Clinical Practice Guidelines

Economic Effects of Clinical Practice Guidelines

Co-Prinicipal Investigator: Brad Doebbeling, MD, MSc

Project Number IIR 02-011 funded by the VA Health Services Research and Development

October 1, 2004-December 31, 2007

The primary goal of this project is to determine the extent to which the adoption and implementation of clinical practice guidelines leads to changes in the costs of providing care within a healthcare system.  Our main objective is to statistically evaluate the effect of two clinical practice guidelines on treatment costs in the VA healthcare utilization patterns and treatment costs. The net result of these changes is short-run cost increases followed by overall cost decreases long term. We propose to study the economic effects of two national VA clinical practice guidelines, diabetes mellitus (DM) and major depressive disorder (MDD), disseminated to VAMC directors in FY98 for system wide implementation, and for which we have extensive data on organizational factors, implementation approaches, and efforts to improve quality. Our project has three aims: (1) Classify VA facilities according to the strategies and intensity of DM and MDD guideline implementation; (2) Determine the extent to which the strategies and intensity of DM and MDD guideline implementation at VA facilities is associated with differences in resource utilization; and (3) Determine the extent to which the strategies and intensity of guideline implementation at VA facilities is associated with differences in treatment costs.  The empirical testing of each of these aims will make use of a unique research tool—a comprehensive VA database created for the purposes of this study that will link together a large national cohort of well-characterized patients in the 1999 Large Health Survey of Veteran Enrollees (LVHS), national guideline, quality improvement and organizational data collected by our study group, and cost data developed by the VA Health Economics Resource Center (HERC).  The 1999 LVHS will serve as the study cohort.  We will focus on patients with the primary diagnosis of DM or MDD, confirmed by rigorous algorithms that consider clinical and administrative data on utilization, testing and treatment.  LVHS respondents will be allocated to VAMCs in which they receive most of their care within a given year, and will be tracked over the six-year period. We will use the database to estimate a set of multivariable statistical models wherein various measures of utilization and treatment cost serve as dependent variables (i.e., we will estimate what economists refer to as “production functions” and “cost functions”). Determining the impact of practice guideline implementation on costs within a healthcare system will contribute importantly to a growing body of health services literature on creating a “business case for quality.” The project will also provide insight into organizational structure and process factors that influence institutional efforts to translate evidence into best practice and bridge the quality chasm. The results will in turn enable clinicians, managers, and policy makers to gain a better understanding of the resource implications associated with changes in clinical and organizational structures and processes.