|
The effectiveness of a home visit to prevent childhood injury |
King W J, Klassen T P, LeBlanc J, Bernard-Bonnin A C, Robitaille Y, Pham B, Coyle D, Tenenbein M, Pless I B |
|
|
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 A home visit programme aimed at improving safety in the home, and decreasing the frequency of injuries in children, was investigated. The programme included the provision of an information package, a discussion of the findings of the baseline home safety inspection, discount coupons, and specific instruction relating to home safety measures.
Type of intervention Primary and/or secondary prevention.
Economic study type Cost-effectiveness analysis.
Study population The population comprised children aged younger than 8 years who had presented to an emergency department with an injury or other medical problem. The injuries or medical problems included tap water scalds, burns from a household fire, poisoning or ingestion, choking from the ingestion of a foreign object, fractures, sprains, strains, cuts, bruises from a fall from height, and head injuries while riding a cycle.
Setting The setting was the community. The economic study was carried out in four urban centres in Canada.
Dates to which data relate The effectiveness and resource use evidence was gathered from September 1994 to October 1996. The price year was 1999.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was carried out prospectively on the same sample of patients as that used in the effectiveness analysis.
Study sample A sample size of 375 participants in each group was determined using power calculations. These were based on a 10% difference in the adoption of the home safety behaviour between the intervention and the comparator, a type I error (two-sided) of 0.05 and a power of 80%.
The participants were identified from the under 8-year olds who were admitted to the emergency department. Two additional controls (one with a non-matching injury and one presenting with a medical problem at the emergency department), matched for gender and within 6 months of age, were selected for each case. The sample seems to have been appropriate to address the study question.
Overall, 1,172 patients were initially randomised. Of these, there were 601 children in the intervention group and 571 in the control group. The median age in both groups was 2 years. The proportion of male participants was 59% in the intervention group and 60% in the control group.
Study design The study was a randomised controlled trial carried out at 5 participating Canadian hospitals. The participants were randomised using identification cards placed in sealed envelopes and mixed in an opaque container. The participants were followed-up for one year after randomisation. At 4 months, 66 participants in the intervention group and 66 in the control group were lost to follow-up. At 8 months, 91 participants in the intervention group and 73 in the control group were lost to follow-up. At one year, 119 participants in the intervention group and 102 in the control group were lost to follow-up. This represented 19% of all those randomised. Compared with those who completed the trial, the drop-outs had significantly younger parents, the mother had her first child at a younger age, and the parent's minimum education (years) was less. Further, the parents of drop-outs were statistically less likely to identify injury as the leading cause of death.
Analysis of effectiveness The analysis used those participants who underwent follow-ups, and was thus limited to treatment completers only. The primary outcomes were related to parental injury awareness and knowledge, the family's use of home safety measures, the rate of injury, and the number of participants in the intervention group who reported home safety modifications.
Outcomes relating to parental injury awareness and knowledge included the severity of the injuries, the prevention of injuries, parental control over the injuries, and the proportion of injuries that required hospital admission. These were assessed using a questionnaire administered by the home inspector.
The home safety measures included the following: no small objects, matches or lighter within the child's reach; no easily opened windows; cleaning supplies stored away; hot tap water not exceeding 54 degrees C; smoke detectors installed and functional; the presence of fire extinguishers; gates at the staircases; use of a child's bike helmet; and observation of the baby walker.
The groups were comparable in terms of their age (median age: 2 years), gender (60% males), case-control status, socioeconomic status, and baseline injury awareness and knowledge.
Effectiveness results There were no significant differences in changes from baseline to follow-up in terms of parental injury awareness and knowledge between the intervention and the control groups.
Significant changes were only observed for two of the home safety measures used. First, the number of participant homes that had hot water not exceeding 54 degrees C (odds ratio, OR 1.31, 95% confidence interval, CI: 1.14 - 1.50). Second, the number of participant homes that had smoke detectors installed (OR 1.45, 95% CI: 0.94 - 2.22).
A significant difference, in favour of the control group, was observed in the number of homes that had a fire extinguisher (OR 0.81, 95% CI: 0.67 - 0.97).
At 4 months, the number of injury visits to the doctor were 7% in the intervention group and 11% in the control group, (p<0.05). At 8 and 12 months, there was no statistically significant difference.
The rate ratio of the reported injury visits to the doctor between the intervention and the control groups was 0.75 (95% CI: 0.58 - 0.96) at one year.
The number of participants in the intervention group who reported home safety modifications was 62% at 4 months and 23% at 8 months.
Clinical conclusions A single home visit to improve the extent to which families use home safety measures was insufficient to influence the long-term adoption of home safety measures. However, it was effective in decreasing the overall occurrence of injuries.
Measure of benefits used in the economic analysis The measure of benefit used in the economic analysis was injuries prevented, which was derived from the effectiveness analysis.
Direct costs All the health care costs of the preventive programme and the costs associated with the treatment of injuries were analysed. The direct cost of treating injuries and the cost of the home visits were included in the analysis. The cost/resource boundary adopted was not explicitly stated, but could have been that of the hospital. The cost of the preventive programme was derived from the salary and infrastructure costs for the home visitors and the cost of the information packet provided to the parents. The unit costs and occurrence rates (expressed per 100 participants) were reported separately for the intervention and control groups. The frequencies of the injuries were obtained from actual data. However, the unit costs for the types of injuries were derived using typical resource profiles obtained from a panel of physicians, and the resource fees from the Children's Hospital of Eastern Ontario and from the Ontario Health Insurance Plan Schedule of Fees and Benefits. The unit costs related to 1999.
Statistical analysis of costs The costs were not treated stochastically. Only the total and average intervention costs were reported.
Indirect Costs No indirect costs were included in the analysis.
Sensitivity analysis Sensitivity analyses were not reported.
Estimated benefits used in the economic analysis The home visit prevented one injury visit to the doctor for every 12 families participating in the study.
Cost results The total cost of injuries was Can$13,482 in the control group and Can$7,028 in the treatment group.
The cost of injuries per participant was Can$23.61 in the control group and Can$11.69 in the treatment group.
The addition of the cost of an additional home visit resulted in an incremental cost of Can$48.11 per patient in the intervention group.
Synthesis of costs and benefits An incremental cost-effectiveness analysis was carried out to combine the costs and the benefits. The incremental cost per injury prevented was estimated as Can$372.
Authors' conclusions The home visit prevented one injury visit to the doctor for every twelve participating families at a small incremental cost in proportion to the benefits gained.
CRD COMMENTARY - Selection of comparators The comparator, the provision of a leaflet only, was selected by the authors as it represented a minimal intervention. This enabled the additional effect of the intervention to be assessed. You should decide whether this is representative of the current practice 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 study sample used cases and controls in a ratio of 1:3, but it was not discussed whether this sample was representative of the study population. The patient groups were shown to differ at baseline, mainly due to the attrition of younger and less educated parents. It is unclear how this could have impacted on the analysis. The authors did not discuss the statistical analysis used to compare the costs.
Validity of estimate of measure of benefit The measure of the benefit used in the economic analysis was injuries prevented, which was obtained directly from the effectiveness analysis. No justification was provided for the choice of this benefit measure.
Validity of estimate of costs The perspective adopted in the analysis was unclear, although it appears to have been that of the hospitals where the trial was carried out. If this was the case, all the relevant costs were included in the analysis. The costs were only reported separately from the quantities for the treatments assessed. Sensitivity analyses on the quantities and the costs were not reported. The dates to which the costs relate were reported. The price year was also reported.
Other issues The authors made few comparisons of their findings with those from other studies. The issue of generalisability to other settings was not addressed. The authors did not present their results selectively. Their conclusions reflected the scope of the analysis. The authors discussed some possible limitations of their study, such as the short duration of the visit.
Implications of the study The authors state that further research will be based on contacting the families to determine the most worthwhile or least beneficial components of the programme. "Future programmes should integrate with other home visitation programmes and target a few, well-focused, evidence-based areas including the evaluation of high-risk groups and the effect of repeated visits on outcome."
Source of funding Supported by Health and Welfare Canada, National Health Research and Development Programme, grant number 6605-4290-BF.
Bibliographic details King W J, Klassen T P, LeBlanc J, Bernard-Bonnin A C, Robitaille Y, Pham B, Coyle D, Tenenbein M, Pless I B. The effectiveness of a home visit to prevent childhood injury. Pediatrics 2001; 108(2): 382-388 Indexing Status Subject indexing assigned by NLM MeSH Accidents, Home /economics /prevention & Canada /epidemiology; Case-Control Studies; Child; Child Health Services /economics /standards; Child, Preschool; Cost-Benefit Analysis; Female; House Calls /economics /utilization; Humans; Infant; Male; Outcome Assessment (Health Care); Preventive Health Services /economics /standards; Safety /standards; Wounds and Injuries /economics /epidemiology /prevention & control; control AccessionNumber 22001001542 Date bibliographic record published 30/11/2002 Date abstract record published 30/11/2002 |
|
|
|