Chapter 09: Departing from Epidemiology and Conducting Cost-Effectiveness Studies


Chapter 09: Departing from Epidemiology and Conducting Cost-Effectiveness Studies



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Dr. Elting talks about how her interest in value of care evolved.

She sets context by noting that in the 2000s many states began requiring that hospitals report the quality of results, making available data about procedures and surgical outcomes. Dr. Elting was able to look at toxicities that caused death and fees for procedures. She explains that expensive and effective new drugs were available to treat toxicities, but insurance companies were unwilling to cover the cost. She says that she initiated cost effectiveness studies to demonstrate that the more expensive drugs ultimately saved money. Her studies were very successful at convincing payers to change their policies. She then talks about the reactions of her colleagues to her change in research direction.

Dr. Elting explains that this research took her away from traditional epidemiology and allowed her to differentiate herself, a fact that was critical to her success.

Dr. Elting tells a story about a period when General Internal Medicine didn’t have enough beds because they were filled with patients made too sleepy to function by their anti-toxicity medications.



Publication Date



Houston, Texas

Topics Covered

The Interview Subject's Story - The Researcher; The Researcher; Professional Path; Discovery and Success; Discovery, Creativity and Innovation; On Research and Researchers; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; MD Anderson Culture; Patients; Patients, Treatments, Survivors; Fiscal Realities in Healthcare; The Healthcare Industry


Linda S. Elting, DrPh:

At the same time that was happening, in my mind, in the community there had been a lot of research published outside of cancer and inside of cancer about the relationship between surgical outcomes and how many procedures are done every year at certain hospitals. And if you go to have a pancreatectomy for cancer of the pancreas at a hospital that's done one in the last three years, your outcomes are not so good as those that do one a month. And so, because of that and the publicity it got, hospitwell, legislatures all over the stthe United States were requiring of the hospitals licensed in their state that they report their quality resultstheir results, to the state. And they addressed questions like volume of procedures per year, and death in the hospital, and those kinds of things. Those kinds of data were made available to researchers. Beginning right aboutaround that time period, in the earlyabout 2000, these started to appear. And so, that was a very good opportunity for me to look at the kinds of toxicities that were causing deaths across Texas or across the United States. And so, my interests sort of moved to the population at about the same time population kinds of data became available. It's like measuring something with a pretty blunt tool, because it's claims. It's not medical records. But it does give you some notion about what's going on. And the cool thing is that it includes thewhat's charged and in some cases what was paid in the databases. And so, itas I began to do that, I would just begin to look, you know, at those kinds of issues. The other thing that I became really aware of in general internal medicine was that, when I looked across the broad spectrum of toxicities, was that there was a huge amount of development at that point in new drugs for toxicities: antibiotics, particularly anti- nausea medicines, all kinds of things like that. And they were really successful. They worked great. But they were expensive. And because of the cost of cancer care in general, we were getting pushback from thefrom payers about paying for what we considered the best care. And so, it got me really interested in why they were making those decisions, because I was looking at the same time of how costly those toxicities were, not just to the patients but also to the insurance company, in terms of extra days in the hospital and extra hospitalizations. And so, I started looking and itno one had really studied that, at all. So there reallywhat wewhat seemed real obvious to all of us who sat in the clinic and saw people coming back into the emergency room and into the hospital because they were nauseated and throwing up, wasn't really making it onto the radar screen of payers. And so, I sort of went on this crusade to describe not only the outcomes and the frequency of these problems, but the cost, you know? And not just the cost when it occurred in an individual, but the cost if you averaged that cost across every single person who got the treatment, whathow much was it incrementally increasing the total cost of care for a provider and a payer? So, those were two kind of big things for me, at that point. And it reallyit took me in ain a different and really productive direction. Before I was doing what I thought was superior epidemiologic studies. But the vast majority of researchers in the field who were clinicians felt like were already addressing the epidemiology of problems, even though I was big into denominators, [laughs] they were also studying these things. But it set me apart from the clinical turf a little bit, and it allowed me to really sort of differentiate myself from that whole huge bunch of clinicians who were doing similar research, but not identical. And I think that was really critical in my success. It was a natural progression for me, academically. But it was also just good luck, because it kind of set me apart, gave me an identity of my own that was real separate from physicians. And it was one that they don't like thinking about, too. [laughs] You know, thatthey don't want to prescribe what medicine is cheapest. They want to prescribe what medicine they know is best, and they don't even worry about those dollar things for the most part, if they can avoid it. So, it wasit was a fortuitous development. I'd love to say I planned it that way, but [laughs] it just sort of fell out that way. I didn'tin retrospect, I recognize that. But at the time, I wasn't attempting to differentiate myself. I was just trying to answer interesting questions that seemed like nobody else was answering.

Tacey A. Rosolowski, PhD:

What was it that intrigued you about the money dimension? You know, was

Linda S. Elting, DrPh:

Well, it was the patients. I mean, I would walk through the clinic, and at that point I was doing a lot of interaction with patients. And I would walk up and I would say, "How are you feeling today?" And they would say, "Oh, I'm so nauseated." And I said, "You know, we have drugs for that." "Yeah, but my insurance company won't pay." And, you know, at the same time, we werewe were in the ambulatory treatment center where all the chemo is given, and we didn't have enough beds. And, for example, in the case of nausea and vomiting, the most common and probably the most feared side effect of chemotherapy by anyone who ever gets chemo. And when people couldn't use the new drugs that are very effective, we had to give them thean alternative that made them really sleepy. And they were in our bed three or four times as long. And we couldn't move them out safely and send them home. And so, we could onwe couldn't treat as many people, and we were always backed up in the clinic. And, you know, we were running till 12:00 or 12:00 at night because people were sound asleep in the bed from their nausea medicine. And so, fromyou know, just from the efficiency standpoint in moving people efficiently through the clinic; from the patient standpoint, because they were miserable from being nauseated. We had patients who wanted to come from work and get their chemo and go back, and they couldn't because they were sound asleep, or because they were too nauseated. And they couldn't drive themselves home, so their spouse had to take off from work. So, those sorts of issuesand so, when we had a drug [cell-phone ringtone] that worked, and welet me just silence this. This can't be an emergency.

Tacey A. Rosolowski, PhD:

It's nice that you know that. [laughter]

Linda S. Elting, DrPh:

So, we couldn't get people to pay for the drugs, and it was costing us more money. It was costing our patients. It made no sense to anybody for anyone to do it this way. And it was just the absence of information, in my view, because any drug that is, you know, four times better at controlling a side effect, and gets people in and out quickly, and doesn't have long-term downstream events like coming back to the emergency room, has to be cost effective if anybody'll just bother to look at it properly. You know, it justit's logical. So that's really what got me into that whole area. And we did some studies that were just simple cost-effectiveness studies of commonly used treatments. We did some that were big claims-database things that just elucidated how frequently people have to be readmitted to the hospital with these side effects if they're not well-controlled at the beginning And they were very, very, very effective with payers. You know, the payers aren't bad people. They're not jerks who are trying to deliver cheap, bad care. They're trying to deliver good care as cost-efficiently as they can with the available money. And when you show them that this is no more expensive to get this drug than it is for the alternative that isn't as good, they always opt for the best drug. So, that was ait was a big step for me. It was a very different way to look at things. You know, I had to teach myself a fair amount of economics and that sort of thing. But it wasit was a real eye-opener for me, and it was veryit was very successful for my career, to move in that direction at that time.

Tacey A. Rosolowski, PhD:

Whathow were your colleagues reacting to this shift in focus?

Linda S. Elting, DrPh:

Initially, there were an awful lot of peoplean awful lot of clinicians who would say, "I really don't want to hear about it. I don't want to think about money. It's hard enough to do the clinical job I have already." And I would explain why I was doing it, and they said, "Oh, that's fine. Somebody ought to do it." There were some people who said, "You know, you're a very good epidemiologist. It's a shame you're wasting yourself on these cost studies." But it didn't take more than a couple years before the impact of cost and economics was so enormous on everybody's practice that I started getting all kinds of calls from all kinds of people who would say, "Can you please figure out this, so that we can go on and do this?" You know, "Can you tell us whether this is gonna be cost-effective, or how we can frame this and deliver it so that it will be reimbursable?" Because that was the huin 2000 and after, that's been the huge issue. You know, not just how do wehow should we treat our patients, but how can we get people to let us treat them, who are payers? So it wasn't very long before that all caught up with every person in the hospital, and every person in the medical community.

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Chapter 09: Departing from Epidemiology and Conducting Cost-Effectiveness Studies