Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study

Abstract

Background: Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness.

Methods: We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided.

Results: Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered.

Conclusion: A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.

Keywords: Audit and feedback; Cost-effectiveness analysis; Injury; Low-value care.

Fig. 1

Decision-analytic model. In the status quo scenario, there is no implementation of the A&F module targeting LVPs. In the intervention scenario, an A&F module targeting LVPs is implemented at baseline (at the beginning of the 1st year). “Use data from year 1” means that data on the effectiveness and costs of A&F module from the 1st year are available at the beginning of the second year and so on for the following years

Fig. 2

Probabilistic sensitivity analysis comparing A&F module and status quo scenario (no A&F module targeting LVPs). The x-axis represents the incremental effectiveness, number of LVPs avoided. The y-axis represents the incremental costs between A&F module and status quo scenario. Each circle represents a single simulation for a total of 10,000 simulations

Fig. 3

Cost-effectiveness acceptability curve (CEAC) between A&F module and status quo scenario and cost-effectiveness acceptability frontier (CEAF). The x-axis represents the willingness-to-pay (WTP) for each LVP avoided. The y-axis represents the percentage of simulations in which the A&F module is cost-effectiveness relative to the status quo scenario at different WTP threshold. The switch point where the A&F module became a cost-effective intervention corresponds to $160 per LVP avoided, equal to the ICER estimate. A&F module became 100% cost-effective at a WTP of $1000 per LVP avoided. The A&F module had the highest expected net benefit, for all values of WTP greater than the ICER. At our ICER estimate, 50% of the distribution of ICERs were cost-effective