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Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic |
Scott J C, Conner D A, Venohr I, Gade G, McKenzie M, Kramer A M, Bryant L, Beck A |
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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 authors examined the Cooperative Health Care Clinic (CHCC) group outpatient model for chronically ill, older health maintenance organisation (HMO) patients. The CHCC group outpatient model comprised monthly group meetings held by patients' primary care physicians. The alternative was usual care.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised chronically ill older persons. Patients were excluded if they did not express an interest in the group care model, were home- or bed-bound, lacked transportation, or had dementia scores that indicated serious cognitive impairment. Patients were then eligible if they reported one or more chronic conditions and their physician approved their participation.
Setting The setting was primary care. The economic study was carried out in Denver (CO), USA.
Dates to which data relate The effectiveness data were collected between February 1995 and July 1996. The cost and quantity data were collected during the same period. A price year was not reported.
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 Power and sample size calculations were carried out on the basis of the results of an earlier pilot study. The largest requirement was to detect an effect size of 0.21 in emergency department visits, which necessitated a sample size of 364. Patients were selected initially by mailing health surveys to patients within the HMO who were aged 60 years or older, had had at least 11 outpatient clinic visits in the prior 18 months, and were members of the group of patients treated by a physician participating in the study. The exclusion and inclusion criteria were then applied. Of the 294 patients entering the study, 145 entered the intervention group and 149 the usual care group. The patients in the intervention group had a mean age of 74.2 years and 61% were female. The patients in the usual care group had a mean age of 74.1 years and 57% were female. The sample was appropriate to answer the clinical question, as it included patients who were willing to receive group care and had the potential to benefit from group care. There was no report of any patients refusing to participate, or individual persons being excluded for any reason.
Study design The analysis was based on a randomised controlled trial with two patient groups, intervention and usual care. Randomisation was stratified within each physician's group of patients, and was performed using a computer-generated random number sequence. The study was undertaken at multiple centres within a single HMO. Follow-up was carried out 24 months after enrolment, at which point 78% of patients returned the mailed survey. There was no report of blinding any outcomes.
Analysis of effectiveness The analysis was not carried out by intention to treat, as the authors made some adjustments at the end of the study for patient switches to non-study physicians and plan termination. The primary health outcomes were:
a composite quality of life score;
various self-efficacy scales;
the patients' immediate satisfaction, based on various aspects of their care; and
the patients' satisfaction at 24 months with various aspects of their care.
The authors reported that no significant differences existed for any baseline comparison between the two groups. The patients were compared in terms of a variety of parameters.
Effectiveness results Areas of significant difference only are reported below.
The quality of life score (10-point scale with 10 indicating greatest quality of life possible) was 7.2 (+/- 1.8) for the CHCC group and 6.3 (+/- 2.0) for the control group, (p=0.002).
Confidence communicating with their physician was 8.9 (+/- 1.3) for the CHCC group and 8.5 (+/- 1.7) for the control group, (p=0.03).
Satisfaction (4-point scale with 1 indicating greatest satisfaction) with the primary care physician was 1.2 (+/- 0.5) for the CHCC group and 1.5 (+/- 0.6) for the control group, (p=0.022).
Satisfaction with the primary care physician's non-hurriedness was 1.5 (+/- 0.6) for the CHCC group and 1.8 (+/- 0.8) for the control group, (p=0.008).
Satisfaction with the overall quality of care was 1.6 (+/- 0.6) for the CHCC group and 1.9 (+/- 0.7) for the control group, (p=0.048).
Satisfaction at 24 months (10-point scale with 1 indicating greatest satisfaction) with talking to the primary care physician about advanced directives was 3.9 (+/- 0.8) for the CHCC group and 3.5 (+/- 0.9) for the control group, (p<0.001).
Satisfaction at 24 months with talking with the pharmacist was 3.9 (+/- 1.0) for the CHCC group and 3.6 (+/- 1.0) for the control group, (p=0.009).
Satisfaction at 24 months with education from the nurse was 3.7 (+/- 0.92) for the CHCC group and 3.5 (+/- 0.94) for the control group, (p=0.048).
Clinical conclusions The authors concluded that CHCCs were associated with increased self-efficacy, better communication between participants and physicians, better quality of life, and fewer health plan terminations and switches to non-study physicians. They also noted that there were no significant changes in function or health status.
Measure of benefits used in the economic analysis The authors used a composite quality of life score in their effectiveness analysis, although this was not incorporated into the economic analysis. Therefore, the authors carried out a cost-consequences analysis.
Direct costs A perspective for the cost analysis was not explicitly reported, although the costs appear to have been estimated from the perspective of the third-party payer. The authors did not report that discounting was carried out, despite the timeframe extending to 24 months. The cost analysis focused on emergency department visits, inpatient services, professional services, home health visits and skilled nursing facility admissions. The unit costs and resource use data were taken from the HMO's administrative databases. The costs were broken down into quantities and unit costs. Patient records were used to estimate the quantities used. The costs were measured for 12 months before enrolment and 24 months after enrolment, and were therefore measured around 1994 to 1998. A price year was not reported.
Statistical analysis of costs The authors used confidence intervals and p values to analyse the cost results.
Indirect Costs The indirect costs were not estimated.
Sensitivity analysis There was no report of sensitivity analyses being carried out.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The total cost was $7,916 (+/- 9,387) (median $3,861) for the CHCC group and $11,115 (+/- 17,037) (median $6,025) for the control group, (p=0.66).
The only component of cost to be statistically different between the two groups was emergency room visits. This was $325 (+/- 675) (median $0) for the CHCC group and $607 (+/- 985) (median $113) for the control group, (p=0.001).
Synthesis of costs and benefits The costs and benefits were not combined.
Authors' conclusions Cooperative Health Care Clinic (CHCC) models were associated with lower use of emergency, hospital and professional services, and increased patient satisfaction and self-efficacy. However, they had no effect on outpatient use, health, or functional status.
CRD COMMENTARY - Selection of comparators The authors compared CHCC with usual care. Usual care enabled the benefits and problems associated with CHCC to be assessed in a real world setting.
Validity of estimate of measure of effectiveness The analysis was based on a randomised controlled trial with two patient groups. Randomisation helped to reduce potential systematic differences between the patient groups, thereby improving the internal validity of the study. As evidence of this, the authors did not detect any significant differences at baseline between patients in the two groups, despite making a wide range of demographic and chronic condition-related comparisons. The study sample was representative of the study population, as it included older patients who were willing to receive group care and who had the potential to benefit from group care. Various statistical analyses were carried out to compare the patients. A number of efficacy scales were used to assess patient wellbeing. These included a self-efficacy score, a satisfaction score and a composite quality of life score. The validity of the quality of life score in particular is uncertain. It would need to be tested elsewhere to assess its ability to capture relevant changes in quality of life and comparability to broadly accepted scores such as quality-adjusted life-years or Short-Form 36 scores.
Validity of estimate of measure of benefit A composite quality of life measure was estimated as part of the effectiveness analysis, but this did not form part of the economic study. Therefore, the study was, in effect, a cost-consequences analysis.
Validity of estimate of costs A perspective for the cost analysis was not reported. Thus it is not possible to assess whether all the relevant cost categories were incorporated. However, the setting of the study and the costs actually reported suggest that the perspective of the third-party payer (HMO) was adopted. Appropriately for this perspective, indirect costs were not estimated. The authors did not detect statistical differences in the total cost between the two patient groups, suggesting that differences in cost estimates due to a new perspective of setting might alter both the results and principle conclusions drawn. Patient records were used to estimate the quantities used. The costs and the quantities were reported separately, allowing the reader to ascertain the principle cost drivers. However, despite the time horizon extending to two years, the cost estimates were not discounted and, moreover, a price year was not reported. These factors reduce the ability of the reader to fully interpret the results and apply them to a new setting.
Other issues The authors made appropriate comparison of their findings with those of other authors, asserting that similar studies have also confirmed the benefits of multidisciplinary teams in the management of patients with chronic conditions. The generalisability of the study results were explicitly considered, with the authors acknowledging that the results are "limited to prefrail, high-usage seniors with limited functional impairments who had expressed an interest in participating in a group care model". Both significant and non significant results were presented, giving the reader a more complete understanding of the factors affecting costs and outcomes. In addition, several limitations were discussed. For example, the 'potential loss of adequate power due to selection of a sub-sample of patients from a larger study population', and the limited generalisability of the study.
Implications of the study The authors did not make any recommendations for policy or practice resulting from their study. They also did not make suggestions for further work.
Source of funding Supported by a grant from the Robert Wood Johnson Chronic Care Initiative.
Bibliographic details Scott J C, Conner D A, Venohr I, Gade G, McKenzie M, Kramer A M, Bryant L, Beck A. Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic. Journal of the American Geriatrics Society 2004; 52(9): 1463-1470 Other publications of related interest Beck A, Scott J, Williams P, et al. A randomised trial of group outpatient visits for chronically ill older HMO members: the cooperative healthcare clinic. Journal of the American Geriatrics Society 1997;45:543-9.
Indexing Status Subject indexing assigned by NLM MeSH Activities of Daily Living; Adult; Aged; Ambulatory Care /organization & Chronic Disease /psychology /therapy; Colorado; Disease Management; Emergency Service, Hospital /utilization; Female; Geriatric Assessment; Health Care Costs /statistics & Health Maintenance Organizations /organization & Health Services Research; Hospitalization /statistics & Humans; Male; Middle Aged; Models, Organizational; Patient Education as Topic /organization & Patient Satisfaction; Primary Health Care /organization & Program Evaluation; Quality of Life; Self Efficacy; Self-Help Groups /organization & administration; administration; administration; administration; administration; numerical data; numerical data AccessionNumber 22004001142 Date bibliographic record published 31/05/2005 Date abstract record published 31/05/2005 |
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