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Preventive services for the elderly: would coverage affect utilisation and costs under Medicare? |
Burton L C, Steinwachs D M, German P S, Shapiro S, Brant L J, Richards T M, Clark R D |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Annual preventive and health risk screening service.
Economic study type Cost-effectiveness analysis.
Study population Study participants were elderly (aged 65 or older), 62.7%in the intervention and 63.6% in the control group were female. 15.1% in the intervention group and 14.4% in the control group had incomes below the poverty line.
Setting The practice setting included the primary and secondary care sectors. The economic study was conducted in Baltimore, America.
Dates to which data relate Effectiveness data, resources used and prices relate to the period May 1989 to April 1991.
Source of effectiveness data Estimates of final outcomes were derived from a single study.
Link between effectiveness and cost data Costing was undertaken prospectively on the same patient sample as that used in the effectiveness study.
Study sample 4,195 persons eligible for Medicare cover were randomized to the standard package (control, n=2090) or enhanced preventive package (intervention, n=2105). There was no mention of power calculations.
Study design The study was a randomised controlled trial with unblinded participants. The study was originally multi-centred but results in this study were based on the Balitmore area alone. The sample was followed for two years.
Analysis of effectiveness The clinical study was based on intention to treat. The primary health outcomes were the health status as a result of the programme, and the death rate. General health status was assessed by the Quality of Well-Being Scale. Current emotional distress was measured using the General Health Status Questionnaire.
Effectiveness results Through the Quality of Well-Being Scale it was found that there was an overall reduction in health status over the two years. The decline was greater in the control group, 0.08 points to 0.06 points (p=0.011). The death rate was greater in the control group: 11.3% compared to 8.3% (p=0.003).
Clinical conclusions The intervention group had a greater health benefit than the control group and a significantly lower death rate. Through the regression model it was found that for men, having a solo practitioner and being married were positively related to uptake of the services. For women, having a confidant, having a mammogram, having a high school education and having a female practitioner were positively associated with accepting the intervention services.
Modelling A mixed-effects model was used to explore whether there were statistically significant differences in allowable charges and in use of inpatient and ambulatory services over the two year period.
Measure of benefits used in the economic analysis The outcome measures used were the Quality of Well-Being Scale and the death rate. The former was undertaken at interview at baseline and at two years.
Direct costs Costs were not discounted. Quantities were reported separately from costs. Quantities and costs measured included hospital, home health and hospice as well as ambulatory visits. The boundary adopted was the Health Care Financing Administration (HCFA). Estimation of quantities and costs was based on actual data. The price dates refer in year one to 1989-1990 and to 1990-1991 in year two.
Statistical analysis of costs Statistical analysis of costs was undertaken with a mixed-effects regression model controlling for time in study.
Sensitivity analysis No sensitivity analysis was undertaken.
Estimated benefits used in the economic analysis There was a reduction in health status over the two years and this was greater in the control group than the intervention group (0.08 to 0.06 points, p=0.011). The death rate was greater in the control group: 11.3% compared to 8.3% (p=0.003).
Cost results The intervention package was utilized by approximately two thirds of eligible people (63% of participants in the intervention used the service at least once). Total Medicare allowable charges were higher in the first year for the control group ($8,826,078 against $8,991, 063) and in the second year ($10,735,142 against $11,014,199). The intervention group had lower monthly hospital/person charges for both years (intervention:control, year 1; $205 vs $216 and year 2; $264 vs $274). Utilisation of Medicare Part A services (hospital, nursing home, home health and hospice) was higher in the control group for both years (Table 2 in the paper) but this group showed a higher hospital discharge rate and lower length of stay in hospital (Table 3 in the paper). For Medicare Part B services (primary care and outpatient visits and investigations) the intervention group had a lower rate of utilisation for both years but a higher rate of ambulatory (outpatient) services.
Synthesis of costs and benefits Costs and benefits were not synthesized. The intervention was found to dominate the control group since the intervention group was found to supply a modest health benefit with no negative cost impact.
Authors' conclusions This study suggests that 2/3 of eligible elderly will take up preventive services if offered and, contrary to expectations, this appears to have no impact on charges and presumably health service costs. This may be partly explained by inadequate randomisation of the two groups (for which there is some evidence as the numbers in each arm are unequal) or by the notable beneficial effect that preventive contacts have on the elderly. The authors concluded that there appears to be a modest health benefit in the preventive package with no cost impact.
CRD COMMENTARY - Selection of comparators The reason for choice of comparator is clear. Validity of estimate of measure of benefit It is possible that randomization did not ensure equality of health related characteristics amongst the two groups since the control group did utilize a higher level of overall average service use. In terms of health measures and self reported health, however, there was little variation between groups. Validity of estimate of costs Resource quantities and prices were reported separately and adequate details of the methods of quantity/cost estimation were provided. However, it is not clear whether the cost of the Medicare vouchers or their administration was included as part of the extended intervention package. Other issues As the authors noted, a longer follow-up period is required to assess whether the benefits achieved in the intervention group remained. The study would benefit from use of a sensitivity analysis. Despite these shortcomings the results of the study are important in indicating that prevention may not be the initial cost-driver for programmes, as generally perceived, and that benefits may accrue in the short term as well as in the long term. Bibliographic details Burton L C, Steinwachs D M, German P S, Shapiro S, Brant L J, Richards T M, Clark R D. Preventive services for the elderly: would coverage affect utilisation and costs under Medicare? American Journal of Public Health 1995; 85(3): 387-391 Other publications of related interest German P S, Burton L C, Shapiro S. Extended coverage for preventive services for the elderly: response and results in a demonstration population. American Journal of Public Health 1995;85:379-386.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Ambulatory Care /utilization; Appointments and Schedules; Case-Control Studies; Cost-Benefit Analysis; Health Services for the Aged /economics /utilization; Humans; Insurance Benefits /economics /legislation & Interviews as Topic; Medicare Part A /legislation & Medicare Part B /legislation & Outcome Assessment (Health Care); Patient Discharge; Preventive Health Services /economics /utilization; Regression Analysis; United States; jurisprudence; jurisprudence /utilization; jurisprudence /utilization AccessionNumber 21995000460 Date bibliographic record published 31/10/1999 Date abstract record published 31/10/1999 |
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