Analysis of Healthcare Interventions that Change Patient Trajectories doc

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THE ARTS CHILD POLICY CIVIL JUSTICE EDUCATION ENERGY AND ENVIRONMENT HEALTH AND HEALTH CARE INTERNATIONAL AFFAIRS NATIONAL SECURITY POPULATION AND AGING PUBLIC SAFETY SCIENCE AND TECHNOLOGY SUBSTANCE ABUSE TERRORISM AND HOMELAND SECURITY TRANSPORTATION AND INFRASTRUCTURE WORKFORCE AND WORKPLACE This product is part of the RAND Corporation monograph series. RAND monographs present major research findings that address the challenges facing the public and private sectors. All RAND monographs undergo rigorous peer review to ensure high standards for research quality and objectivity. Sponsored by Cerner Corporation, General Electric, Hewlett-Packard, Johnson & Johnson, and Xerox Analysis of HEALTHCARE Interventions That Change Patient Trajectories James H. Bigelow Kateryna Fonkych Constance Fung Jason Wang The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. © Copyright 2005 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2005 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 201 North Craig Street, Suite 202, Pittsburgh, PA 15213-1516 RAND URL: http://www.rand.org/ To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: order@rand.org A profile of RAND Health, abstracts of its publications, and ordering information can be found on the RAND Health home page at www.rand.org/health. Cover design by Barbara Angell Caslon The research described in this report was conducted within RAND Health and sponsored by a consortium of private companies, including Cerner Corporation, General Electric, Hewlett-Packard, Johnson & Johnson, and Xerox. Library of Congress Cataloging-in-Publication Data Analysis of healthcare interventions that change patient trajectories / James H. Bigelow [et al.]. p. cm. “MG-408.” Includes bibliographical references. ISBN 0-8330-3844-3 (pbk. : alk. paper) 1. Health maintenance organization patients. I. Bigelow, J. H. (James H.) II. Rand Corporation. [DNLM: 1. Medical Informatics Applications. 2. Cost-Benefit Analysis. 3. Technology Assessment, Biomedical. W 26.5 A532 2005] R729.5.H43A63 2005 362.1'068—dc22 2005022219 iii Preface It is widely believed that broad adoption of Electronic Medical Record Systems (EMR-S) will lead to significant healthcare savings, reduce medical errors, and im- prove health, effectively transforming the U.S. healthcare system. Yet, adoption of EMR-S has been slow and appears to lag the effective application of information technology (IT) and related transformations seen in other industries, such as bank- ing, retail, and telecommunications. In 2003, RAND Health, a division of the RAND Corporation, began a broad study to better understand the role and importance of EMR-S in improving health and reducing healthcare costs, and to help inform government actions that could maximize EMR-S benefits and increase its use. This monograph provides the technical details and results of one component of that study. It examines interventions in the healthcare system that affect patient trajectories, i.e., the sequence of encounters a patient has with the healthcare system. The monograph analyzes interventions to improve patient safety, increase preventive services, expand chronic disease management, and foster healthier lifestyles. It estimates their effects on healthcare utilization, healthcare expenditures, and population health status. Related documents are as follows: • Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville, and Roger Taylor, “Can Electronic Medical Record Systems Transform Healthcare? Potential Health Benefits, Savings, and Costs,” Health Affairs, Vol. 24, No. 5, September 14, 2005. • Roger Taylor, Anthony Bower, Federico Girosi, James Bigelow, Kateryna Fonkych, and Richard Hillestad, “Promoting Health Information Technology: Is There a Case for More-Aggressive Government Action?” Health Affairs, Vol. 24, No. 5, September 14, 2005. • James Bigelow et al., “Technical Executive Summary in Support of ‘Can Elec- tronic Medical Record Systems Transform Healthcare?’ and ‘Promoting Health Information Technology’,” Health Affairs, Web Exclusive, September 14, 2005. iv Analysis of Healthcare Interventions That Change Patient Trajectories • Kateryna Fonkych and Roger Taylor, The State and Pattern of Health Information Technology, Santa Monica, Calif.: RAND Corporation, MG-409- HLTH, 2005. • Federico Girosi, Robin Meili, and Richard Scoville, Extrapolating Evidence of Health Information Technology Savings and Costs, Santa Monica, Calif.: RAND Corporation, MG-410-HLTH, 2005. • Richard Scoville, Roger Taylor, Robin Meili, and Richard Hillestad, How HIT Can Help: Process Change and the Benefits of Healthcare Information Technology, Santa Monica, Calif.: RAND Corporation, TR-270-HLTH, 2005. • Anthony G. Bower, The Diffusion and Value of Healthcare Information Technol- ogy, Santa Monica, Calif.: RAND Corporation, MG-272-HLTH, 2005. The monograph should be of interest to healthcare IT professionals, other healthcare executives and researchers, and officials in the government responsible for health policy. This research has been sponsored by a generous consortium of private companies: Cerner Corporation, General Electric, Hewlett-Packard, Johnson & Johnson, and Xerox. A steering group headed by Dr. David Lawrence, a retired CEO of Kaiser Permanente, provided review and guidance throughout the project. The right to publish any results was retained by RAND. The research was conducted in RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health. v Contents Preface iii Figures xi Tables xiii Summary xvii Acknowledgments xxxiii Acronyms xxxv CHAPTER ONE Introduction 1 Organization of This Monograph 3 CHAPTER TWO Building the Trajectory Database from the MEPS 5 Introduction 5 Develop Person-Level Weights 7 Baseline Person-Level Weights 7 Adjustments to the Baseline Weights 8 Future-Years Adjustment 10 Prison Population Adjustment 10 Nursing Home Resident Adjustment 10 Inflate Price 11 Map MEPS Diagnoses into Medical Conditions 12 Calculate Health Outcome Variables 14 CHAPTER THREE Interpreting MEPS-Based Estimates 17 Introduction 17 vi Analysis of Healthcare Interventions That Change Patient Trajectories Precision of Estimates from the MEPS Database 18 Errors and Omissions in MEPS-Based Estimates 20 Utilization Measures 20 Expenditures 24 Outcomes 33 Adjusting MEPS-Based Estimates for Errors and Omissions 34 Projecting Estimates to Future Years 35 Future Projections Based on Demographic Changes 36 The NHE Projections of Expenditures 38 Projecting Future Utilization 39 Factors Not Included in These Adjustments 41 Technology 41 Cultural Attitudes 42 Indirect Effects 42 CHAPTER FOUR Avoiding Adverse Drug Events Through Computerized Physician Order Entry 47 Introduction 47 Computerized Physician Order Entry 47 Adverse Drug Events 48 The Inpatient Setting 49 Opportunity and Frailty Scores 49 The National Inpatient Sample (NIS) 50 Hospital Data 51 Rates of Medication Errors and ADEs 52 Estimating Selected Effects of Inpatient CPOE 52 The Ambulatory Setting 53 Drugs That Pose ADE Risks 54 The National Ambulatory Medical Care Survey 55 Rates of Medication Errors and ADEs 55 Estimating Effects of Ambulatory CPOE 56 Mortality Due to Adverse Drug Events 57 Estimating Savings from Reduced Laboratory and Radiology Utilization 58 Inflating Savings to Future Years 59 CHAPTER FIVE Short-Term Effects of Preventive Services 61 Introduction 61 The Absence of HIT Limits Participation 63 Contents vii The Presence of HIT Enables Greater Participation 64 The Impact of HIT on Compliance 64 Plan for the Remainder of the Chapter 65 Influenza Vaccination 65 Population 65 Costs 65 Benefits 66 Pneumococcal Vaccination 72 Population 72 Costs 72 Benefits 72 Screening for Breast Cancer 76 Population 76 Costs 76 Benefits 78 Screening for Cervical Cancer 80 Population 80 Costs 81 Benefits 81 Screening for Colorectal Cancer 83 Population 83 Costs 83 Benefits 83 CHAPTER SIX Management of Chronic Diseases 87 Introduction 87 Program Design 88 HIT in Disease Management 90 Estimating the Costs of Disease Management Programs 91 Estimating the Benefits of Disease Management 94 Spreadsheets 96 Diabetes Management 97 The Population with Diabetes 97 Diabetes Management Costs 100 Diabetes Management Benefits 101 CHF Management 105 The Population with CHF 105 CHF Management Costs 105 CHF Management Benefits 107 viii Analysis of Healthcare Interventions That Change Patient Trajectories Asthma Management 110 The Population with Asthma 110 Asthma Management Costs 110 Asthma Management Benefits 111 COPD Management 114 The Population with COPD 114 COPD Management Costs 115 COPD Management Benefits 115 Aligning and Projecting Effects of the Four Disease-Management Programs 118 CHAPTER SEVEN Estimating Long-Term Effects of Healthy Behavior on Population Health Status and Healthcare 121 Introduction 121 Target Conditions 122 Potential Reductions in the Incidences of Target Conditions 126 Long-Term Effect on Prevalence 126 The Algorithm 128 Our Algorithm Is Flexible . . . 131 . . . But It Has Shortcomings 131 The Effects 132 Aligning and Projecting Effects of a Lifestyle-Change Program 136 Combining Disease-Management and Lifestyle-Change Programs and Adjusting for Lower Participation Rates 138 CHAPTER EIGHT The Patient’s Role in Disease Management and Lifestyle Changes 141 Introduction 141 Present-Day Patient Behavior 143 Potential Benefits 144 What Can Be Done? 145 Adherence in a Disease Management Program 145 Adherence to a Healthy Lifestyle 147 The Potential Success Rate 150 [...]... support lifestyle change Our national efforts to influence lifestyles have mostly taken the form of public health campaigns, such as the campaigns to reduce tobacco use and to improve nutrition In xx Analysis of Healthcare Interventions That Change Patient Trajectories the absence of data, we are forced to argue that it is plausible that HIT can play a role in lifestyle change The Evolution of Intervention... is a great deal of variation from one study to another Studies show that patients comply with xxviii Analysis of Healthcare Interventions That Change Patient Trajectories Figure S.5 Combined Effects of Disease Management Plus Lifestyle Change (assumes 100-percent participation) Diabetes COPD Asthma CHF Lifestyle Utilization measures Inpatient stays –8M Hosp ambulatory visits –15M MD of ce visits –103M... xvii xviii Analysis of Healthcare Interventions That Change Patient Trajectories prevalences) of a number of conditions that require substantial amounts of healthcare Because this work was part of a larger study, “Using Information Technology to Create a New Future in Healthcare: The RAND Health Information Technology (HIT) Project,” we chose interventions that should be facilitated by HIT HIT operates... sectors of the economy (Bower, 2005) We have defined our interventions in terms of changes in the way the healthcare system works Our results are therefore estimates of what could be, not predictions of what will be Estimating Potential Effects of Interventions We estimated the potential effects of each intervention on healthcare utilization (e.g., hospital stays, office visits, prescription drug use), healthcare. .. assessment of how difficult it is likely to be to realize a large fraction of the potential benefit It is based partly on the strength of the evidence and the amount of experience, and partly on the amount of change our interventions require of the healthcare system For each of our interventions, there is some risk that the potential benefits will not be fully realized, and, as we move down the rows of Table... several years of the Medical Expenditure Panel Survey (MEPS), the third in a series of national probability surveys conducted by the Agency for Healthcare Research and Quality (AHRQ) on the financing and utilization of medical care in the United States We created a database of patient trajectories (the sequences of events that involve patients with the healthcare system) from several years of the MEPS.2... Lifestyle changes can reduce the incidences (and ultimately the 1 Not all interventions affect patient trajectories For example, an intervention might replace manual transcription of physician notes by computerized voice recognition This intervention and many others that do not affect patient trajectories are discussed in Girosi, Meili, and Scoville (2005) xvii xviii Analysis of Healthcare Interventions. .. of MEPS Utilization for Future Years 37 Projections of MEPS Expenditures for Future Years 37 Projections of MEPS Outcome Measures for Future Years 38 xiii xiv Analysis of Healthcare Interventions That Change Patient Trajectories 3.20 3.21 3.22 3.23 3.24 4.1 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Projections of. .. reason is that our interventions require that the healthcare system undergo some change Change is disruptive, and people resist it But unless providers, payers, and consumers do change, the benefits will not be realized Most existing HIT applications operate within a single provider organization, and they require changes of only the staff of that organization Even within a single organization, those changes... Combined Effects of Disease Management and Lifestyle Change for Various Participation Rates 139 Summary Potential Net Benefits of Interventions 154 Summary A patient trajectory is the sequence of events that involves the patient with the healthcare system An intervention can affect trajectories by improving health, thereby reducing healthcare utilization or replacing a costly form of utilization . (2005). xviii Analysis of Healthcare Interventions That Change Patient Trajectories prevalences) of a number of conditions that require substantial amounts of healthcare. Because. MEPS-Based Estimates 17 Introduction 17 vi Analysis of Healthcare Interventions That Change Patient Trajectories Precision of Estimates from the MEPS Database