

Objective. To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life—a group that accounts for more than one-quarter of Medicare's annual expenditures.

Data Source. Medicare administrative claims for 1994 and 1995.

Study Design. We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters.

Data Extraction Methods. The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors.

Principal Findings. Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments.

Conclusions. More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.

Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures.

Data Source. The 1985–1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files.

Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity.

Data Collection. The data were collected by the Centers for Medicare and Medicaid Services.

Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission.

Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred.

Private health plans and government health insurance programs in the United States base their coverage decisions on evidence criteria, rather than explicit cost-effectiveness criteria. As health spending continues to grow rapidly, however, approaches to coverage policy that ignore costs fail to meet the needs of consumers, employers, health plans, and federal and state governments. I describe the role of evidence-based criteria in formal coverage decision making and contrast the ways that these criteria differ from cost-effectiveness criteria. Finally, I discuss options for incorporating considerations of cost-effectiveness into coverage policy and other aspects of benefit design.

Objective. To quantify the effects of informal caregiver availability and public funding on formal long-term care (LTC) expenditures in developed countries.

Data Source/Study Setting. Secondary data were acquired for 15 Organization for Economic Cooperation and Development (OECD) countries from 1970 to 2000.

Study Design. Secondary data analysis, applying fixed- and random-effects models to time-series cross-sectional data. Outcome variables are inpatient or home heath LTC expenditures. Key explanatory variables are measures of the availability of informal caregivers, generosity in public funding for formal LTC, and the proportion of the elderly population in the total population.

Data Collection/Extraction Method. Aggregated macro data were obtained from OECD Health Data, United Nations Demographic Yearbooks, and U.S. Census Bureau International Data Base.

Principal Findings. Most of the 15 OECD countries experienced growth in LTC expenditures over the study period. The availability of a spouse caregiver, measured by male-to-female ratio among the elderly, is associated with a $28,840 (1995 U.S. dollars) annual reduction in formal LTC expenditure per additional elderly male. Availability of an adult child caregiver, measured by female labor force participation and full-time/part-time status shift, is associated with a reduction of $310 to $3,830 in LTC expenditures. These impacts on LTC expenditure vary across countries and across time within a country.

Conclusions. The availability of an informal caregiver, particularly a spouse caregiver, is among the most important factors explaining variation in LTC expenditure growth. Long-term care policies should take into account behavioral responses: decreased public funding in LTC may lead working women to leave the labor force to provide more informal care.

Objectives The study was designed to determine whether racial disparity in utilization of the implantable cardioverter-defibrillator (ICD) has improved over time, and whether small-area geographic variation in ICD utilization contributed to national levels of racial disparity.

Background Although racial disparities in cardiac procedures have been well-documented, it is unknown whether there has been improvement over time. Low ICD utilization rates in predominantly black geographic areas may have exacerbated national levels of disparity.

Methods Discharge abstracts from elderly black and white Medicare beneficiaries hospitalized with ventricular arrhythmias from 1990 to 2000 were analyzed to determine if ICD implantation occurred within 90 days of initial hospitalization. Multivariate logistic regression models were constructed to assess the relationship between ICD implantation, year of admission, and the percentage of black inhabitants in each patient's county of hospitalization while controlling for clinical, hospital, and demographic characteristics.

Results There was improvement in ICD implantation racial disparity: In the period 1990 to 1992, black patients had an odds ratio of 0.52 (95% confidence interval [CI] 0.42 to 0.64) for receiving an ICD compared with whites. However, by 1999 to 2000, the odds ratio for blacks had risen to 0.69 (95% CI 0.61 to 0.78) (test-for-trend p = 0.01). Approximately 20% of this trend could be explained by reduction in geographic variation in ICD use between areas with larger black and predominantly white populations.

Conclusions Rates of ICD implants became more equal among whites and blacks during the 1990s, although persistent disparity remained at the decade's end. Geographic equalization in cardiovascular procedure rates may be an essential mechanism in rectifying disparities in health care.