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Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families |
Pritchard C, Foulkes L, Lang D A, Neil-Dwyer G |
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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 evaluated a specialist liaison nurse (SLN) service that aimed to reduce the psychosocial trauma of patients who had suffered an aneurysmal subarachnoid haemorrhage (ASAH). This "enhanced service" was compared with "treatment as usual" (TAU).
The 'enhanced service', provided by a SLN, was complimentary to inpatient care. The SLN was an experienced neurosurgical ward sister whose role was to support and counsel patients and their families from the point of admission through to postdischarge. The SLN focused primarily on discharge issues and worked with patients and their families on the ward, at outpatient clinics and/or via a telephone advice line and home visits. The TAU group received medical and nursing care as inpatients. They were then predominately discharged back into the community under the care of their general practitioner (GP).
Type of intervention Treatment and rehabilitation.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised ASAH patients treated by clipping and coiling at a regional neurosurgical unit, and their carers. No other information was provided.
Setting The setting was both secondary and community care. The economic study was conducted in Southampton, UK.
Dates to which data relate The effectiveness data for the SLN service were collected between August 2001 and July 2003. The effectiveness data for the TAU cohort were collected between June 1999 and December 2000. The costs were reported in 1999 prices.
Source of effectiveness data The evidence of effectiveness was derived from a single study.
Link between effectiveness and cost data The costing of the SLN service was undertaken prospectively on the same patient sample as that used in the effectiveness study. However, the costing of the TAU cohort was undertaken retrospectively.
Study sample No power calculations were performed to determine the sample size. The sample comprised consecutively treated ASAH patients. The SLN group contained 184 patients and the TAU group contained 142 patients. The majority of the sample in both cohorts was female (TAU 67%, SLN 61%), aged under 54 years (TAU 52%, SLN 54%) and belonged to social classes 1-3 (TAU 81%, SLN 83%). No information was given on the proportion of patients and families who refused to participate, or whether any were excluded from the initial sample.
Study design The study was a single-centre prospective comparative study with historical control. Follow-up was 6 months after discharge of the patients for the SLN cohort and between 6 and 18 months after discharge for the TAU cohort. A total of 153 patients from the SLN cohort were followed-up at 6 months. Seventeen cases were lost, of which 12 had died, 2 had no translator and 3 were untraceable. There were 14 nonresponders. It was unclear exactly how many of the TAU completed follow-up. There were 33 nonresponders. There were significantly more non-responders in the TAU cohort than in the SLN cohort, (p<0.01). There were no significant clinical differences between the responders and nonresponders in the SLN or TAU cohorts. The clinical team were blinded to the psychosocial results of the study.
Analysis of effectiveness The basis of the analysis was treatment completers only. The primary outcomes were psychosocial trauma, satisfaction with inpatient and postdischarge care, and confidence in the GP's knowledge of ASAH. These were derived from the standardised patient/carer designed postal Wessex Patient Carer Questionnaire (WPCQ). This comprised 67 structured statements for patients and 68 for carers, with 6 open-ended questions for respondents to outline their experiences. The authors acknowledged that the questionnaire was structured slightly differently for the two groups. The questionnaire evaluating the SLN service included 5 structured and 2 open-ended questions on the role of the SLN. There were also 20 random stratified in-depth home interviews conducted with patients and carers who received the SLN service.
At baseline, the groups were clinically comparable with no significant differences in types of operation, delays in diagnosis, medical complications or re-bleeds. The SLN group did, however, have significantly more high-risk aneurysms, (p<0.01) and experienced longer inpatient stays, (p<0.02). The control group had a significantly higher proportion of GCS Grade 1 patients (78% versus 62%). There were no significant differences in social characteristics between the two groups of patients.
Effectiveness results The analysis of the enhanced SLN was based on the responses of 136 patients and 143 carers, as patients and some carers did not complete a questionnaire. In the TAU group, the analysis of effectiveness was based on the responses of 97 patients and 98 carers. The authors presented the proportion of patients and carers from both groups who agreed and disagreed with various statements derived from WPCQ. These covered areas concerned with inpatient care received, postdischarge care, emotional state at home and community care. Only statements for which there were statistical significances between the two cohorts were presented, and p values were reported for levels of significance of 5%, 2%, 1% and 0.1%. There were 36 statements for which there was a significant difference between the responses of SLN and TAU patients. In addition, there were 34 statements for which there was a significant difference between the responses of the carers of SLN patients and the carers of TAU patients.
The number of significant responses precludes a full presentation of the results. A general outline of the results is instead presented with some specific examples of where the difference in response was found to be highly significant, (p<0.001). For the full results the reader is referred to the paper.
Inpatient care.
There were 12 significant responses from the questionnaire that indicated that SLN patients were more satisfied with their inpatient care than TAU patients. Compared with the TAU cohort, SLN patients were more satisfied with communication, consultant and medical contact, and had less anxiety, apprehension and pain. The carers of SLN patients also were more satisfied with inpatient care than carers of TAU patients, as illustrated by significant differences on 15 items. They were more satisfied with information and communication, and experienced less negative impact of the ASAH with lower general health problems and less stress during inpatient treatment. Highly significant differences between the responses of SLN and TAU carers were found for information about medication always being clear (Agree: SLN carers 68% versus TAU carers 41%; p<0.001) and communication between staff and relative being mainly very good (Agree: SLN carers 90% versus TAU carers 34%; p<0.001).
Postdischarge care.
TAU patients had significantly more physical health problems than the SLN cohort of patients in terms of mobility (TAU 25% versus SLN 16%; p<0.01), general health (37% versus 23%; p<0.02) and stress levels (43% versus 19%; p<0.01). The SLN cohort did, however, have more problems with exhaustion (42% versus 26%; p<0.02) and concentration (34% versus 18%; p<0.02) than the TAU group.
In relation to postdischarge experience and emotional state, the SLN group had a significantly better experience than the TAU group on 15 items. Only 13% of SLN patients disagreed with the statement that they had all the support they needed, compared with 53% of TAU patients, (p<0.001). The SLN group experienced significantly better family or patient relations. For example, 72% of TAU patients versus 18% of SLN patients agreed that "after discharge my family were worse-off than at the time of the ASAH crises", (p<0.001). SLN patient psychological response was significantly better than TAU patients in 5 areas, and 63% of SLN patients versus 34% of TAU patients were not often frightened, (p<0.001).
Carers of SLN patients showed significantly better experience and emotional response than the controls on 12 statements, with highly significant differences found for employment problems. Seventy-two per cent of carers of TAU patients agreed with the statement that "worries about their relative affected their work", compared with 39% of carers of SLN patients (p<0.001). Fifty-one per cent of TAU carers agreed with the statement that "being unsupported put major strains on family", compared with 32% of carers of SLN patients (p<0.001).
Community care.
The majority of patients and carers in both groups expressed dissatisfaction with their postdischarge care.
Among those receiving the SLN service, the results were examined to identify any differences between those who were confident in their GP's knowledge of ASAH (GPC) and those who were neutral about the level of GP's knowledge of ASAH (GPN). Carers of the GPC patients had better psychosocial outcomes, with 18 statistically significant differences between the responses of carers of GPC and NPC patients. There were 10 statistically significant differences between the responses of GPC and GPN patients, favouring GPC patients.
Clinical conclusions The enhanced service incorporating a SLN resulted in significantly improved satisfaction with inpatient and discharge care, and reduced psychosocial trauma.
Measure of benefits used in the economic analysis No summary health benefit was used in the economic analysis. In effect, a cost-consequences analysis was performed.
Direct costs The resource quantities were not reported, and the quantity/cost boundary adopted was that of the health service. The direct costs covered the use of consultant and GP time following discharge, the SLN post (including staff supervision), the neurosurgical unit and readmission to hospital. The source of this cost data was not provided. The method of cost analysis drew on the work of Drummond et al. 1997 (see "Other Publications of Related Interest" below for bibliographic details). Discounting was not undertaken, which was appropriate given the short timeframe of the study. The study reported the average annual costs. The costs were reported at 1999 prices.
Statistical analysis of costs The costs were treated deterministically (i.e. only point estimates were provided).
Indirect Costs The quantities and the costs were reported separately. The cost boundary adopted was that of patients and relatives. The indirect costs of the patients and carers' time off work, which was derived by extrapolating wage or salary levels associated with occupations from official estimates, were measured. The method of cost analysis drew on the work of Drummond et al. 1997. Discounting was not undertaken, which was appropriate given the short timeframe of the study. The costs were reported at 1999 prices.
Sensitivity analysis No sensitivity analysis was undertaken.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The average annual cost of the SLN project was 32,000.
The total whole annual cost of the neurosurgical Wessex unit was 2.132 million at 2001/02 prices.
The total cost of time off work was 185,000 for TAU carers, 563,000 for TAU patients, 89,700 for SLN carers and 401,000 par SLN patients. The introduction of SLN led to estimated savings from reduced "time-off-work" costs of 176,000 per annum at 1999 prices.
The family costs of those who received SLN care were 61% less than the control TAU families, as their average "time-off-work" cost fell from 6,338 to 2,441 per family.
The SLN made further savings through dealing with some of the consultants outpatient work, preventing readmissions to the hospital, and by reducing unnecessary calls upon the GP.
Savings to families and the National Health Service through reduced time off work, medical time and readmissions was 156,400 per annum. This was 4.9 times the annual cost of the project.
The authors prospectively estimated that 1.6 million annual "savings" would result from 80% of employed ASAH patients returning to work.
Synthesis of costs and benefits Not relevant as a cost-consequences analysis was performed.
Authors' conclusions The specialist liaison nurse (SLN) service was clinically and fiscally cost-effective. With reference to the hypotheses outlined in the paper that there would be no differences between the SLN and "treatment as usual" (TAU) cohorts in terms of: general satisfaction with neurosurgical inpatient care, this was rejected; general satisfaction with postdischarge care, this was rejected; confidence levels in the GP's knowledge of aneurysmal subarachnoid haemorrhage (ASAH), this could not be rejected; and psycho-socioeconomic "costs", this was strongly rejected.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator was clear. The "enhanced" SLN service was compared with the usual approach before the enhanced service was implemented. 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 a prospective comparative study with a historical cohort. This was appropriate for evaluating the impact of the new intervention in comparison with previous patterns. However, such a study is associated with some disadvantages, such as time-related bias and confounding. The lack of random allocation of the patients to the study groups might have resulted in bias, and in confounding factors affecting the observed outcomes. Since the control group was retrospectively evaluated, the impact of changes occurring between the two study periods cannot be ruled out. Further, follow-up of the SLN cohort was 6 months after patients were discharged, whereas for the TAU cohort it was between 6 and 18 months after patient discharge. The authors acknowledged this limitation and stated that this might have led to an underestimate of the positive benefits of the SLN service. The validity of the study was also affected by the lack of power calculations and the limited details provided on the study population. The authors acknowledged that, although a coterminous randomised controlled trial would have been more valid, they lacked the resources to conduct such a study and felt it was inappropriate due to ethical reasons. The authors also believed that it would not have been possible to blind clinical staff to the different patient groups.
In addition, it is not known whether the study sample was representative of the study population since inclusion and exclusion criteria were not reported. No information was given on the proportion of patients and families who refused to participate, and very scant information was provided on exactly how many of the TAU completed follow-up. Although at baseline the groups were socially comparable and mostly clinically comparable, the SLN group did have significantly more high risk aneurysms and experienced longer inpatient stays, which could have impacted on outcomes. The analysis of effectiveness was based on treatment completers only. The outcomes were derived from the WPCQ, which was designed in conjunction with ASAH patients and carers, to determine psycho-socioeconomic outcomes. However, it was unclear whether it had been validated. In addition, as a single outcome measure there is the potential problem that not all patient responses would have been an accurate reflection of their experiences.
Validity of estimate of measure of benefit The authors did not derive a measure of health benefits. The analysis was effectively a cost-consequences analysis.
Validity of estimate of costs All the categories of cost relevant to the perspective adopted were included in the analysis. A detailed breakdown of the direct cost components (e.g. staff, materials) was not given, and not all of the costs and quantities were reported separately. In addition, there was limited information on the sources of the costs and no statistical analysis was performed. These factors limit the validity and generalisability of the cost analysis. Discounting was not undertaken, which was appropriate given the short timeframe of the study. The dates to which the prices related were reported, which will aid any future inflation exercises.
Other issues The authors made appropriate comparisons of their findings with those from other studies. The issue of generalisability to other settings was not addressed. The authors presented their results selectively, owing to the large number of questions examined by the questionnaire. They chose to highlight those for which there were significant findings. The authors' conclusions reflected the scope of the analysis.
Implications of the study The authors acknowledged that the non-randomised nature of the study limits its usefulness, and they recommended a proper randomised trial to assess the benefits and cost-effectiveness. They also believed that it would be useful for a prospective randomised controlled trial to analyse the extent to which psychosocial outcomes are related to physical disability.
Bibliographic details Pritchard C, Foulkes L, Lang D A, Neil-Dwyer G. Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families. British Journal of Neurosurgery 2004; 18(4): 347-356 Other publications of related interest Pritchard C, Foulkes L, Lang DA, Neil-Dwyere G. Psychosocial outcomes for patients and carers after aneurismal subarachnoid haemorrhage. British Journal of Neurosurgery 2001;15:456-63.
Drummond MS, O'Brien DJ, Stoddart G, Torrance GW. Methods for the economic evaluation of health care programmes. New York: Oxford University Press; 1997.
Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Attitude to Health; Caregivers; Community Health Services /standards; Costs and Cost Analysis; Emotions; Family Practice /standards; Female; Health Status; Hospitalization; Humans; Male; Middle Aged; Nurse's Role; Nursing Care /standards; Patient Satisfaction; Prospective Studies; Social Class; Stress, Psychological /economics /etiology; Subarachnoid Hemorrhage /economics /psychology /therapy AccessionNumber 22004009305 Date bibliographic record published 30/11/2005 Date abstract record published 30/11/2005 |
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