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A pediatric asthma unit staffed by respiratory therapists demonstrates positive clinical and financial outcomes |
Myers T R, Chatburn R L, Kercsmar C M |
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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 Respiratory therapists (RT) in a pediatric asthma unit.
Economic study type Cost-effectiveness analysis.
Study population Male and female asthma patients with a mildvere disease severity.
Setting Hospital (Asthma Care Unit). The economic study was carried out in Cleveland, Ohio, USA.
Dates to which data relate The main effectiveness data were obtained from a single trial conducted between 1995 and 1997. Resource and cost data were derived from 1995-97 sources. The price year was not stated.
Source of effectiveness data The estimates of care path variances, hospital length of stay (LOS), care path duration, symptomatic days, school days missed and parents' workdays missed were derived from a single study.
Link between effectiveness and cost data The costing was undertaken prospectively on the same patient sample as that used in the effectiveness study.
Study sample In all, 262 patients (183 male; mean age: 6.3 years) in the ACU group and 267 patients (153 male; mean age: 6.8 years) in the historical control group were included in the analysis. A power analysis (2-tailed t test) was used to determine an appropriate sample size.
Study design This wasnon-randomised trial with historical controls. The duration of the follow-up was not stated. There was no loss to follow-up.
Analysis of effectiveness The analysis of effectiveness was based on treatment completers only. The primary outcomes used in the analysis were:care path variances, hospital length of stay (LOS), care path duration, symptomatic days, school days missed and parents' workdays missed. The patient groups were shown to be comparable with respect to age (p=0.191), race (p=0.839), percentage of admissions through the emergency department (ED) (p=0.504), distribution of disease severity (p=0.792) and by treatment groups between boys and girls in LOS (ACU p=0.110 and control p=0.107). The patient groups were not comparable in terms of gender (there was a higher percentage of boys in the ACU group).
Effectiveness results There was a 71% reduction in care path variances (2.7 in the ACU group and 9.4 in the control group) for patients in the ACU compared to the control group, (p<0.0001). Patients in the ACU had a 13% reduction in hospital LOS (1.78 in the ACU group and 2.04 in the control group), (p=0.0003). The care path duration was 1.41 days (ACU) and 1.75 days (control), (p=0.028). The symptomatic days were 4.9 in the ACU and 5.6 in the control group, (p=0.346).5.3 school days were missed in the ACU group compared to 3.8in the control group, (p=0.026). The ACU group missed 3.9 work days and the control group missed 3.3 work days, (p=0.358).
Clinical conclusions An asthma care unit with respiratory therapists as the primary care givers can deliver individualised, high-quality care within a standard setting resulting in a reduction of LOS and care path variances.
Measure of benefits used in the economic analysis No summary benefit measure was used in the analysis and, as such, the benefits are considered to be the same as the outcome measures. As such a cost-consequences analysis was performed.
Direct costs Costs and charges were included in the analysis. Resources and costs were reported separately. The quantity/cost boundary adopted was the societal point of view (hospital and patient). Discounting was not undertaken due to the short study period. The price year was not stated.
Statistical analysis of costs Sensitivity analysis No sensitivity analysis was performed.
Estimated benefits used in the economic analysis There was a 71% reduction in care path variances (2.7 in the ACU group and 9.4 in the control group) for patients in the ACU compared to the control group, (p<0.0001). Patients in the ACU had a 13% reduction in hospital LOS (1.78 in the ACU group and 2.04 in the control group), (p=0.0003). The care path duration was 1.41 days (ACU) and 1.75 days (control), (p=0.028). The symptomatic days were 4.9 in the ACU and 5.6 in the control group, (p=0.346).5.3 school days were missed in the ACU group compared to 3.8in the control group, (p=0.026). The ACU group missed 3.9 work days and the control group missed 3.3 work days, (p=0.358).
Cost results There was a 10% decrease in both cost/case and charges/case (hospital cost/case:$1,375 in the ACU and $1,522 in the control group; patient charge/case:$2,447 in the ACU group and $2,732 in the control group). Overall, there was a total cost saving of $169,583. Estimated hospital cost savings/year at this hospital were $135,000. An additional $170,000 could be saved in the conversion of full-time RNs to RTs and patient care assistants.
Synthesis of costs and benefits Costs and benefits were not combined.
Authors' conclusions An ACU staffed by RTs is associated with a reduced LOS and care path variances and lower costs of care compared to standard treatment by RNs. These outcomes are realised with no increase in post-discharge functional morbidity.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator is clear. The effects of an asthma care unit, staffed primarily by respiratory therapist (RTs), on the acute management of hospitalised asthmatics have been analysed mainly with reference to an adult population. Therefore, there is a need to extend the analysis to a pediatric cohort. You, as a user of this database, should consider whether this is a widely used health technology in your own setting. Validity of estimate of measure of benefit As the authors employed a power calculation to determine sample size and undertook statistical analysis of the outcomes assessed, the estimate is likely to be internally valid. The data do not appear to have been used selectively. However, as the authors stated, the use of a historical control group raises the potential for bias. Furthermore, the control group included two months of the year (May-June) not covered by the ACU group, while the ACU group included September. As the authors stated, the inability to track and calculate missed school days constitutes a potential limitation of the study. Validity of estimate of costs Resource and cost data were reported separately and adequate details of methods of quantity/cost estimation were given. No important cost items appear to have been omitted. Other issues The authors' conclusions are likely to be justified given the uncertainties in the data. However, as the authors noted, despite differences in gender and in the use of supplemental oxygen between the two groups, these imbalances did not account for the improved LOS in the ACU group. The issue of the generalisability of the asthma care path and its benefits to other settings was addressed. Furthermore, appropriate comparisons were made with other studies supporting the clinical results from the present investigation. Results do not appear to have been presented selectively. Implications of the study Further research is required within the context of a prospective, randomised study to document both the effects of asthma pathways and the role of respiratory therapists in asthma units and pathways. Bibliographic details Myers T R, Chatburn R L, Kercsmar C M. A pediatric asthma unit staffed by respiratory therapists demonstrates positive clinical and financial outcomes. Respiratory Care 1998; 43(1): 22-29 Indexing Status Subject indexing assigned by CRD MeSH Adolescent; Asthma /therapy; Child; Child, Preschool; Clinical Protocols; Cost of Illness; Costs and Cost Analysis; Critical Pathways; Hospitals, Pediatric; Length of Stay; Medical Staff, Hospital; Outcome Assessment (Health Care); Patient Care Planning; Respiratory Therapy /economics; Treatment Outcome AccessionNumber 21998007548 Date bibliographic record published 31/08/1999 Date abstract record published 31/08/1999 |
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