Cost-effectiveness of implementation research: the VA QUERI program
- Presenter:
Chair: David Meltzer; Discussant: David Meltzer Wed June 7, 2006 8:00-9:30 Room 309
Objectives: (1) to assess how traditional cost-effectiveness analysis (CEA) methods must be tailored and expanded for implementation research; (2) to introduce QUERI, the national VA program to support implementation of medical best practices.
Methods: We will describe traditional CEA methods and their use in current VA research. Next we will discuss how implementation research differs from traditional clinical trials, and how this impacts both the range and measurement of economic outcomes. We will present data on economic studies within the QUERI program and suggest ways in which future projects could be used to test new methods.
Results: Implementing an intervention raises economic issues beyond those encountered in standard CEA. Data are needed on the costs and impacts of both the underlying intervention and the program that implements it. The societal perspective of a standard CEA may be less influential than a managerial perspective that emphasizes a short time horizon, fixed staffing and facilities, and community standards of care. The comparator intervention (“usual care”) may depend on the level at which the intervention takes place, which in turn affects the range of study designs available.
We have two major lessons: (1) An implementation effort itself has costs and effectiveness separate from the intervention it is spreading. This has two implications. First, cost-effective interventions may not be cost-effective when implemented. Second, the best response to poor cost-effectiveness during implementation may be to redesign the implementation strategy rather than to alter or drop the underlying intervention. (2) Economic analyses of implementation research should reflect the needs of end users at a variety of levels. Policymakers at local, regional, and national levels are likely to view cost burdens differently and may have differing thresholds for cost-effectiveness.
VA presents many advantages for studying implementation methods. These include a uniform electronic patient record system nationwide, a comprehensive set of encounter-level data open to researchers, the ability to link VA and Medicare records, and administrative information on the 140+ local VA health systems and the regional networks they belong to. Although they belong to a single national system, there is still considerable diversity in medical practice and administration among VA facilities. Nationally, VA has committed to implementing best practices throughout its system and considers economic analysis an important element of the process.
Conclusions: Improved economic analyses can and should be implemented alongside implementation projects. Doing so is feasible in terms of both data collection and cost. Researchers should consider VA a laboratory for developing and testing new CEA methods alongside implementation projects.
