Using a Health Economic Framework to Prioritize Quality Indicators: An Example With Smoking Cessation in Chronic Obstructive Pulmonary Disease

Abstract

Background. Health care performance monitoring is a major focus of the modern quality movement, resulting in widespread development of quality indicators and making prioritizations an increasing focus. Currently, few prioritization methods of performance measurements give serious consideration to the association of performance with expected health benefits and costs. We demonstrate a proof-of-concept application of using a health economic framework to prioritize quality indicators by expected variations in population health and costs, using smoking cessation in chronic obstructive pulmonary disease (COPD) as an example. Methods. We developed a health state transition, microsimulation model to represent smoking cessation practices for adults with COPD from the health care payer perspective in Ontario, Canada. Variations in life years, quality-adjusted life years (QALYs), and lifetime costs were associated with changes in performance. Incremental net health benefit (INHB) was used to represent the joint variation in mortality, morbidity, and costs associated with the performance of each quality indicator. Results. Using a value threshold of $50,000/QALY, the indicators monitoring assessment of smoking status and smoking cessation interventions were associated with the largest INHBs. Combined performance variations among groups of indicators showed that 81% of the maximum potential INHB could be represented by three out of the six process indicators. Conclusions. A health economic framework can be used to bring dimensions of population health and costs into explicit consideration when prioritizing quality indicators. However, this should not preclude policymakers from considering other dimensions of quality that are not part of this framework.

Keywords: COPD; health economics; quality indicators; smoking cessation.

Figure 1

Health state transition model.

Figure 2

Flow diagram of process indicators in the model. Process indicators influence the occurrence of other process indicators, intermediate events, and the abstinence rate.

Figure 3

Total variation in life years, quality-adjusted life years, costs, and net health benefit associated with smoking cessation quality indicators. Incremental outcomes between performance levels of 0% to 100%. Bars are positioned around outcomes at baseline performance levels (vertical line). Maximum range represents combined changes to all process indicators and does not include explicit changes to outcome indicators.