Value-based health care in inflammatory bowel diseases : creating the value quotient

The essence of VBHC is to improve patients' outcomes at lower costs. This thesis attempts to construct the value quotient (vQ) for IBD: a metric for value which incorporates patient value, defined as a combination of disease control, quality of life, and productivity in the numerator, and divides it by the associated IBD-related costs in the denominator. In this thesis we showed the feasibility of monitoring clinical disease control remotely using a mobile app, we showed the impact of IBD on work productivity, and we developed a patient-centric composite score that incorporates all three outcomes as well as individual patient preferences. However, metrics for long term outcomes still need to be incorporated in the vQ. Although ideally this would be done by measuring disease outcomes long-term, this is not practical for short-term improvements. Process measures that are associated with long term outcomes and that are well-grounded in the medical literature offer a feasible short term alternative. Future research is needed to assess which process measures would be appropriate in this context, and to develop a quantifiable way to include these in the vQ.Leiden University Medical Center, Department of Gastroenterology and Hepatology / University of California, Los Angeles, Center for Inflammatory Bowel DiseasesUBL - phd migration 201

A retrospective data analysis in veterans with inflammatory bowel disease: Using Wagner\u27s Chronic Care Model to explore medication adherence

Background Medication adherence in inflammatory bowel disease (IBD) ranges between 7-72% . Increased healthcare utilization has been associated with non-adherence in IBD. Wagner\u27s Chronic Care Model (CCM) posits that care coordination between primary and gastroenterology (GI) specialty care could improve adherence and healthcare utilization. Methods Guided by the CCM, a retrospective analysis was conducted in veterans with IBD to: describe medication adherence rates; describe healthcare utilization measured by ER visits and inpatient admissions; and describe care coordination measured by primary care and GI specialty care use. A secondary study aim was to explore the relationships between those key outcome variables and select demographic/health history characteristics. A local Veteran\u27s Affairs database was used to extract a cohort of individuals with Crohn\u27s disease and ulcerative colitis for fiscal year (FY) 2011. Medical utilization and IBD medication refills were collected. A dichotomized medication possession ratio (MPR .80) was used in logistic regression to identify factors affecting medication adherence. Logistic regression was also used to examine factors affecting ER visits, inpatient utilization, and care coordination. Results The cohort consisted of 165 White male veterans 75 with Crohn\u27s disease and 89 with ulcerative colitis. The overall rate of adherence was 50.9% with a median MPR of .82. Regression models did not render any statistically significant predictors of adherence. ER utilization was significantly associated with adherence (OR=.314, 95%CI=.111-.886, p=.029) and care coordination (OR=45.73,95%CI=9.053-231,p=.001) in multivariate analysis. Inpatient admission was associated with: younger age (OR=.108,95%CI:.019-.609,p=.012), adherence (OR=.113,95%CI=.014-.939,p=.044), IBD diagnosis (OR=.117,95%CI=.017-.784,p=.027), and care coordination (OR=11.89,95%CI=1.228-115,p=.033). Logistic regression identified statistically significance associations with care coordinated between primary and GI specialty care and the following factors: taking both a 5-ASA and immunomodulating medication (OR=5.122,95%CI=1.874-14.00, p=.001), younger age (OR=.905,95%CI=.871-.940,p=.001), and having a comorbidity (OR=2.643,95%=1.171-5.965,p=.027). Conclusions No predictors of medication adherence emerged. However, the CCM element of care coordination provided additional insight into the healthcare utilization of veterans with IBD as statistically significant associations between care ER visits and hospitalization were identified. Further inquiry into the influences of medication adherence and healthcare utilization in this population is warranted

Economic Evaluation of Biological Therapy Use among Patients with Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory disorder that substantially impairs quality of life for patients and entails enormous economic burden to the US society. Biological therapies can effectively treat Crohn's disease. The treatment strategy of using biological therapy for CD is currently shifting from the conventional 'bottom-up' approach that reserves biological therapy as the last medical resort to a more aggressive 'top-down' approach that endorses early use of biological therapy. This dissertation sought to evaluate the impact of this shift in treatment on healthcare utilization by CD patients and healthcare costs to payers. First, we examined healthcare utilization and costs for CD patients in a large claims database dating from 2005 to 2009. We found that early biological users had lower utilization of inpatient services and higher prescription drug costs than late biological users. Annual medical costs for both biological user groups were comparable. We constructed a decision tree model and conducted budget impact analysis to predict the financial ramifications for third party payers of the change in prescription drug costs resulting from top-down treatment approach. Our results showed that the top-down approach of biological therapy was associated with increased prescription drug costs in the first year of disease. Incremental drug costs from top-down approach were significantly reduced in the second and third years following CD diagnosis. Last, we conducted a cost analysis to compare total healthcare costs for patients who adopted biological therapy following top-down or bottom-up approach. We found that patients following the top-down strategy incurred higher healthcare costs in the first year of disease. In the second and third years, the top-down strategy appeared to be cost neutral, which was mainly attributed to a cost reduction in non-drug services. In conclusion, novel biological therapies have been increasingly used among CD patients, and the new top-down treatment strategy can affect allocation of healthcare costs. Top-down treatment approach resulted in higher prescription drug costs for patients, especially in the first year of disease, when compared to patients following the conventional bottom-up approach. The top-down strategy for CD is projected to be cost neutral in the long term.Doctor of Philosoph

Ökonomische Dimensionen der Versorgungsforschung

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