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Aim: Analyze the impact of nationwide implementation of teledermatological care for psoriasis. Methods: Develop a Markov model that estimates the impact of telehealth technology for treatment of moderate-to-severe psoriasis on health and healthcare expenditures compared with in-person clinical care. Results: Lower medical costs by US$1.5 billion and total social costs of US$4.3 billion over 5 years. Patients save more than 67 million hours in work absenteeism and travel time, valued at US$598 million. Employers save US$1.2 billion over 5 years due to decreased employee absenteeism. Conclusion: National implementation of telehealth for psoriasis care has the potential to substantially reduce both formal healthcare costs and informal costs for families and patients, while maintaining equivalent clinical outcomes as traditional in-person care.

Aim: To estimate the impact of universal anti-TNF therapy in patients with moderate-to-severe Crohn’s disease. Materials & methods: Developed a population-level Markov model to estimate the impact on health outcomes and medical expenditures of expanding anti-TNF therapy use versus current treatment practices. Results: Reductions in deaths (2600), hip fractures (980), major adverse cardiac events (2700) and patient out-of-pocket medical spending (2%) over 5 years. Total societal costs would be US$22,100 higher per patient per year, primarily due to the high cost of anti-TNF therapy. Conclusion: Expanding anti-TNF therapy use among US adult patients with moderate-to-severe Crohn’s disease would reduce morbidity and mortality, decrease disease-related medical costs and increase treatment costs compared with current practice. Despite the higher costs, this approach could substantially benefit patients.

Aim: Analyze the impact of national implementation of ‘low intensity’ post-treatment colorectal cancer surveillance compared with current practices. Materials & methods: Create a population-level Markov model to estimate impacts of expansion of low versus high intensity surveillance post-treatment on healthcare utilization, costs and caregiver time loss. Results: Shifting to low intensity colorectal cancer surveillance would reduce patient burden by 301,830 h per patient annually over 5 years. Cost reductions over 5 years were US$43.5 million for Medicare and US$4.2 million for Medicaid. Total societal cost savings equaled US$104.2 million. Conclusion: National implementation of low intensity post-treatment colorectal cancer surveillance has the potential to significantly reduce burden and costs on patients and their caregivers with no added risks to health.

Aim: To estimate the economic impacts of increased use of specialty care infusion centers for treating adults experiencing vaso-occlusive crises. Methods: A Markov model is developed to estimate the impact of expanding use of specialty care infusion centers to treat vaso-occlusive crises compared to emergency department care. Results: Access to infusion centers for sickle cell disease could result in savings over US$1.9 billion in formal medical costs and over US$2 billion in societal costs, based on uptake assumptions over 10 years. Conclusion: Expansion of adult sickle cell disease centers across the nation could lead to considerably better economic outcomes in the form of reduced costs and hospital length of stay in addition to improved clinical outcomes as reported in the existing literature.

Aim: Estimate the impacts treating acute respiratory tract infections (ARTIs) in children aged 6 months through 12 years with narrow-spectrum antibiotics. Materials & methods: Decision-tree model to estimate children’s health, healthcare utilization and costs, and caregiver’s time and costs for using narrow-spectrum antibiotics in eligible children with an ARTI, compared with current use of narrow- and broad-spectrum antibiotics. Results: Reduced adverse drug reactions by 35,750 (14%) cases) and 4750 (12%) fewer emergency department visits, 300 (12%) fewer hospitalizations, and 50,500 (10%) avoided outpatient visits. Annual healthcare costs fell by US$120 million (22%). Total societal costs declined by US$131 million (20%). Conclusion: National implementation of narrow-spectrum antibiotics to treat ARTIs in children improves patient outcomes and reduces caregiver burden and annual healthcare costs.

Objective: To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State. Design: Practice-level, randomized prospective evaluation. Setting: Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan). Participants: Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices). Intervention: For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. Aftereach chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care. Main Outcome Measures: Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis). Results: The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization forchildren in treatment relative to control practices. Conclusions: A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.

Aim: This article describes American Reinvestment and Recovery Act comparative effectiveness research data infrastructure (DI) investments and identifies facilitators and barriers to implementation. Materials & methods: We reviewed original project proposals, conducted an investigator survey and interviewed project officers and principal investigators. Results: DI projects assembled or enhanced existing clinical datasets, established linkages between public and private data sources and built infrastructure. Facilitators included building on existing relationships across organizations and making collection as seamless as possible for clinicians. Conclusion: To sustain DI, investigators should reduce the burden of comparative effectiveness research data collection on practices, adequately address data privacy and security issues, resolve or lessen the impact of data-linking issues and build research capacity for other investigators and clinicians.

Multidisciplinary, multi-institutional collaboration has become a key feature of comparative effectiveness research (CER), and CER funders have made promotion of these types of collaboration an implicit, and sometimes explicit, goal of funding. An important challenge in evaluating CER programs is understanding if and how different forms of collaboration are associated with successful CER projects. This article explores the potential use of social network analysis to address research questions about the associations between collaboration and the success of CER projects.

Aim: To describe the evaluation design of the American Recovery and Reinvestment Act of 2009 comparative effectiveness research (CER) investment, how funds were allocated and how CER priorities were addressed. Materials & methods: Primary and secondary data included information from redacted project proposals, an investigator survey and federal project officers, investigators and expert panel discussions. Results: More than 420 projects (US$1.1 billion) were awarded. Those generating new or synthesizing existing CER made up the plurality (194, or US$524 million). Data infrastructure projects were the second-largest area (28%, US$302 million). More than three-fourths addressed at least one priority population, condition category or intervention category. Conclusion: These investments expanded the nation's CER activities and its future capacity to conduct CER.

Aims: This study elaborates on the public's understanding of comparative effectiveness research (CER) or patient-centered outcomes research (PCOR), attitudes toward CER/PCOR and use of evidence in healthcare decision-making. Materials & methods: We conducted six focus groups with the general public – three with individuals actively engaged in healthcare decision-making and three with individuals more passive in their approach. Results: The general public has little knowledge of CER/PCOR, and its perceptions of certain CER/PCOR concepts are inconsistent with those of researchers and policy-makers. Active healthcare consumers value information more than passive consumers and are likely to use evidence in decision-making. Conclusion: Providers are an important source for disseminating and communicating CER/PCOR evidence to active and passive consumers.

To improve health outcomes, clinicians and patients must have evidence-based information available to help them make informed decisions, the knowledge and skills to use this information, and positive attitudes about the value of using comparative effectiveness research (CER) in decision making. As a part of the midstream evaluation of the American Recovery and Reinvestment Act CER portfolio, we collected information from a variety of sources regarding perspectives on CER and engagement of clinicians and patients in CER.

Background: The American Recovery and Reinvestment Act of 2009 (ARRA) directed nearly US$29.2 million to comparative effectiveness research (CER) methods development. Aim: To help inform future CER methods investments, we describe the ARRA CER methods projects, identify barriers to this research and discuss the alignment of topics with published methods development priorities. Methods: We used several existing resources and held discussions with ARRA CER methods investigators. Results & conclusion: Although funded projects explored many identified priority topics, investigators noted that much work remains. For example, given the considerable investments in CER data infrastructure, the methods development field can benefit from additional efforts to educate researchers about the availability of new data sources and about how best to apply methods to match their research questions and data.

The American Recovery and Reinvestment Act (ARRA) of 2009 directed US$1.1 billion to the US Department of Health and Human Services for support of comparative effectiveness research (CER). As part of this investment, US Department of Health and Human Services commissioned a midstream evaluation of the ARRA CER portfolio. One goal of the evaluation was to identify issues to consider for a future evaluation of the long-term impact of this portfolio and other CER investments. In planning the ARRA CER evaluation, we developed and revised a conceptual framework and related policy research questions that may be useful to future efforts to assess the impact of CER or patient-centered outcomes research investments. In addition, we explored methodological challenges related to designing an evaluation to assess investments in CER that may be informative to any future plans to evaluate the long-term impact of ARRA CER as well subsequent investments made from the Patient-Centered Outcomes Research Trust Fund.

Aim : We conducted a midstream assessment of the comparative effectiveness research (CER) training programs funded by the American Recovery and Reinvestment Act (ARRA) by examining program characteristics, planned curriculum development activities and core competencies. Materials & methods : We examined all 43 training projects funded by the US$46 million ARRA CER investment, collecting data from key informant discussions and a technical expert panel. Results : The majority of projects leveraged institutional resources to provide an individualized combination of didactic and experiential learning supported by strong mentorship. Core competencies included skills in statistical modeling, evidence synthesis (systematic reviews and meta-analysis) and general research design skills. Conclusion : ARRA-supported CER training programs enhanced workforce capacity by developing curricula and preparing CER researchers to apply emerging methods and utilize new CER infrastructure.

Interest in disease management programs continues to grow as managed care plans, the federal and state governments, and other organizations consider such efforts as a means to improve health care quality and reduce costs. These efforts vary in size, scope, and target population. While large-scale programs provide the means to measure impacts, evaluation of smaller interventions remains valuable as they often represent the early planning stages of larger initiatives. This paper describes a multi-method approach for evaluating small interventions that sought to improve the quality of care for Medicaid beneficiaries with multiple chronic conditions. Our approach relied on quantitative and qualitative methods to develop a complete understanding of each intervention. Quantitative data in the form of both process measures, such as case manager contacts, and outcome measures, such as hospital use, were reported and analyzed. Qualitative information was collected through interviews and the development of logic models to document the flow of intervention activities and how they were intended to affect outcomes. The logic models helped us to understand the underlying reasons for the success or lack thereof of each intervention. The analysis provides useful information on several fronts. First, qualitative data provided valuable information about implementation. Second, process measures helped determine whether implementation occurred as anticipated. Third, outcome measures indicated the potential for favorable results later, possibly suggesting further study. Finally, the evaluation of qualitative and quantitative data in combination helped us assess the potential promise of each intervention and identify common themes and challenges across all interventions.