Economic Analysis of an Information Technology-Assisted Population-Based Cancer Screening Program (Massachusetts)

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Summary:

Despite the high cost of health care and the increasing adoption of basic health information technology (IT), studies reveal that only half of eligible patients are up-to-date on all indicated preventive cancer screening tests in a given year. Currently, preventive care is delivered in the context of routine visits, however non-visit-based strategies for improving preventive care have the potential to improve clinicians’ ability to successfully provide this care.

The Massachusetts General Hospital Primary Care Practice-based Research Network (MGPC PBRN) developed an innovative health information technology (IT) approach that they applied to comprehensive cancer screening. The program, the Technology for Optimizing Population Care in a Resource-limited Environment (TopCare), uses a health IT interface to facilitate the identification, individualized outreach, and subsequent tracking of patients who are overdue for breast, cervical, and colorectal cancer screening.

This project evaluated the cost of cancer screening reminders either through an automated, escalating outreach program alone (augmented standard care [ASC]), or an extension of that program via TopCare. ASC used an outreach algorithm to encourage overdue patients to be screened. The TopCare program leveraged providers’ personal knowledge to update patients’ screening status or designate them for specific outreach strategies including a personalized letter, phone, or outreach from a navigator.

The specific aim of this project was to:

  • Evaluate the marginal cost per patient screened of the TopCare and augmented standard care programs compared to baseline standard care from an integrated care organization perspective. 

Micro-costing techniques were used to estimate the costs of the technology, training for the technology, mailing materials, and clinical staff time over 1 year. Software costs were estimated from the perspective of a provider organization implementing a custom system. The cost of the software was estimated by a consulting firm that examined the software and interviewed the IT staff who developed it to understand the software’s structure, how it was developed, and the time it took to construct critical components of the software infrastructure. These included coding the algorithm that translates clinical data into guideline-based screening recommendations; coding to execute data transfer between various clinical health IT systems as necessary to build the registry; project management; and the development of a refined user interface that clinicians in the TopCare network were comfortable engaging. Hardware and software costs of the existing systems were not included.

Over the study period, ASC achieved identical screening success compared to TopCare. The cost of ASC was estimated at approximately $167,000 and TopCare at approximately $215,000. The costs for both were driven by the cost of the underlying software. The project team concluded that standardized software design could reduce one-time costs and make such an intervention more cost-effective than traditional care.

Economic Analysis of an Information Technology-Assisted Population-Based Cancer Screening Program - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality through Health Information Technology (IT) (R03)
  • Grant Number: 
    R03 HS 020308
  • Project Period: 
    March 2011 – February 2013
  • AHRQ Funding Amount: 
    $100,000
  • PDF Version: 
    (PDF, 289.38 KB)

Summary: The Massachusetts General Hospital Primary Care Practice-Based Research Network (MGPC PBRN) has developed an innovative health information technology (IT) approach that is being applied to comprehensive cancer screening. The program, Technology for Optimizing Population Care in a Resourcelimited Environment (TOP-CARE), uses a health IT interface to facilitate the identification, individualized outreach, and subsequent tracking of patients overdue for breast, cervical, and colorectal cancer screening.

The purpose of this project is to study TOP-CARE’s impact on improvements beyond the use of automated reminders, particularly with regard to its unique outreach strategy, which is based on the provider’s individual knowledge of each of his or her patients. More specifically, this is an economic analysis of alternative strategies for improving cancer-screening rates in the context of a large provider organization. Utilizing data that was collected during an initial randomized trial on costs, preferences, and clinical and process outcomes, this study will compare increasingly intensive interactions from baseline standard of care (BSC) and augmented standard care (ASC) to the TOP-CARE intervention. For the purpose of this study, BSC refers to visit-based reminders, whereas ASC is defined as a population-level reminder system with automated patient outreach. TOP-CARE is more intense than BCS or ACS due to its individualized outreach approach.

By examining the incremental cost-effectiveness of increasingly intensive interventions, this project is assessing the impact of technologically improved care management in large primary care networks. The analysis will determine the extent to which investments in health IT systems, combined with primary care providers’ knowledge of their patients, yield improvements in breast, cervical, and colorectal cancer screening rates. Ultimately, the study will help determine whether ASC and TOP-CARE interventions are worth the additional investment in health IT and physician time. Evaluating the efficiency of health IT-assisted population-based care is essential to determine if it is a strategy worth disseminating broadly.

In order to achieve the project aim, the study team established five milestones: 1) gathering wage data; 2) developing BSC time-use estimates from surveys; 3) developing time-use estimates from survey data and direct observation for the TOP-CARE intervention and ASC; 4) developing software cost estimates; and 5) conducting the cost-effectiveness and sensitivity analyses.

Specific Aim:

  • Evaluate the marginal cost per patient screened of the TOP-CARE and augmented standard care programs compared to baseline standard care from an initial cash outlay perspective. (Ongoing)

2012 Activities: The focus of activity was on completing the collection of wage data, developing the timeuse estimates from direction observation, and developing the software cost estimates. Dr. Levy and his study team received wage data for physicians, navigators, and delegates, and staff responsible for managing patient responses to the TOP-CARE-related mailings. The data was used to determine an average hourly rate for various levels of staff. These rates were then used to calculate the estimated costs associated with cancer screening using TOP-CARE and ASC programs compared to BSC.

Dr. Levy and his project manager visited two clinics participating in TOP-CARE to observe how staff interacted with the tool and to observe time use. In addition to clinic staff, delegates and physicians were observed to track the amount of time it took delegates to contact patients on their list and how long it took physicians to review the patient record using the TOP-CARE tool. When physicians could not be observed, a self-timed measurement was used to supplement the data. Subsequent to direct observations and selftimed measurements, the project team fielded a followup study to capture any changes relative to the time use that was measured at baseline. The study team then analyzed the changes in time use.

The development of software cost estimates was achieved with assistance from a technology consultant who developed a full report that estimated the cost of implementing the TOP-CARE tool and included a detailed list of all the cost components.

As last self-reported in AHRQ’s Research Reporting System, project progress and activities are on track in some respects but not others and project budget spending is on target. In 2012 there was some delay in data availability as well as a slight reduction in the amount of time Dr. Levy was available to devote to the project, which resulted in the need to use a 6-month no-cost extension through the end of February 2013. A programmer-analyst was hired to help Dr. Levy complete the analysis and write up the results by the end of the no-cost extension period.

Preliminary Impact and Findings: The project has no findings to date.

Target Population: Adults, Cancer

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Economic Analysis of an IT-Assisted Population-Based Cancer Screening Program - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-268: Small Research Grant to Improve Health Care Quality through Health Information Technology (IT) (R03)
  • Grant Number: 
    R03 HS 020308
  • Project Period: 
    March 2011 - August 2012
  • AHRQ Funding Amount: 
    $100,000
  • PDF Version: 
    (PDF, 191.58 KB)

Summary: The Massachusetts General Hospital Primary Care Practice-based Research Network (MGPC PBRN) has developed an innovative health information technology (IT) approach that is currently being applied to comprehensive cancer screening. The program, the Technology for Optimizing Population Care in a Resource-limited Environment (TOP-CARE), is using a health IT interface to facilitate the identification, individualized outreach, and subsequent tracking of patients overdue for breast, cervical, and colorectal cancer screening.

This project is looking at TOP-CARE's impact on improvements beyond the use of automated reminders, particularly with regard to its unique outreach strategy, which is based on the provider's individual knowledge of each of his/her patients. More specifically, this is an economic analysis of alternative strategies for improving cancer screening rates in the context of a large provider organization. Utilizing data that was collected during the initial randomized trial on costs, preferences, and clinical and process outcomes, this study will compare increasingly intensive interactions from Baseline Standard of Care (BSC) and Augmented Standard Care (ASC) to the TOP-CARE intervention. For the purpose of this study, BSC refers to visit-based reminders, whereas ASC is defined as a population-level reminder system with automated patient outreach. TOP-CARE is more intense than BCS or ACS due to its individualized outreach approach.

By examining the incremental cost-effectiveness of increasingly intensive interventions, this project will assess the impact of technologically-improved care management in large primary care networks. The analysis will determine the extent to which investments in health IT systems, combined with primary care providers' unique knowledge of their patients, yield improvements in breast, cervical, and colorectal cancer screening rates. Ultimately, the study will help determine whether ASC and TOP-CARE interventions are worth the additional investment in health IT and physician time. Evaluating the efficiency of health IT-assisted population-based care is essential to ensuring it is a strategy that can be disseminated broadly.

Specific Aim:

  • Evaluate the marginal cost per patient screened of the TOP-CARE and augmented standard care programs compared to baseline standard care from an ICO perspective. (Ongoing)

2011 Activities: In order to achieve the project aim, the study team has established five milestones: 1) gathering wage data; 2) developing BSC estimates from surveys; 3) developing time use estimates from survey data and direct observation for the TOP-CARE intervention and ASC; 4) developing software cost estimates; and 5) conducting the cost-effectiveness and sensitivity analyses. The focus during 2011 was on the milestones related to gathering wage data and developing the BSC and time estimates.

In their effort to gather wage data, the study team worked closely with the TOP-CARE staff to assess all active users of the system, including primary care physicians, nursing staff, medical assistants, patient coordinators and secretaries, and administrative staff. While all providers have been identified, the team continues to identify all the patient navigators who are using the system. Wage data for the intervention staff has been obtained and cost estimates are being calculated based on the average wage for each job class applied to the average daily cost of time devoted to cancer screening activities during BSC.

To determine the BSC estimates, the study team has identified the variables necessary for cost analyses, including the nature of the data and whether it would be available from current data systems. Information that will require survey methodology was identified. The survey instrument for primary care physicians, practice delegates, and navigators was developed, as well as a strategy to field the surveys to all TOP-CARE clinical personnel. The survey was administered in paper form to primary care providers and practice delegates during initial meetings and training sessions. Providers who were not present during the initial meeting or who did not turn in a completed survey were subsequently sent an electronic version and another paper copy. The survey will be re-administered at the completion of the study.

Time estimates for using the intervention and ASC are being established by evaluating the personnel time use by health IT personnel, physicians, case managers, delegates, and patient navigators. Training sessions on how to use the system were conducted beginning in May 2011 and health IT staff documented the time spent in initial training sessions and followup training sessions to reflect part of the implementation costs of TOP-CARE. The staff is also documenting time spent on additional support and training activities on an ongoing basis. Direct observation of system users will occur in the near future.

As last self-reported in AHRQ's Research Reporting System, the project progress and activities are on track and project budget spending is on target.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Adults, Cancer

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Economic Analysis of an Information Technology-Assisted Population-Based Cancer Screening Program - Final Report

Citation:
Levy D. Economic Analysis of an Information Technology-Assisted Population-Based Cancer Screening Program - Final Report. (Prepared by Massachusetts General Hospital under Grant No. R03 HS020308). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 90.26 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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