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Electronic clinical pathway for community acquired pneumonia (e-CP CAP) |
Usui K, Kage H, Soda M, Noda H, Ishihara T |
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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 electronic clinical pathway (e-CP) for community-acquired pneumonia (CAP) was examined. The pathway covered the management of medical procedures, including physical and laboratory examinations, medical care, prescriptions, diets, activities and patient education.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised hospitalised patients who were suffering from CAP. The patients included those suffering from serious pneumonia (according to the guidelines set by the Japanese Society for Respirology), those with a fever of over 38.5 degrees which had lasted more than a week, and those having difficulty with the oral intake of medication. Also included were patients suffering from side effects of antibiotics given as outpatients, and those with accompanying diseases relating to respiratory organs, diabetes etc.
Exclusion criteria for the use of the e-CP for CAP included age over 80 years old, lung tumours or pleurisy, lung obstruction (less than 40% of expected FEV1.0), bronchial asthma, cardiac insufficiency, and diabetes which was difficult to control or disorders of the central nervous system. Further exclusion criteria were patients on steroids or other kinds of immune suppressants, those with pulmonary aspiration, and those who had breathing difficulties and needed an artificial respirator. The setting was secondary care. The economic study was conducted at the Division of Respirology and Chest Surgery, Kanto Medical Centre, NTT-EC, Tokyo, Japan.
Dates to which data relate The effectiveness data came from a single study conducted between January 2002 and December 2003. The resource use data related to the same period. The price year was not stated.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data The cost data for the single study were collected retrospectively from the same sample as that used in the effectiveness analysis.
Study sample Power calculations were not utilised in the determination of sample size. The study sample consisted of 30 hospitalised patients who received treatment based on the e-CP for CAP (e-CP group). Another 31 patients who formed the control group received conventional treatment without the e-CP for CAP. The mean age of the patients was 44.0 years in the e-CP group and 51.4 years in the control group. The female-to-male ratio was 19:11 for the e-CP group and 15:16 for the control group.
Study design This was a non-randomised controlled trial that was carried out in a single centre. The period of follow-up was until hospital discharge. No loss to follow-up was reported.
Analysis of effectiveness The analysis of effectiveness was conducted on an intention to treat basis. The outcomes assessed were the initial treatment outcomes, the duration of hospitalisation and the duration of antibiotic infusion. In terms of the baseline characteristics, differences in mean age, gender ratio and other measures (e.g. body temperature, the number of white blood cells, CRP, PaO2, PSI class, and the number and kinds of accompanying diseases) were non significant between the e-CP and control groups.
Effectiveness results The initial treatment success rate was 90% for the e-CP group and 90.3% for the control group. This difference, together with differences in the use of antibiotics, was statistically non significant.
The duration of hospitalisation was 8.03 days for the e-CP group and 10.77 days for the control group. The difference was significant, (p=0.013).
The duration of antibiotic infusion was 6.47 days for the e-CP group and 8.22 days for the control group. The difference just failed to reach significance, (p=0.058).
Clinical conclusions The e-CP for CAP has similar clinical effectiveness to standard treatment but leads to a reduction in the duration of patient hospitalisation.
Measure of benefits used in the economic analysis As no difference in clinical effectiveness was found, the economic analysis was based on a cost-minimisation approach that was principally driven by differences in the length of hospitalisation.
Direct costs The direct costs used were for treatment (antibiotic infusions), laboratory and radiography tests. The costs and the quantities were not reported separately. Discounting was not relevant because of the short period of analysis. The cost data were based on health insurance points for the Japanese Health Care system. The price year was not stated.
Statistical analysis of costs The cost data were treated stochastically. The Mann-Whitney U-test was used to examine cost-differences between the e-CP and control groups.
Indirect Costs The indirect costs were not included.
Currency No currency was used as the economic analysis was based on Japanese health insurance points.
Sensitivity analysis No sensitivity analysis was carried out.
Estimated benefits used in the economic analysis Not applicable since a cost-minimisation analysis was conducted.
Cost results The total costs were 24,338 points for the e-CP group and 34,048 points for the control group. The difference, which resulted from a significant reduction in the costs for laboratory and radiography tests in the e-CP group, was significant, (p=0.0031).
Synthesis of costs and benefits The costs and benefits were not combined. Compared with the control group, a significant reduction was observed in both the duration of hospitalisation and the total costs for the e-CP group. Although non significant, a trend for a reduction in the duration of antibiotic infusion was also observed.
Authors' conclusions The introduction of an electronic clinical pathway (e-CP) for community-acquired pneumonia (CAP) led to a reduction in the duration of hospitalisation and antibiotic infusion, while reducing the medical costs. No differences were evident in the clinical effectiveness outcomes. It is therefore useful for the standardisation of medical care for patients with CAP.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator (standard treatment) was clear and was justified by the authors. However, the protocols for standard treatment were not described in detail in the paper, thus objective assessments of the validity of the comparator were not possible.
Validity of estimate of measure of effectiveness In design terms, this was a non-randomised controlled trial with a relatively small sample size (seemingly not determined by a power calculation). Although a baseline comparison of the patient characteristics did not reveal any significant differences between the groups, a larger sample size in conjunction with a randomised design would have helped to enhance the strength of the findings. Differences between the groups were statistically assessed and reported appropriately.
Validity of estimate of measure of benefit Although the authors did not classify the analysis as such, the analysis was, in fact, based upon a cost-minimisation approach as the clinical outcomes were not statistically different. The main benefit was therefore expressed in economic terms, which is a valid approach for this clinical scenario.
Validity of estimate of costs Only limited data were reported for the cost analysis. Some limitations exist in that the costs and the quantities were not reported separately, the price year was not stated, and insurance points were used to proxy actual costs. This approach has relevance for the Japanese context, but the cost results cannot be generalised or transferred to other health care systems. However, in relative terms, the results do reveal a significant difference in economic terms in favour of the e-CP for CAP.
Other issues The authors compared their results with the findings of one other study, and similar results were found. The issue of the generalisability of the results to other settings was not addressed, but the authors indicated that the results are applicable to patients with milder symptoms of pneumonia. The authors also noted that the clinical pathway itself needs to be improved in terms of revising clinical goals, duration and appropriate medication for specific steps. The validity of the results for other health care systems has to be considered in the light of the limitations of the study, which have been outlined already.
Implications of the study In terms of clinical practice, the e-CP for CAP appears to offer economic advantages without affecting clinical outcomes. For decision-makers it therefore warrants consideration. In terms of future research, the authors highlighted the need for further development and testing of the clinical pathway as specified in the "Other issues" field (above) of this commentary.
Bibliographic details Usui K, Kage H, Soda M, Noda H, Ishihara T. Electronic clinical pathway for community acquired pneumonia (e-CP CAP) Journal of the Japanese Respiratory Society 2004; 42(7): 620-624 Indexing Status Subject indexing assigned by NLM MeSH Adult; Case Management; Community-Acquired Infections /economics; Costs and Cost Analysis; Critical Pathways /economics; Electronics, Medical; Female; Humans; Length of Stay; Male; Middle Aged; Pneumonia /economics; Severity of Illness Index AccessionNumber 22004006482 Date bibliographic record published 31/08/2005 Date abstract record published 31/08/2005 |
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