Abstract
BackgroundThe United States (U.S.) Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has implemented economic analyses in single-site and multi-site clinical trials. To date, no one has reviewed whether the QUERI Centers are taking an optimal approach to doing so. Consistent with the continuous learning culture of the QUERI Program, this paper provides such a reflection.MethodsWe present a case study of QUERI as an example of how economic considerations can and should be integrated into implementation research within both single and multi-site studies. We review theoretical and applied cost research in implementation studies outside and within VA. We also present a critique of the use of economic research within the QUERI program.ResultsEconomic evaluation is a key element of implementation research. QUERI has contributed many developments in the field of implementation but has only recently begun multi-site implementation trials across multiple regions within the national VA healthcare system. These trials are unusual in their emphasis on developing detailed costs of implementation, as well as in the use of business case analyses (budget impact analyses).ConclusionEconomics appears to play an important role in QUERI implementation studies, only after implementation has reached the stage of multi-site trials. Economic analysis could better inform the choice of which clinical best practices to implement and the choice of implementation interventions to employ. QUERI economics also would benefit from research on costing methods and development of widely accepted international standards for implementation economics.
Highlights
The United States (U.S.) Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has implemented economic analyses in single-site and multi-site clinical trials
Known as the "reference case," this method prescribes that health care innovations be compared to standard care, that all costs incurred by society over a lifetime time-horizon be counted, and that outcomes be valued in quality-adjusted life years (QALYs), a measure of morbidity-adjusted survival
QUERI researchers have made notable contributions to the qualitative methods of implementation research, and several QUERI Centers are exemplary in incorporating a variety of economic evaluations into multi-site implementation projects
Summary
Economic analyses have played an important role in QUERI since its inception. Researchers with experience in health economics were engaged in the creation of QUERI in the late 1990s. Applied research Economic analyses have played an important role in identifying best practices for implementation (QUERI step 2; Table 1) and documenting existing practice patterns (step 3) They have included using a literature review or metaanalysis to assess the cost-effectiveness of a clinical intervention [32] and developing a decision-analytic model to characterize its cost-effectiveness [33,34,35,36]. Identifying a best practice (step 2) QUERI researchers have used literature reviews and decision-analytic models to estimate the cost-effectiveness of clinical interventions that are candidates for implementation They have developed and tested new interventions, assessing costs and outcomes within clinical trials. VA researchers sometimes treat economic analysis as an adjunct that can be dropped when funds are tight, leading to many missed opportunities to gather economic data during the pre-implementation phase
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