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The American Journal of Managed Care September 2013
Referring Patients for Telephone Counseling to Promote Colorectal Cancer Screening
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Improving BP Control Through Electronic Communications: An Economic Evaluation
Paul A. Fishman, PhD; Andrea J. Cook, PhD; Melissa L. Anderson, MS; James D. Ralston, PhD, MPH; Sheryl L. Catz, PhD; David Carrell, PhD; James Carlson, PharmD; and Beverly B. Green, MD, MPH
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Improving BP Control Through Electronic Communications: An Economic Evaluation

Paul A. Fishman, PhD; Andrea J. Cook, PhD; Melissa L. Anderson, MS; James D. Ralston, PhD, MPH; Sheryl L. Catz, PhD; David Carrell, PhD; James Carlson, PharmD; and Beverly B. Green, MD, MPH
Home blood pressure (BP) monitoring and use of secure webbased tools to manage care collaboratively with pharmacists is a cost-effective way to improve BP control.
We estimate the change in life-years for each intervention arm (identified by the subscript i) by summing across time periods (identified by the subscript t) from the point an individual enrolled in the program for the remainder of their expected life. The  probability of improved blood pressure control is derived from the trial results reported in Green et al4 and the change in life expectancy is derived from 2 sources: average life expectancy for adults in the United States as reported by the US Social Security Administration18 and evidence from the scientific literature on the impact that uncontrolled hypertension has on life expectancy.19-23 Our estimates of changes in life expectancy attributable to controlled hypertension is based on the experience of a cohort of 50-year-old men and women in order to reconcile evidence from the published literature and data available from Social Security. To estimate the present value of the impact that the current investment in BP control has on life-years saved we discount the stream of increased life expectancy using alternative values for the social rate of discount between 3% and 7%  (represented as r in equation 2) as recommended by several leading guides to the economic evaluation of health programs.16,17 Life expectancy and the impact that uncontrolled BP has on life expectancy differ by gender and we therefore present separate ICER results for controlled BP–attributable life-years saved for men and women.

Cost assignment for each intervention arm is based on the project team’s report of resources used to deliver each intervention arm and an activity accounting model method24 for allocating costs incurred in delivering the interventions. Activity accounting uses micro-costing to assign unit costs to every physical and human resource required to deliver an intervention. To micro-cost the intervention, we identified each resource used to deliver each component of each intervention, whether this was staff time, office space, supplies, or travel time. Unit costs relevant to each resource, for example hourly wage, rent per square foot of office space, or cost per sheet of paper, were multiplied by the total units of each resource used to deliver the intervention. The sum of these amounts was the total costs for each intervention. We assume that a health plan would incur all of the expenditures required to deliver the intervention except for building and maintaining the health plan’s information systems. Dollar values used were 2009 local market costs for personnel, office space, and furnishings, to avoid idiosyncrasies in Group Health’s  purchasing or human resource policies. We estimate the range of intervention costs by examining possible and plausible  variation in both the unit costs and the amount of each resource used to deliver each intervention.

Costs associated with UC include identifying patients with uncontrolled BP and informing them of their clinical status and distributing Group Health pamphlets. Additional BPM costs incurred include a face-to-face session in which patients were instructed on the resources available on the MyGroupHealth website including the secure messaging feature and medication refills, and training on the home BP monitor, which project records indicate took about 1 hour. The cost of the monitor was based on the negotiated rate that would likely be available to any purchaser ordering the devices in bulk.

Most of the incremental cost for e-BP patients is the effort spent by clinical pharmacists being trained in evidence-based management of hypertension and in direct patient contact.Pharmacists also met with a senior clinical pharmacist and physicians to review patient progress and medication regimens and to monitor potential adverse events and treatment programs. Three clinical pharmacists that evenly divided the 261 randomized patients into equally sized patient panels of 87 individuals each spent an average of 4 hours per week—with this weekly average based on project logs maintained by each pharmacist—answering patient secure messages and reviewing edical records, and an additional 2 hours per month on average assessing patient progress with a senior clinical pharmacist.

We assess incremental cost-effectiveness based on mean point estimates and test the sensitivity of our findings by estimating 95% confidence intervals though a bootstrap method for each ICER.25

RESULTS

The parameters used to estimate ICER in the model are reported in Table 2, with details on the estimation of per patient costs reported in Table 3. Mean UC costs of $10.56 (range: 8.48-12.64) were driven by the time spent by project staff identifying and contacting health plan members and measuring their BP. Mean costs for the BPM arm of $67.36 (53.88-80.83) include the 1 hour spent training each patient on the website and the home BP monitor and the cost of the monitor. The e-BP program includes all of these costs plus training and supervising the pharmacists, with time spent by pharmacists managing patients’ medication regimens being the primary factor in the $400.36 (263.41-565.77) per patient cost. Data on mm HG systolic and diastolic BP and BP control reported in Table 2 were discussed above and are obtained directly from trial results.

Mean life expectancy for 50-year-old men and women in the United States in 2009 was 28.9 and 32.7 years for men and women respectively. Published evidence from randomized trials reported that controlled BP results in an increased life expectancy ranging from 3.4 to 6.2 years for men and 1.6 to 4.9 years for women. By applying equation 2 to the actuarial data on life expectancy, the range of values for the impact that controlled BP has on life expectancy, the range of values for BP control, and the alternative social rates of discount, we generate estimates of the discounted change in life-years saved attributable to each intervention arm. As reported in Table 2, the present discounted change in life-years saved attributable to each intervention arm ranges from 0.25 years (95% CI: 0.18-0.32) for women receiving UC to 0.53 years (0.37-0.69) for men receiving the e-BP program. The relative increase in life expectancy for both men and women achieved through the BPM arm was not statistically different from the UC arm, a result driven by the fact that the BPM arm did not result in improved BP control relative to UC. The increase in life expectancy for the e-BP arm relative to BPM is on average 0.18 years for men and 0.15 years for women (P <.10).

ICER estimates for each outcome are reported in Table 4. Because there was no statistically significant improvement in BP control or for the change in diastolic BP for the BPM arm relative to UC, these ICERs are dominated, which means that the additional costs associated with BPM do not yield an improved outcome on these measures. The BPM arm did achieve significant improvements in systolic BP with an ICER of $29.63 (27.23-32.03) per mm HG systolic BP.

The ICERs for e-BP relative to BPM reported in Table 4 are $16.65 (95% CI 15.37-17.94) for each percent increase in the percent of patients with BP control, $65.29 (59.91-70.67) and $114.82 (111.90-117.74) per mm HG for each decrease in systolic and diastolic BP respectively, and $1850 (1635.76- 2064.24) and $2220 (1745.09-2694.91) per year for life-years saved for men and women, respectively.

DISCUSSION

In a healthcare system with an existing patient-shared EMR and secure messaging, the addition of home BP monitoring and web-based pharmacist care improved BP control by 25% at a mean per patient cost of $400 and an incremental cost of $16.65 per 1% increase in number of patients with BP control. The pharmacist-led program achieved lower systolic and diastolic BP at a cost of $65.29 and $114.82 per 1 mm HG and resulted in increased life expectancy at a cost of $1850 and $2220 per year of life saved for men and women, respectively. The 31% improvement in hypertension control among UC patients suggests that uncontrolled hypertension may be addressed in the short run with a brief intervention that identifies the issue for patients and provides them with minimal self-management tools. However, some of the improvements in the UC group might have been related to regression to the mean,15 the normal variation in blood pressure measurement, or the Hawthorne effects of volunteering to participate in a study.16

Few studies have evaluated the effectiveness and costeffectiveness of web-based quality of care interventions. In a recent comprehensive assessment of interactive information technology interventions for patients with chronic health conditions, those that included monitoring patient status to inform treatment decisions along with communications back to the patient were most likely to have a positive effect on health outcomes.26 We are unaware of any studies that examined the cost-effectiveness of using an existing EMR with a patient web portal to improve treatment outcomes.

Our research contributes to a small number of studies that have examined the cost-effectiveness of collaborative approaches to hypertension control. Soghikian et al27 report that patients provided a BP monitor had lower total healthcare costs resulting in a net program cost of $28 (in 1992 dollars) in the initial year and lower healthcare costs despite a lack of significant differences between home BP and UC and smaller reductions in systolic and diastolic BP than our study. Carter and colleagues’13 review of team-based interventions for hypertension care found only 1 economic analysis,28 which found that patients in a pharmacist-managed hypertension clinic group had significantly (P <.001) lower mean BP at 1 year than patients in UC. Although the costs of managing the 2 approaches were similar (approximately $240 per patient in 1998 dollars), cost per outcome was lower in the pharmacist-managed group ($27 vs $193/mm Hg systolic BP, and $48 vs $151/mm Hg diastolic BP). Reed et al29 evaluated a multi-component telephonic behavioral lifestyle intervention and patient self-monitoring to improve hypertensioncontrol, which resulted in significantly lower systolic BP relative to UC at a cost of $416 (SD $93) in 2008 US dollars. The authors do not report a cost-effectiveness analysis, but our analysis of the published data yields an ICER of the joint intervention of $31 per mm Hg reduced systolic BP.

We note several limitations with our study. First, the trial was conducted within an integrated healthcare system that had already invested in the necessary information technology infrastructure. In addition to leveraging investments in health information technology, integrated systems facilitate the interaction within and among clinical care teams on which the e-BP program relied. Most Americans must still bundle their healthcare from providers that practice independently from one another, making it difficult to achieve the level of care coordination possible within integrated systems. The incentives for providers to create and join accountable care organizations may facilitate the translation of programs such as the e-BP to community settings that do not have the organization advantages of integrated systems such as Group Health.

 
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