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Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital |
Beech R, Rudd A G, Tilling K, Wolfe C 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 Early acute hospital discharge (EAHD) to a package of home-based physiotherapy, occupational therapy and speech therapy, which was available for up to 3 months for medically stable patients with stroke, was studied. Patients could not have more than one visit per day from each type of therapist.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised medically stable patients with stroke who were able to transfer independently or with the aid of a caregiver.
Setting The settings were secondary, tertiary and community care. The study was carried out in London, UK.
Dates to which data relate The effectiveness and resource use data related to January 1993 to July 1996. The cost data were collected during the same period and from a study published in 1997. The price year was 1997.
Source of effectiveness data The effectiveness and resource use data were obtained from a single study (Rudd et al., see Other Publications of Related Interest).
Link between effectiveness and cost data Resource use was obtained prospectively from the same study sample as that used in the effectiveness analysis.
Study sample Power calculations were performed in the planning phase of the study, and also retrospectively, to assure a certain power. The authors calculated that a sample size of 130 per group was needed to assure a power of 80% at the 5% level of detection for a 3.5-point difference in Barthel score, based on a standard deviation of 10. Among 660 patients with stroke admitted to St. Thomas' Hospital, 300 were randomly allocated. Thirty-one patients from King's College were also randomly allocated. Thus, of an initial group of 691 patients, the final sample comprised 331 patients. Of these, 167 were randomly allocated to the EAHD group and 164 to the control group. Reasons for exclusion were patients living too far for the team to visit (n=76), deaths in hospital (n=160), patients not matching the entry criteria (n=119), lack of a fixed abode (n=3), and refusal (n=2). The authors did not provide any evidence that the study sample was representative of the study population.
Study design This was a randomised controlled trial that was multi-centred (patients from St. Thomas' Hospital and the King's College were considered in the effectiveness analysis). Permuted blocks were used to randomly allocate patients to one of the study groups, but no stratification was conducted. The duration of follow-up was 12 months. Five patients in the EAHD group and 4 in the control group were lost to follow-up. In addition, 26 patients in the EAHD group and 34 in the control group died during the follow-up period. The authors reported that although the baseline characteristics and outcomes at 12 months were assessed blind, it was possible that the investigator got to know the group to which the patient belonged in the 12-month assessment.
Analysis of effectiveness The authors did not report the basis of the clinical analysis, although it appears to have been treatment completers only. The primary health outcomes assessed at 12 months for both the EAHD and control groups were impairment and disability. Impairment was assessed using the motoricity index, the minimental state examination, and the Frenchay aphasia screening test. Disability was assessed using the modified Barthel score, the Rivermead activities of daily living score, the hospital and depression scale, the 5-metre time walk, and the Nottingham health profile. Caregiver strain (caregiver strain index) and the number and proportion of patients and carers satisfied with hospital care, therapy provision, community support and satisfied in general (stroke-specific questionnaires) were also reported. The authors reported that there were no significant differences between the two groups of patients at baseline and at the time of randomisation in terms of gender, age, ethnic group, recurrent stroke, prior Barthel score, dysphasia and incontinence. The study groups were shown to have been comparable at baseline for the demographic and clinical characteristics.
Effectiveness results The authors reported in this study that the only significant difference found between the EAHD and control groups was that EAHD patients were more satisfied with their hospital care than the patients in the control group. In total, 79% of the EAHD patients were satisfied with hospital care versus 65% of the patients in the control group. The difference was 14% (95% confidence interval, CI: 1 - 27), (p=0.032).
However, a review of the study where the authors reported the effectiveness results (Rudd et al., see Other Publications of Related Interest) showed that there were also statistically significant differences between the groups in terms of the number and proportion of patients with anxiety, as assessed using the hospital anxiety and depression scale:
79 patients (69%) in the EAHD group versus 79 patients (81%) in the control group had normal scores;
16 patients (14%) in the EAHD group versus 12 patients (12%) in the control group were borderline;
20 patients (17%) in the EAHD group versus 7 patients (7%) in the control group had abnormal scores; and
28 patients in the EAHD group versus 24 in the control group were not assessed, (p=0.02).
Clinical conclusions The effectiveness analysis showed that the study interventions were comparable with respect to almost all of the outcome measures considered in the study. However, patients in the EAHD group were significantly more satisfied with the hospital care they received than those patients receiving conventional care, although the latter (conventional care patients) presented lower percentage of patients with anxiety. Despite the difference in the satisfaction score, the authors stated that conventional care and EAHD were comparable in terms of their effectiveness.
Measure of benefits used in the economic analysis No summary measure of benefit was used in the economic analysis because the authors considered the two interventions to be equally effective. The study was therefore categorised as a cost-minimisation analysis.
Direct costs The resource quantities (or the percentage of patients using a specific service) and the costs were reported separately. The direct costs considered at analysis appear to have been those of the health service. These included the use of acute inpatient services (hospital stay, tests, procedures), rehabilitation services (physiotherapy, occupational therapy, speech therapy) and non-inpatient services. Non-inpatient services were clinical services such as visits to a hospital physician, contact with a general practitioner (either at home or at the clinic), and other community services.
The use of rehabilitation services was obtained from standardised forms completed by the therapists. Data on the patients' contact with hospital physicians, general practitioners and social services were obtained from questionnaires completed by the patients or their caregivers. The direct costs were obtained from the departmental heads of the hospitals, the hospital finance department, the local finance department, and a publication (Netton and Dennett, see Other Publications of Related Interest). The authors also made some assumptions when estimating the costs. Therefore, the costs were estimated on the basis of actual data, guesses and the authors' assumptions. Discounting was not performed, but it was irrelevant since the period considered at analysis was less than 2 years. The study reported the total costs according to the type of care and the average costs per patient. The price year was 1997. The authors reported that the costs of patient contacts with psychiatric nurses and respite care were excluded because they were negligible.
Statistical analysis of costs Statistical analyses of the resource quantities were performed. The authors used the chi-squared test for categorical variables and the Mann-Whitney test for numerical variables. This appears to have been appropriate. However, statistical analyses of the costs were not performed.
Indirect Costs No indirect costs were reported in the economic analysis. The authors stated that the earnings lost and time away from normal activities borne by the patients and caregivers were important, but due to the quality of the data they were not reported.
Sensitivity analysis Sensitivity analyses were performed to assess the robustness of the results. Variations in the cost assumptions made by the authors and in some resource quantities (such as post- and pre-randomisation hospital stay) were considered. One-way sensitivity analyses appear to have been performed. The area of uncertainty investigated was variability in the data.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The total annual costs were 1,135,609 for the EAHD group and 1,218,802 for the group receiving conventional treatment. The annual average costs were 6,800 per EAHD patient and 7,432 per patient receiving conventional treatment.
Synthesis of costs and benefits The costs and benefits were not combined since a cost-minimisation analysis was undertaken.
Authors' conclusions Early acute hospital discharge (EAHD) had a neutral effect on the health outcomes and led to lower costs in comparison with conventional care. Therefore, it would be a cost-effective strategy for the treatment of medically stable patients with stroke. However, the financial savings would be very small and the major benefit of EAHD would be the release of beds in order to increase caseload.
CRD COMMENTARY - Selection of comparators The comparator chosen was justified on the grounds that conventional inpatient and community-based care was current practice in the authors' setting. You should decide whether this is a widely used health technology in your own setting.
Validity of estimate of measure of effectiveness The analysis used a randomised controlled trial, which was appropriate for the study question. The authors did not provide any evidence that the study sample was representative of the study population, although the fact that patients from two centres were included in the effectiveness analysis and the use of a pragmatic approach for patient inclusion may have increased the likelihood of this. The authors showed that the groups were comparable in terms of gender, age, ethnic group, recurrent stroke, prior Barthel score, dysphasia and incontinence. However, other important risk factors of stroke, such as high blood pressure, family history of stroke, smoking, diabetes, high cholesterol or prior heart disease, were not considered when showing the comparability of the groups at analysis. This introduces uncertainty into the reliability of the conclusions, as there may have been confounding factors that were not considered at analysis and these could have influenced the effectiveness results. Although a randomised controlled trial was conducted, the effectiveness outcomes appear to have been analysed for treatment completers only. Therefore, it is not possible to assess whether the results obtained can be generalised to the study population.
Validity of estimate of measure of benefit No summary measure of health benefit was used in the economic analysis because of the clinical equivalence of the two interventions. The study was therefore categorised as a cost-minimisation analysis. This was the interpretation of the authors, despite the fact that one outcome measure (patient satisfaction) varied statistically between the study groups.
Validity of estimate of costs The perspective adopted was not reported, but it seems to have been that of the health service. Most of the categories of costs relevant to the health service perspective were considered in the economic analysis. The authors reported that the costs of patient contacts with psychiatric nurses and respite care were excluded because they were negligible. Moreover, the costs borne by patients and caregivers (such as productivity losses) were not included in the economic analysis due to problems with the quality of the data. The consideration of these costs would have been useful for adopting a societal perspective. Most of the resource quantities were reported separately from the unit costs, and the price year was stated. The authors commented that others could substitute their local unit costs in order to perform reflation exercises to other settings. Statistical analyses of the quantities and sensitivity analyses of the costs were performed. These enhance the reliability of the economic analysis.
Other issues The authors compared their results with those from a similar study and found similar results once they had considered differences in the costs due to the location. The authors commented that the generalisability of the costs results depends on two factors. First, resource utilisation, which may be different depending on the location. Second, the cost data, which appear to have been representative for England and Wales once the higher costs of London had been taken into consideration. No comments on the generalisability of the effectiveness results were made.
Implications of the study The results of this study showed that, in terms of resource use and the costs of the interventions compared, EAHD can increase the existing hospital capacity to treat more patients with stroke, although the financial savings would be relatively small.
Source of funding Supported by the Stroke Association; Lambeth, Southwark, and Lewisham Health Authority; the Special Trustees of St Thomas's Hospital; the Nuffield Provincial Hospitals Trust; and Wandsworth Health Gain Fund.
Bibliographic details Beech R, Rudd A G, Tilling K, Wolfe C D. Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital. Stroke 1999; 30(4): 729-735 Other publications of related interest Gladman J, Foster A, Young J. Hospital- and home-based rehabilitation after discharge from hospital for stroke patients: analysis of two trials. Age and Ageing 1995;24:49-53.
Gladman JR, Lincoln NB, Barer DH. A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital. Journal of Neurology, Neurosurgery, and Psychiatry. 1993;56:960-6.
Netton A, Dennett J. Unit costs of health and social care. Canterbury: University of Kent at Canterbury, Personal Social Services Research Unit; 1997.
Rudd AG, Wolfe CD, Tilling K, Beech R. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. BMJ 1997;315:1039-44.
Topol EJ, Burek K, O'Neill WW, Kewman DG, Kander NH, Shea MJ, et al. A randomised controlled trial of hospital discharge three days after myocardial infarction in the era of reperfusion. New England Journal of Medicine 1988;318:1083-8.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Cerebrovascular Disorders /economics /rehabilitation; Community Health Planning /economics /utilization; Cost-Benefit Analysis; Health Care Costs; Hospitals, Teaching /economics; Hospitals, Urban /economics; Humans; Length of Stay /economics; London; Occupational Therapy /economics /utilization; Patient Discharge /economics; Physical Therapy Modalities /economics /utilization; Random Allocation; Rehabilitation Centers /economics /utilization; Speech Therapy /economics AccessionNumber 21999000680 Date bibliographic record published 29/02/2004 Date abstract record published 29/02/2004 |
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