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Cost-effectiveness of nursing interventions in a post-stroke eating training programme: a pilot study |
Jacobsson C, Lindholm L, Waldau S, Engstrom B |
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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 An eating training programme for patients who had had a stroke was examined. The programme was conducted by hospital nursing staff.
Study population The study population comprised patients who had had a stroke. Further inclusion or exclusion criteria were not reported.
Setting The setting was a university hospital. The economic study was carried out at the Norrland's University Hospital in Umea, Sweden.
Dates to which data relate No dates for the effectiveness and resource use data were reported. The price year was 1997.
Source of effectiveness data The effectiveness evidence came from a single study.
Link between effectiveness and cost data The costing was performed on the same sample of patients as that used in the effectiveness study. It was not clear whether it was carried out prospectively.
Study sample Power calculations to determine the sample size were not performed. A sample of 11 patients was enrolled in the study. There was no explicit comparison group. Patients were identified from those who were being treated at the study hospital. It was not stated whether any patient refused to participate, or was excluded for any reason from the initial study sample.
Study design The effectiveness evidence was based on a case series study. There was no explicit control group. The effect of the intervention was assessed in terms of improvements among the case series within a before-and-after design. The study was carried out in a single centre, the Norrland's University Hospital. The length of follow-up was not reported. It appears that no patient was lost to follow-up.
Analysis of effectiveness All of the patients included in the initial study sample were taken into account when estimating the effectiveness. The health outcome used in the analysis was the change in the utility score associated with the eating training programme. This was calculated using the multi-attribute model, which considered several aspects of the patients' health status: sensations, mobility, emotion, cognition, self-care, and pain. The scores ranged from 1 (perfect health) to 0 (death).
Effectiveness results The utility scores changed from 0.55 to 0.94 for patient 1, from 0.31 to 0.55 for patient 2, from 0.29 to 0.40 for patient 3, from 0.30 to 0.35 for patient 5, from 0.49 to 0.72 for patient 6, from 0.72 to 0.78 for patient 7, from 0.67 to 0.72 for patient 8, from 0.67 to 0.84 for patient 9, and from 0.49 to 0.61 for patient 10. The utility scores were unchanged for patient 4 (0.76) and patient 11 (0.27).
Patients 1 and 7 to 11 had a nasogastric tube or a gastric tube.
Clinical conclusions The effectiveness analysis showed that, for most of the patients enrolled in the study, the eating training programme improved their health status. The analysis allowed the difference in quality of life before and after the eating training programme was implemented to be measured.
Measure of benefits used in the economic analysis The summary benefit measure used in the economic analysis was the quality-adjusted life-years (QALYs). These were derived from the effectiveness study. The QALYs were discounted using a rate of 5% because the improvements achieved were considered to persist over a 10-year period.
Direct costs A 5% discount rate was applied since the time horizon of the analysis was 10 years. The unit costs were reported separately from the quantities of resources used. The health services included in the economic evaluation were personnel services for patient assessment, formation and implementation of the training programme (5 days), co-ordination of the results of the examination or assessment, conversation on discharge, participation of next of kin, hospitalisation, and telephone contacts after discharge. The cost/resource boundary adopted in the study was not reported, but it appears to have been that of the health care system. The costs were estimated using actual data derived from the Norrland's University Hospital. Resource consumption was derived from data related to each patient involved in the effectiveness study. Savings resulting from the eating training programme were also evaluated in terms of patients who did not require gastric tubes. Thus, savings were calculated as the avoided costs of gastric tubes, changes of tubes, and nutritional substances fed via tubes. The costs of reverting from nutrition fed via tube to "ordinary" food were also included in the economic analysis. The price year appears to have been 1997.
Statistical analysis of costs The costs were treated deterministically.
Indirect Costs The indirect costs were not included in the analysis.
Currency Swedish kroner (SEK). The authors stated that SEK 8 = US$1.
Sensitivity analysis Sensitivity analyses were not conducted.
Estimated benefits used in the economic analysis The QALYs gained using the eating training programme (implicitly in comparison with no programme) over the 10-year period were 3.01 for patient 1, 1.85 for patient 2, 0.85 for patient 3, 0 for patient 4, 0.39 for patient 5, 1.78 for patient 6, 0.46 for patient 7, 0.39 for patient 8, 1.31 for patient 9, 0.93 for patient 10, and 0 for patient 11. Thus, the average QALY gained in the sample of 11 patients was 1.0.
Cost results The costs of the eating training programme were SEK 27 for patients 1, 4 and 6 to 9, and SEK 54 for patients 2, 3, 5, 10 and 11.
The mean costs of the eating training programme were SEK 39.
Savings were observed only for patients 1, 9 and 10. These amounted to SEK 275.
Synthesis of costs and benefits An incremental cost-utility analysis was conducted to combine the costs and benefits of the post-stroke training programme (implicitly in comparison with the no programme option). When considering the whole group of 11 patients, the training intervention was dominant as it produced positive QALYs and the savings exceeded the costs, although this was not true for all patients. For patients who did not have a gastric tube, the cost per QALY was about SEK 44,000. An earlier study reported that the cost per QALY of antihypertensive therapies was between SEK 600,000 and SEK 700,000. Thus, the cost-effectiveness of the eating training programme was far below the acceptable benchmark.
Authors' conclusions The post-stroke eating training programme represented a cost-effective intervention in the Swedish health care setting. Patients who benefited most from the intervention were those whose gastric tubes could be removed.
CRD COMMENTARY - Selection of comparators The choice of the comparator represents a critical point of the analysis. The authors stated that the appropriate comparator was antihypertensive treatment, which is aimed at preventing stroke. However, the actual comparison (never mentioned in the analysis) was the option of a "no-training programme", which represented the basis for the calculation of the extra costs (and subsequent savings) of the eating training programme. The "no-training programme" appears the most appropriate comparator in the present study, while there are some doubts about the choice of antihypertensive therapies. You should decide whether it represents a valid comparator in your own setting.
Validity of estimate of measure of effectiveness The analysis of effectiveness used data collected from a group of patients with no explicit control group. This represents a weak source of evidence and may limit the internal validity of the analysis. Further, the sample size was quite small and details on the clinical conditions and demographics of the patients enrolled in the study were not reported. It was unclear whether there was a sampling process when selecting the patients, or whether some patients refused to participate in the study. The authors hypothesised that the baseline utility values (before the introduction of the training programme) could represent the values that would have been observed without the programme, but they did not consider the possibility that these utility values could change (either improve or worsen) irrespective of any programme.
Validity of estimate of measure of benefit QALYs were selected as the main benefit measure of the economic analysis. The choice of QALYs appears appropriate, as it enhances the comparability of the benefits of the present study intervention with those of other technologies funded in the health care system. The QALYs were discounted due to the long time horizon of the analysis. Utility values were based on patient values. The authors noted that the method used to calculate the QALYs was not adapted specifically to nursing care, thus it may not have been appropriate for the intervention under study.
Validity of estimate of costs The perspective adopted in the study appears to have been that of the health care system, and only personnel services associated with the training programme were included in the economic evaluation. The unit costs were appropriately reported separately from the quantities of resources used. In addition, the price year was given. These issues enhance the reproducibility of the cost analysis in other settings. The cost estimates were specific to the study settings and sensitivity analyses were not conducted. Both the costs and quantities were treated deterministically. The source of the cost data was reported.
Other issues The authors did not compare their findings with those from other studies. In addition, they did not address the issue of the generalisability of the study results to other settings. Thus, the external validity of the analysis was quite limited due to the fact that sensitivity analyses were not conducted. The study referred to post-stroke patients and this was reflected in the conclusions of the analysis. The authors acknowledged that the costs and quality of life of the patients' caregivers were not taken into account.
Implications of the study The study suggests that an eating training programme was cost-effective among post-stroke patients in Sweden. However, caution is required when interpreting the study results due to the limitations of the present analysis. The authors stated that they were aware of the shortcomings of their analysis and suggest that further studies based on randomised designs should be conducted.
Source of funding Supported by the County Council of Vasterbotten in collaboration with the Department of Nursing and the Department of Epidemiology and Public Health, Umea University.
Bibliographic details Jacobsson C, Lindholm L, Waldau S, Engstrom B. Cost-effectiveness of nursing interventions in a post-stroke eating training programme: a pilot study. Journal of Nursing Management 2000; 8(5): 297-306 Indexing Status Subject indexing assigned by CRD MeSH Cost-Benefit Analysis; Feeding Behavior; Feeding Methods; Feeding and Eating Disorders /complications /psychology; Humans; Nursing Research; Nutritional Status; Patient Education as Topic /economics; Patient Satisfaction; Quality-Adjusted Life Years; Stroke /complications /rehabilitation; Sweden; Treatment Outcome AccessionNumber 22000007650 Date bibliographic record published 31/12/2003 Date abstract record published 31/12/2003 |
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