Page 1 of 1

Appendix F: The Expected Population Value of Quality Indicator Reporti

Future Directions for the National Healthcare Quality and Disparities

Appendix F. The Expected Population Value of Quality Indicator Reporting (EPV-QIR): A Framework for Prioritizing Healthcare Performance Measurement

Appendix C: Data Sources Used in EVQI Calculations Presented in This Report

[NHQR_DMHTN] Percent of adults with diagnosed diabetes with most recent blood pressure <140/80 mm/Hg.

Costs and Effectiveness
  • The CDC Diabetes Cost-Effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for Type 2 diabetes. JAMA 2002; 287(19):2542-2551.
  • Note—this study evaluated an intervention involving the use of ACE-I or Beta-blocker to achieve a blood pressure of <144 /82 mmHg compared to "usual care."
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
  • Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
Current Implementation Rate
  • NHQR 2008 (Data from 2003-6).

[NHQR_DMCHOL] Adults age 40 and over with diagnosed diabetes with total cholesterol <200 mg/dL.

Costs and Effectiveness
  • The CDC Diabetes Cost-Effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for Type 2 diabetes. JAMA 2002; 287(19):2542-2551.
  • Note—this study evaluated an intervention involving the use of Pravastatin to achieve a serum cholesterol level < 200mg/dL compared to "usual care."
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
  • Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
Current Implementation Rate
  • NHQR 2008 (Data from 2003-6).

[NHQR_DMFOOT] Adults age 40+ with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year.

Costs and Effectiveness
  • Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care 2004;27:901-907.
  • Note—this study evaluated an intervention involving a program of "optimal foot care" designed to achieve a 0% reduction in foot lesions compared to "usual care."
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
  • Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
Current Implementation Rate
  • NHQR 2008 (Data from 2005).

[NHQR_DMHBA1C] Percent of adults with diagnosed diabetes with HbA1c level <9.5% (poor control); <7.0 (optimal); <9.0 (minimally acceptable).

Costs and Effectiveness
  • The CDC Diabetes Cost-Effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for Type 2 diabetes. JAMA 2002; 287(19):2542-2551.
  • Note—this study evaluated an intervention involving the use of insulin/sulfonylurea to achieve a glycemic level < 108 mg/dL or 6 mmol/L compared to "usual care."
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
  • Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
Current Implementation Rate
  • NHQR 2008 (Data from 2003-6).

[NHQR_HIVEVER] People ages 15-44 who ever received an HIV test outside of blood donation.

Costs and Effectiveness
  • Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, Douglass LR, Lazzeroni LC, Holodniy M, Owens DK. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. NEJM 2005;352:570-85.
  • Note—this study evaluated HIV testing at age 43 in a population with a 1% prevalence of HIV. We used estimates of the costs and health benefits accruing to the individual tested, and ignore costs and benefits due to spillover to the individual's partner.
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
Current Implementation Rate
  • Kaiser State Health Facts, 2001.

[NHQR_PAP3YR] Percent of women (age 18 and over) who report they had a Pap smear within the past 3 years.

Costs and Effectiveness
  • The CDC Diabetes Cost-Effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for Type 2 diabetes. JAMA 2002;287(19):2542-2551.
  • Note—this study evaluated an intervention involving the use of insulin/sulfonylurea to achieve a glycemic level < 108 mg/dL or 6 mmol/L compared to "usual care."
Population
  • Table 2: Annual Estimates of the Resident Population by Sex and Selected Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-02). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
Current Implementation Rate
  • BRFSS 2005

[NHQR_DMEYE] Adults age 40+ with diagnosed diabetes who received a dilated eye examination in the calendar year.

Costs and Effectiveness
  • Vijan S, Hofer TP, Hayward RA. Cost-utility analysis of screening intervals for diabetic retinopathy in patients with Type 2 diabetes mellitus. JAMA 2000;283(7):889-896.
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
  • Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
Current Implementation Rate
  • NHQR 2008 (Data from 2005).

[NHQR_CRC50EVERCOLON] Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy.

Costs and Effectiveness
  • Frazier AL, Colditz GA, Fuchs CS et al. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA 2000;284(15):1954-1961.
  • Note—this study evaluated annual FOBT in a population representative of the population of adults age 50+ in the U.S., but the study data come from white males age 50+.
  • Note—this study evaluated one-time colonoscopy at age 55.
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
Current Implementation Rate
  • BRFSS 2005.

[NHQR_BRCA2YRMAMM] Percent of women (age 40+) who report they had a mammogram within the past 2 years.

Costs and Effectiveness
  • Stout NK, Rosenberg MA, Trentham-Dietz A, Smith MA, Robinson SM, Fryback DG. Retrospective cost-effectiveness analysis of screening mammography. J Natl Cancer Inst 2006;98(11):774-82.
  • Note—this study evaluated biennial screening beginning at age 40 and ending at age 80.
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
Current Implementation Rate
  • BRFSS 2005.

[NHQR_CRCBIFOBT] Adults age 50 and over who received a fecal occult blood test (FOBT) in the last 2 years.

Costs and Effectiveness
  • Frazier AL, Colditz GA, Fuchs CS et al. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA 2000;284(15):1954-1961.
  • Note—this study evaluated annual FOBT in a population representative of the population of adults age 50+ in the U.S., but the study data come from white males age 50+.
  • Note—this study evaluated two types of FOBT�rehydrated FOBT (RFOBT) and unrehydrated FOBT (UFOBT). We used an averaged the NHBs associated with RFOBT and UFOBT in our calculations.
Population
  • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
Current Implementation Rate
  • BRFSS 2005.

[NHQR_CAPVACC65EVER] Percent of individuals age 65+ who ever received a pneumococcal vaccination.

Costs and Effectiveness
  • Sisk JE, Moskowitz AJ, Whang W, Lin JD, Fedson DS, McBean AM, Plouffe JF, Cetron MS, Butler JC. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA 1997;278:1333-1339.
Population
  • Table 2: Annual Estimates of the Resident Population by Sex and Selected Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-02). Source: Source: Population Division, U.S. Census Bureau. Release Date: May 14, 2009.
Current Implementation Rate
  • NHQR 2008 (2006).

[NHQR_BSICVC] Bloodstream infections (BSIs) per 1,000 central venous catheter (CVC) placements.

Costs and Effectiveness
  • Halton KA, Cook DA, Whitby M, Paterson DL, Graves N. Cost-effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision. Critical Care 2009;13(2):R35.
  • Note—costs were presented in 2006 Australian Dollars. We converted costs to 2006 U.S. Dollars using a historical currency exchange table, and then adjusted costs to 2009 U.S. Dollars using the Consumer Price Index.
Population
  • Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, controlled trial. Annals of Internal Medicine 1997;127(4): 257-66.
Current Implementation Rate
  • NHQR 2008 (2004).

[NHQR_AMIBB] Percent of AMI patients administered beta blockers prescribed at discharge.

Costs and Effectiveness
  • Phillips KA, Shlipak MG, Coxson P, Heidenreich PA, Hunink M, Goldman PA, Williams LW, Weinstein MC, Goldman. Health and economic benefits of increased beta-blocker use following myocardial infarction. JAMA 2000;284:2748-2754.
Population
  • 2005 National Hospital Discharge Survey. Available at: http://www.cdc.gov.
  • Population-weighted estimates of hospital discharges with 3-digit ICD-9-CM code = 410 as primary diagnosis.
Current Implementation Rate
  • NHQR 2008 (2004).

[NHQR_HFACE] Percent of hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed ACE inhibitor or ARB at discharge.

Costs and Effectiveness
  • Boyko WL Jr, Glick HA, Schulman KA. Economics and cost-effectiveness in evaluating the value of cardiovascular therapies. ACE inhibitors in the management of congestive heart failure: comparative economic data. Am Heart J 1999;137(5):S115-9.
Population
  • 2005 National Hospital Discharge Survey. Available at: http://www.cdc.gov.
  • Population-weighted estimates of hospital discharges with 3-digit ICD-9-CM code = 428 as primary diagnosis.
  • Prevalence of LVSD among patients with HF: Senior R, Galasko G. Cost-effective strategies to screen for left ventricular systolic dysfunction in the community—a concept. Congestive Heart Failure 2007;11(4):194-211.
    Also see:
    • Kelly R, Staines A, MacWalter R, Stonebridge P, Tunstall-Pedoe H, Struthers AD. The prevalence of treatable left ventricular systolic dysfunction in patients who present with noncardiac vascular episodes: a case-control study. J Am Coll Cardiol 2002;39(2):219-24.
Current Implementation Rate
  • NHQR 2008 (2004).

[NHQR_AMIACE] Percent of hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed ACE inhibitor or ARB at discharge.

Costs and Effectiveness
  • Tsevat J, Duke D, Goldman L, Pfeffer MA, Lamas GA, Soukup JR, Kuntz KM, Lee TH. Cost-effectiveness of captopril therapy after myocardial infarction. JACC 1995;26(4):914-919.
Population
  • 2005 National Hospital Discharge Survey. Available at: http://www.cdc.gov.
  • Population-weighted estimates of hospital discharges with 3-digit ICD-9-CM code = 410 as primary diagnosis.
  • Prevalence of LVSD among patients with AMI—we use an estimate of 27.2% in all patients hospitalized patients with AMI. This estimate was taken from the SOLVD Trial, as summarized in: Weir R McMurray JJ, Velazquez EJ. Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance. Am J Cardiol 2006;97[suppl]:13F-25F.
Current Implementation Rate
  • NHQR 2008 (2005-2006, all payers).

Calculation 3. Outcomes-Based Quality Measure�Standard of Care Not Specified. Bloodstream Infections (BSIs) per 1,000 Central Venous Catheter (CVC) Placements [NHQR BSICVC]

Standard of Care. This is an outcomes measure that tracks an adverse event during hospitalization, namely, bloodstream infection resulting from a central venous catheter. The standard of care is not defined. There are multiple processes of care that can reduce bloodstream infections associated with central venous catheter placements: for example, hand-washing, skin cleaning, and the use of antimicrobial dressing and antimicrobial-coated catheters. Because cost-effectiveness studies have investigated the use of coated catheters in reducing CVC-related BSIs, we use coated catheters as our standard of care in calculating the value of quality improvement with respect to reducing the number of CVC-related BSIs.

Number of Individuals Receiving Standard of Care and Non-Standard Care. We could not find data on the number of catheter placements in the U.S., so for our calculations, we used an estimate of the number of CVCs sold in the U.S. each year from Maki et al. (1997). This is likely to be an overestimate of the number of CVC placements in the U.S. Based on infection rates published in the 2008 NHQR, there were approximately 140,000 CVC-related BSIs in the U.S. (3% infection rate applied to a base denominator of 5 million catheters). We make an implicit assumption that an infection rate of zero is possible and desirable. Table A.3.1 shows our estimates of the denominator population and number of infections for the CVCBSI measure.

Table A.3.1 Number of Individuals Receiving Non-standard Care: CVCBSI

ParameterValueSource
Base Population5,000,000# of CVCs sold annually in U.S. Maki et al. (1997)
Current Infection Rate3%NHQR 2008 (2006) Rate of BSI in CVCs
N Infections140,000 

Source: Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, controlled trial. Annals of Internal Medicine 1997;127(4): 257-66.
NHQR 2008.

Calculation of Net Health Benefit. We use data from Halton et al. (2009) that compares the costs and effectiveness of various antimicrobial catheters compared to uncoated catheters in preventing infections. Although this study was conducted in Australia (and focused on the cost-effectiveness of antimicrobial catheters in intensive care units), this was the only study with usable, published estimates of costs and effectiveness in QALYs for uncoated catheters (comparator) as well as coated catheters (standard of care). Halton et al. evaluated four different types of coated CVCs relative to uncoated CVCs: chlorhexidine/silver sulfadiazine externally coated catheters; chlorhexidine/silver sulfadiazine internally and externally coated catheters; silver, platinum, and carbon-coated catheters; and minocycline and rifampicin-coated catheters. We calculated the NHB of each type of catheter relative to uncoated catheters. Table A.3.2 presents the components of the NHB calculation for the CVCBSCI measure for each catheter type, as shown in Column 1. This study only published the incremental cost and the incremental effectiveness of each coated catheter relative to uncoated catheters. Columns 2 and 3 present these numbers. We again assume a value of $100,000 for the cost-effectiveness threshold (Column 4). Column 5 presents our calculation of the NHB given incremental costs and effectiveness published in the study. Column 6 presents data from Halton et al. (2009) on the number of infections that use of each catheter type can prevent. We divided the NHB (Column 5) by the number of infections avoided (Column 6) to estimate the net health benefit per infection avoided, as shown in Column 7.

Table A.3.2 Calculation of Net Health Benefits: CVCBSI

Care TypeIncremental
Cost
Effective-
ness in QALYs
λ ($/QALY)Net Health Benefit
in QALYs
N Infections
Avoided
NHB QALYs per
Infections Avoided
Chlorhexidine silver sulfadiazine catheters
(external coat)*
-75,8560.91000100,0001.6685680.19864
Chlorhexidine silver sulfadiazine catheters
(internal+external coat)*
-41,5760.80000100,0001.2157670.16429
Silver, platinum and carbon catheters*-97,6341.23000100,0002.20634110.19354
Minocycline and rifampicin coated catheters*-105,9511.64000100,0002.69951150.17760
Uncoated central venous catheter (Baseline)  100,000   

Incremental cost and effectiveness are relative to baseline care type of uncoated central venous catheter utilization.
* Care Type compliant with quality measure.
Source: Halton KA, Cook DA, Whitby M, Paterson DL, Graves N. Cost-effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision. Critical Care 2009;13(2):R35.

EPV-QIR Calculations. Our EVQI calculations for the NHQR_CVCBSCI measure are shown in Table C.3. Again, each catheter type is displayed in Column 1 of Table A.3.3. We reason that NHBs gained per infection avoided, can also be viewed as the net health benefit lost for every infection that occurred. Thus, Column 2 presents the NHBs lost per infection under different catheter "regimes." Column 3 reports the NHB lost per infection under perfect implementation. This column is zero because under perfect implementation, we assume that there would be no bloodstream infections associated with central venous catheters. Column 4 reports the number of infections, which is 140,000 (Table C.1). The value of perfect implementation is zero, because this measure pertains to an adverse outcome that should not occur under perfect implementation. Thus, the only "gains" are losses averted. These losses are shown in Column 5. Compared to a regime where externally coated chlorhexidine silver sulfadiazine catheters are used exclusively, current implementation results in a loss of 27,809 QALYs. Compared to a regime in which minocycline and rifampicin-coated catheters are used exclusively, current implementation results in a loss of 24,864 QALYs. The value of quality improvement—which, in our analysis, implies switching regimes from uncoated catheters to a coated catheter, is equal to the absolute value of the QALYs currently lost. For example, the maximum value of quality improvement resulting from a switch from uncoated catheters to chlorhexidine silver sulfadiazine externally coated catheters is 27,809 QALYs.

Table A.3.3 The Value of Perfect and Current Implementation, and Quality Improvement: CVCBSI

Care TypeNHB QALYs
(Lost) per
Infection
NHB QALYs
(Lost) per Infection
Under Perfect Implementation
QALYs
N InfectionsPopulation
Value of Perfect
Implementation
(VPI) QALYs
Population
Value of Current
Implementation
(VCI) QALYs
Maximum
Population Value of Quality Improvement
QALYs
Chlorhexidine silver sulfadiazine catheters
(external coat)*
-0.198640.00000140,0000-27,80927,809
Chlorhexidine silver sulfadiazine catheters
(internal+external coat)*
-0.164290.00000140,0000-23,00123,001
Silver, platinum and carbon catheters*-0.193540.00000140,0000-27,09527,095
Minocycline and rifampicin coated catheters*-0.177600.00000140,0000-24,86424,864
Uncoated central venous catheter (Baseline)  140,000   

* Care Type compliant with quality measure.

Calculation 4. Complex Denominator Populations. Percent of hospital patients with heart attack and left ventricular systolic dysfunction who were prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at discharge [AMIACE]

Standard of Care. The standard of care in this measure is the receipt of a prescription for ACE/ARB at discharge among patients hospitalized for acute myocardial infarction (AMI).

Number of Individuals Eligible for the Standard of Care. We used the 2005 National Hospital Discharge Survey to obtain population-weighted estimates of the number of hospital discharges in the U.S. in 2005 that had a primary diagnosis of acute myocardial infarction (AMI)6, by age group. Age groups were defined on the basis of the cost-effectiveness study from which we obtain our estimates of costs and effectiveness, as we describe in the following section. Because the AMIACE measure applies only to hospital discharges with heart failure and left ventricular systolic dysfunction (LVSD), we assumed an LVSD prevalence of 27% among patients with AMI also based on data from the Valsartan in Acute Myocardial Infarction Trial (VALIANT) (Weir et al. 2006).

According to the 2008 NHQR, the current rate of implementation for ACE/ARB at discharge for patients with AMI and LVSD is 86% in the overall population of patients with AMI and LVSD. Rates stratified by age group are not reported. Thus, we made the assumption that current implementation rates did not differ by age group. Table A.4.1 reports our estimates of the number of patients receiving the standard of care in each age group.

Table A.4.1 Number of Individuals Receiving Standard and Non-standard Care: AMIACE

ParameterValueSource
Base Population—Age < 6051,054NHDS 2005 (AMI Discharges, age < 60), 27% LVSD
Base Population—60 ≤ Age < 7039,171NHDS 2005 (AMI Discharges, 60 ≤ age < 70), 27% LVSD
Base Population 70 ≤ Age95,470NHDS 2005 (AMI Discharges, age ≥ 70) 27% LVSD
Current Implementation Rate86%NHQR (2008) (2003-2006, All Payers)
N Receiving Standard of Care—Age < 6043,855 
N Receiving Standard of Care—60 ≤ Age < 7033,648 
N Receiving Standard of Care—Age ≥ 7082,008 
N NOT Receiving Standard of Care—Age < 607,199 
N NOT Receiving Standard of Care—60 ≤ Age < 705,523 
N NOT Receiving Standard of Care—Age ≥ 7013,461 

Source: 2005 National Hospital Discharge Survey.
Weir RAP, McMurray JJV, Velazquez EJ. Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics and prognostic importance. American Journal of Cardiology 2006;97[suppl]:13F-25F).

Calculation of Net Health Benefit. Data on the costs and effectiveness of ACE/ARB come from a cost-effectiveness study by Tsevat et al. (1995) on the use of Captopril (an ACE inhibitor) among survivors of AMI in three age groups: 50-60, 60-70, 70-80, and 80+ year-olds. We used figures from the "limited-benefit" model estimated by Tsevat et al., which assumes that ACE-I does not confer survival benefits beyond 4 years post-AMI. Table A.4.2 provides the inputs and final NHB calculations for ACE therapy in each age group (Column 1). Columns 2 and 3 report the costs and effectiveness of ACE-I and no ACE-I in each age group, and Columns 4 and 5 report the incremental costs and effectiveness. Note the much larger incremental difference in the effectiveness of ACE-I in the oldest age group compared to the youngest age group.

Table A.4.2 Calculation of Net Health Benefits: AMIACE

Care TypeCost per Person
in 2009 $USD
Outcomes
(QALYs per Person)
Incremental
Cost
Effective-
ness in QALYs
λ ($/QALY)Net Health Benefit
in QALYs
Age 50
No Captopril47,9838.10000  100,000 
Captopril*50,7158.130002,7320.03000100,0000.00268
Age 60
No Captopril38,6296.33000  100,000 
Captopril*41,2826.510002,6530.18000100,0000.15347
Age 70
No Captopril30,1764.72000  100,000 
Captopril*32,8995.070002,7220.35000100,0000.32278

Incremental cost and effectiveness are relative to baseline care type of no Captopril (no ACE/ARB).
* Care Type compliant with quality measure.
Source: Tsevat J, Duke D, Goldman L, Pfeffer MA, Lamas GA, Soukup JR, Kuntz KM, Lee TH. Cost-effectiveness of captopril therapy after myocardial infarction. Journal of the American College of Cardiology 1995;26(4):914-19.

Table A.4.3 shows the final EVQI calculations for ACEAMI. For each age group in Column 1, Column 2 of Table A.4.3 shows the NHB of ACE-I after AMI in that age group. Column 4 shows the number of patients in each age group who currently receive ACE-I, and the number who do not currently receive ACE-I after AMI. The value of perfect implementation is reported in Column 5, and represents the maximum NHB that would be obtained if all patients in each age group received ACE-I after AMI. Column 6 shows the value of current implementation, given extant rates of prescribing ACE-I at discharge. Column 7 shows the maximum potential NHB that can be gained from improving ACEAMI to 100% from current levels of implementation.

Table A.4.3 The Value of Perfect and Current Implementation, and Quality Improvement: AMIACE

Care TypeNet Health Benefit in QALYsNHB Under Perfect Implementation QALYsN PersonsPopulation Value of Perfect Implementation
(VPI) QALYs
Population Value of Current Implementation
(VCI) QALYs
Maximum Population
Value of Quality
Improvement QALYs
Age 50
No Captopril 0.002687,19919019
Captopril*0.002680.0026843,8551181180
Age 60
No Captopril 0.153475,5238480848
Captopril*0.153470.1534733,6485,1645,1640
Age 70
No Captopril 0.3227813,4614,34504,345
Captopril*0.322780.3227882,00826,47026,4700
Total  185,69436,96431,7525,212

* Care Type compliant with quality measure.


6 We identified hospital discharges with AMI based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code recorded under primary diagnosis (ICD-9-CM = 410).


Return to Appendix F

 

Current as of December 2010
Internet Citation: Appendix F: The Expected Population Value of Quality Indicator Reporti: Future Directions for the National Healthcare Quality and Disparities . December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/iomqrdrreport/futureqrdrapfapc.html