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Impact of a multidisciplinary day program on disease and healthcare costs in children and adolescents with severe asthma: a two-year follow-up study |
Bratton D L, Price M, Gavin L, Glenn K, Brenner M, Gelfand E W, Klinnert M 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 The study set out to evaluate a paediatric day programme involving intensive medical, nursing, psychosocial, and rehabilitation assessment of, and intervention with, patients with severe asthma.
Type of intervention Treatment and rehabilitation.
Economic study type Cost-effectiveness analysis.
Study population The study population consisted of 98 consecutive children with severe asthma were enrolled from throughout the United States. The mean age was 10.9 years (range: 9 months - 18 years). Entry criteria included a primary diagnosis of severe asthma refractory to routine medical treatment, no admission to the National Jewish Medical and Research Centre (NJMRC) during the previous five years, aged under 19 years, and the presence of a parent or legal guardian at admission.
Setting The study was carried out at the National Jewish Medical and Research Centre in Denver, USA.
Dates to which data relate Data on both effectiveness and resource use were collected between 1995 and 1998. 1996 prices were used.
Source of effectiveness data Effectiveness data 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 Families of 114 children and adolescents referred from throughout the United States and consecutively admitted to the National Jewish Pediatric Day Programme were eligible for study enrolment. Of the 111 families meeting entry criteria, 13 declined to participate resulting in a final study population of 98 patients. Data were available for 98 patients at 1-year and 90 patients at 2-year follow-up. There were no differences between the group of children with follow-up data and those without. Forty-four per cent of the sample were female, 17% from a minority ethnic group, and 25% were in Medicaid. There were no power calculations; the authors simply stated that the use of analysis of variance (ANOVA), as opposed to repeated measures designs, allowed maximisation of power for the analyses.
Study design This was a cohort study, apparently carried out at a single site. Follow-up was conducted at both 12 and 24 months. Data were available on all patients at one year but data on eight patients were lost at the 2-year follow-up. Medical record data were available for 83 and 77 patients, and questionnaire data were available for 87 and 71 patients, respectively, for follow-up years one and two.
Analysis of effectiveness The primary health outcomes used in the study were severity of asthma (measured by Functional Severity of Asthma Scale), caregivers' quality of life (measured by Caregiver's Quality of Life Questionnaire), child's quality of life (measured by Pediatric Quality of Life Scale). Analysis of the clinical study appears to have been based on treatment completers only, although the authors did not specifically state this.
Effectiveness results The group showed significant improvement (p<0.0001) from admission to 1- and 2-year follow-up in median corticosteroid use (66% of patients required oral corticosteroids at admission compared with 26% after 1-year and 13% at 2 years);
asthma functional severity (decrease from a mean of 16.5 (+ or - 5.26) to 9.5 (+ or - 6.5) at 1-year to 8.3 (+ or - 5.5) at 2-year follow-up);
perceived competence in asthma management;
and quality of life for both caregiver (mean composite scores improved from 4.2 (+ or - 1.2) at admission to 5.6 (+ or - 1.2) and 6.1 (+ or - 0.9) at 1 and 2 years, respectively) and child (mean composite scores improved from 4.4 (+ or - 1.3) at admission to 5.8 (+ or - 1.2) at 1-year and 6.1 (+ or - 0.9) at 2-year follow-up).
Clinical conclusions The authors concluded that multidisciplinary care in a short-term, outpatient, day treatment programme could significantly contribute to improvement in asthma severity and quality of life for both caregivers and asthmatic children.
Measure of benefits used in the economic analysis No summary benefit measure was used. Clinical outcomes were left disaggregated within a cost-consequences analysis.
Direct costs Estimates of quantities of resource use were based on actual data, being derived from patient surveys of health care contacts and subsequent checking of medical records by two members of staff (thus providing high interrater reliability). A number of items were collected from medical records (number of glucocorticoid bursts, asthma-related emergency department visits, asthma-related hospital stays, catastrophic events, 'sick' and 'well' physician visits) and these were put together to produce a composite score for medical encounter utilisation. Similarly, the data were also used to derive a composite medical encounter cost score based on services rendered. Cost of services was estimated by averaging 1996 data from six local hospitals and the Colorado Hospital Association. Discounting was not relevant due to the short time frame of the analysis (2 years).
Statistical analysis of costs Comparisons were made between admission and 1- and 2-year follow-up data, using ANOVA for normally distributed data, or the Wilcoxon rank sum test when using data with skewed distributions.
Indirect Costs Indirect costs were not included and no rationale was given for this exclusion.
Sensitivity analysis No sensitivity analysis was carried out.
Estimated benefits used in the economic analysis No summary benefit measures were determined in the study and thus the reader is referred to the effectiveness results reported above.
Cost results Medical record data showed significant improvement (p<0.0001) at both 1- and 2-year follow-up in median number of corticosteroid bursts, emergency department visits, hospital days, and overall utilisation of medical care encounters. A median total medical encounter cost/patient of $16,250 (interquartile range (IQR): $6,972 - $25,714) for the year prior to programme participation was reduced to $1,902 (IQR: $505 - $6,524) at 1-year and $690 (IQR: $185 - $3,550) at 2-year follow-up (p<0.0001).
Synthesis of costs and benefits A synthesis of costs and benefits was not carried out.
Authors' conclusions The authors concluded that a multidisciplinary approach such as that performed in this day programme could have a significant, positive effect on a number of clinical and economic outcomes including asthma severity, quality of life, and healthcare costs.
CRD COMMENTARY - Selection of comparators The comparator was care given prior to the intervention which was appropriately used to judge the 1- and 2-year follow-up results.
Validity of estimate of measure of effectiveness The validity may have been compromised by the fact that the analysis was carried out on treatment completers only. The absence of a control group also affects the validity. The authors attempted to justify the lack of a control group by stating how difficult it would be to get an appropriate control group given the severe and complex nature of patients referred to their programme. No power calculations were provided to justify the size of the sample.
Validity of estimate of measure of benefit No summary measure of benefit was provided due to the cost-consequences approach adopted.
Validity of estimate of costs Sources of direct costs and resource utilisation were clearly presented. However, the lack of a sensitivity analysis around resource usage and cost elements is likely to limit the generalisability of the findings. In addition, only direct costs were used in a study where the close involvement of all family members makes it likely that indirect costs could be significant in terms of productivity losses. As with the effectiveness data, no power calculations were included to determine whether the sample size was sufficient to detect differences in the economic analysis. The authors did not specify the perspective from which the economic analysis was conducted.
Other issues The authors proposed that this 'model' of care could be used in the treatment of other chronic illnesses. However, there is a lack of reference to the generalisability of the study to other populations and to other settings. There was little comparison with other studies, although this may be due to the relative paucity of studies relating to this kind of multidisciplinary approach. The only attempt at a comparison appears to have been against the study carried out at the same centre a decade ago. The results of the study appear to be very impressive, but it is hard to judge their true effectiveness without either a control group or a feeling for how generalisable the results might be.
Implications of the study The shorter length of stay compared to the previous study at this centre has considerable resource implications bearing in mind how impressive the results appear to be. Further research needs to be carried out on how this type of shorter, multidisciplinary approach could be used in other settings and for other chronic illnesses.
Source of funding Grant sponsor: NIH: Grant number: General Clinical Research Center Grant MO1 RR00051: Grant sponsor: Dr Scholl Foundation.
Bibliographic details Bratton D L, Price M, Gavin L, Glenn K, Brenner M, Gelfand E W, Klinnert M D. Impact of a multidisciplinary day program on disease and healthcare costs in children and adolescents with severe asthma: a two-year follow-up study. Pediatric Pulmonology 2001; 31(3): 177-189 Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Asthma /economics /therapy; Child; Child, Preschool; Day Care, Medical /economics; Female; Follow-Up Studies; Health Care Costs; Humans; Infant; Male; Outcome Assessment (Health Care); Quality of Life AccessionNumber 22001000707 Date bibliographic record published 30/11/2001 Date abstract record published 30/11/2001 |
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