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Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children |
Koskinen H, Rautakorpi U M, Sintonen H, Honkanen P, Huikko S, Huovinen P, Klaukka T, Palva E, Roine R P, Sarkkinen H, Varonen H, Makela M |
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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 use of national guidelines in the treatment of acute otitis media (AOM) in children was investigated. These guidelines were part of a programme introducing guidelines for six common infections. The patients or the caregiver filled in a questionnaire before the consultation and the health personnel filled in a questionnaire during or just after the consultation. The health personnel had been on a 2-hour course to update them on the AOM treatment guidelines, which covered the diagnostic tools that should be used, the choice and duration of medication, appropriate pain relief and a recommended follow-up visit one month later.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised children aged between 0 and 6 years old with AOM who were visiting a health centre for the first time.
Setting The setting was primary care. The economic study was carried out in Finland.
Dates to which data relate The effectiveness and resource evidence related to a 1-week period in November from 1998 to 2002. The price year was 2002.
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 patient sample as that used in the effectiveness analysis.
Study sample No power calculations were reported. The study sample consisted of all patients aged between 0 and 6 years with AOM who were visiting one of 30 health centres for the first time. There were 579 patients (46% female) in the study before the guidelines were implemented and 369 (47% female) after their implementation. The mean age of the patients was 2.56 years before implementation and 2.63 years after implementation.
Study design This was a multi-centre non-randomised study with historical controls. The patients were followed up for 14 days after their initial visit to the health centre. No loss to follow-up was reported.
Analysis of effectiveness The analysis was conducted on an intention to treat basis. The primary health outcome was the percentage of symptom-free patients 14 days after the initial consultation. Data were collected using questionnaires. The authors reported that a random sample of patients was also interviewed by telephone 2 weeks after the consultation. The patients appear to have been comparable at baseline, although no statistical analysis was conducted.
Effectiveness results The percentage of symptom-free patients 2 weeks after the initial consultation was 68% (95% confidence interval, CI: 58 to 77) in 1998 and 78% (95% CI: 68 to 85) in 2002.
Clinical conclusions The authors concluded that the introduction of national guidelines for patients with AOM attending a clinic for the first time had improved health outcomes for those patients.
Measure of benefits used in the economic analysis The measure of benefit used was the increase in the percentage of symptom-free patients 2 weeks after the initial consultation. It was derived from the effectiveness analysis.
Direct costs Discounting was not carried out as the costs were incurred during less than 1 year. The quantities and the costs were not analysed separately but unit costs for the different cost components were given, as were the total costs for every 100 patients. Thus, the resource quantities could easily be derived. Costs to the health system were measured. These were the cost of a basic visit to a general practitioner with no diagnostic tests, the cost of an extended visit including diagnostic tests, the cost of a health care visit in a private practice, nursing staff, the phone consultation, a specialist appointment, a hospital outpatient visit, hospital treatment in a children's ward, medicines and the cost of the educational intervention. Travel and time costs (used in visits) to the patients and their families were also estimated. The costs were estimated using actual data from the study. The quantities were obtained from the study, while prices were taken from the study or from published sources. All costs were inflated to the year 2002, which was the price year for the study.
Statistical analysis of costs The costs were treated deterministically and no statistical tests were carried out.
Indirect Costs Although they were not included in the base-case analysis, the indirect costs were assessed in the sensitivity analysis through the loss of parental earnings. The unit cost of this was reported, an average wage being used and taken from national statistics. The quantities and the costs were not analysed separately. The quantities were obtained from the study. The price year was 2002.
Sensitivity analysis The effect of including productivity costs was estimated. The effect of excluding hospital costs, which arise very rarely for a patient with AOM, was also estimated. The effect on the incremental cost-effectiveness ratio (ICER) of a range of estimates (extremes of the 95% CIs) for the effectiveness results was assessed.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The cost per patient (excluding indirect costs) was EUR 152 before the introduction of the guidelines and EUR 150 after their introduction.
Synthesis of costs and benefits In the initial calculations, which excluded the indirect costs, the effectiveness was higher and the costs were lower after the introduction of the guidelines. Thus, the implementation of guidelines was the dominant strategy.
If the costs of hospital treatment were ignored, then the cost per patient was reduced from EUR 152 before implementation of the guidelines to EUR 128 after implementation. Again, this made the implementation of guidelines a dominant strategy.
When the values at the extremes of the 95% CIs were used in the sensitivity analysis, there was only one possibility that produced a positive ICER. This was when the percentage of symptom-free patients was at the top end of the 95% CI before guideline implementation and at the bottom end of the 95% CI after their implementation. The ICER was EUR 23.
If the indirect costs were included, the cost per patient was EUR 194 before the introduction of the guidelines and EUR 214 afterwards. Therefore, the implementation of national guidelines ceased to be the dominant policy and the ICER was EUR 205 (10 extra patients symptom-free at a cost of EUR 2,046).
Authors' conclusions The introduction of national guidelines for the treatment of acute otitis media (AOM) in children was associated with extra health benefits at slightly lower direct costs and was thus a dominant strategy. When productivity costs were taken into account, the social cost of one extra symptom-free patient was EUR 205.
CRD COMMENTARY - Selection of comparators The authors assessed the cost-effectiveness of introducing national guidelines and stated that this was compared with treatment given before the national guidelines. The readers' understanding of the study and their ability to generalise the results to their own setting would have been improved had the authors specified the exact nature of the standard practice before the national guidelines.
Validity of estimate of measure of effectiveness The source of the effectiveness data was a single study. The study design was appropriate for the hypothesis, although it did not consider that there might have been changes in circumstances that were unrelated to the national guidelines. The authors were aware that certain pain relief medication became available over the counter during the time of the study and this might have affected the results. An ideal study would have introduced national guidelines into some areas of the country and compared the results there with those in other areas. The study sample was representative of the study population in terms of the rural/urban mix and geographical location. The population covered by the health centres in the study represented 16% of the Finnish population. The patient groups were shown to be comparable at analysis and the analysis of effectiveness was handled credibly. There were no other sources of effectiveness data.
Validity of estimate of measure of benefit The measure of benefits (i.e. the number of symptom-free patients) was obtained directly from the effectiveness analysis, which was justified. This measure does not enable broad comparisons to be made with a range of other health care-related technologies.
Validity of estimate of costs From the perspective adopted, all the relevant categories of cost appear to have been included in the analysis. As mentioned already, the cost of over-the-counter medication was not included and, therefore, there might have been an underestimate of the costs after introduction of the guidelines. The unit costs were not reported separately from the resource quantities but, as the unit costs and total costs were given, the quantities could easily be derived. The resource use quantities were taken from a single study, while the prices were taken from the authors' setting and published sources. No other sources were used for either the resource quantities or prices. A sensitivity analysis of the costs was carried out, which estimated the effect of not including indirect costs and not including hospital costs. No statistical or any other analysis of the quantities was carried out. Although some costs were during 5 years, no discounting was carried out. The price date was reported, which will aid any future inflation exercises.
Other issues The authors made limited comparisons of their results with those from other studies, but this might reflect the lack of similar studies. The issue of generalisability to other settings was not directly addressed. The authors did not present their results selectively and their conclusions reflected the scope of the analysis. The authors acknowledged some limitations of their study. One has already been mentioned, that is, the change in availability of symptomatic relief over the counter between 1998 and 2002. The authors also mentioned the possibility that the caregiver may not always give an accurate description of the patient. Finally, the focus of the study was on the short-term effects of the treatment, thus the inclusion of long-term effects might affect the results.
Implications of the study The authors concluded that the national guidelines introduced into Finland improved the health of children suffering from AOM and reduced costs for the health system, although they did not reduce social costs. The authors stated that, because one of the aims of the guidelines was to reduce long-term adverse effects resulting from antibiotics, further work with a longer follow-up period is needed.
Source of funding Supported by the National Insurance Institution, the National Agency for Medicines, the Research and Development Centre for Welfare and Health, the Finnish Office for Health Care Technology Assessment and the Finnish Medical Society Duodecim.
Bibliographic details Koskinen H, Rautakorpi U M, Sintonen H, Honkanen P, Huikko S, Huovinen P, Klaukka T, Palva E, Roine R P, Sarkkinen H, Varonen H, Makela M. Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children. International Journal of Technology Assessment in Health Care 2006; 22(4): 454-459 Other publications of related interest Because readers are likely to encounter and assess individual publications, NHS EED abstracts reflect the original publication as it is written, as a stand-alone paper. Where NHS EED abstractors are able to identify positively that a publication is significantly linked to or informed by other publications, these will be referenced in the text of the abstract and their bibliographic details recorded here for information.
Indexing Status Subject indexing assigned by NLM MeSH Acute Disease; Child; Child, Preschool; Cost-Benefit Analysis; Female; Finland; Guideline Adherence /economics; Health Care Costs /statistics & Humans; Infant; Male; Otitis Media /diagnosis /economics /therapy; Practice Guidelines as Topic; numerical data AccessionNumber 22006008410 Date bibliographic record published 31/03/2007 Date abstract record published 31/03/2007 |
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