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Economic analysis of an early discharge rehabilitation service for older people |
Miller P, Gladman J R, Cunliffe A L, Husbands S L, Dewey M E, Harwood R H |
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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 early discharge and rehabilitation service (EDRS) was examined. This comprised a home care and rehabilitation package providing up to four visits per day for up to 4 weeks, delivered by a team of nurses, physiotherapists, occupational therapists and rehabilitation assistants.
Study population The study population comprised old patients aged 65 or older, who were medically fit for discharge and had social and rehabilitation needs that could be met at home, and could manage without 24-hour care.
Setting The setting was the community. The economic study was carried out in the UK.
Dates to which data relate The effectiveness and resource use data were gathered in 1999 and 2000. The costs were estimated using 2000/01 prices.
Source of effectiveness data The effectiveness evidence was derived from a single published study (Cunliffe et al. 2004, see 'Other Publications of Related Interest' below for bibliographic details).
Link between effectiveness and cost data The costing was carried out prospectively on the same sample of patients as that used in the effectiveness study.
Study sample Power calculations were not reported. Of the 17,500 people potentially eligible, a sample of 498 patients was initially selected. However, 128 patients did not enter the study (82 were referred during periods of non-randomisation, 27 did not meet criteria, and 19 did not give consent). Thus, the final study sample comprised 370 patients, of which 185 were allocated to UC and 185 to EDRS. The participants had a median age of 80 years, 246 (67%) were female, 247 (67%) lived alone, and the median hospital stay at randomisation was 13.5 days.
Study design This was a prospective, randomised clinical trial that was carried out at several medical centres in Nottingham, UK. Details of the methods of randomisation and outcome assessment were not reported. The length of follow-up was 12 months but the outcomes were also assessed at 3 months. At the end of the follow-up period, 32 patients in the UC group had died, 8 had withdrawn consent, and 5 had either declined follow-up or given an uninterpretable reply. In the EDRS group, 34 patients had died, 11 had withdrawn consent, and 8 had either declined follow-up or given an uninterpretable reply. One patient initially included in the UC group received EDRS instead. Thus, clinical data were available for 140 patients in the UC group and 132 patients in the EDRS group.
Analysis of effectiveness It was not stated whether the analysis of the clinical study was conducted on an intention to treat basis or on treatment completers only. The outcome measures used in the economic evaluation were:
improvements in personal activities of daily living, kitchen and domestic activities of daily living, and psychological well-being;
length of hospital stay; and
quality of life, which was estimated using the EuroQol EQ-5D.
The authors that the study groups were comparable at baseline in terms of their age, gender, diagnosis, and current or prior activity limitation.
Effectiveness results The results of the clinical trial were reported in a narrative fashion.
At 3 months, the EDRS patients performed better in personal activities of daily living, kitchen and domestic activities of daily living, and had greater psychological well-being.
Benefits in domestic activities of daily living and psychological well-being remained significant at 12 months.
The EDRS carers had better psychological well-being at 3 months.
The EDRS reduced the mean length of hospital stay by 9 days, based on an average of 22 home visits.
The results of the other outcome measures were not reported.
Clinical conclusions The effectiveness analysis showed that the EDRS improved several aspects of the patients' health.
Measure of benefits used in the economic analysis The summary benefit measure used was the number of quality-adjusted life-years (QALYs). The QALYs were estimated by combining expected survival with utility weights derived from the clinical trial. A zero score was given to the 66 participants who were dead at 12 months. The calculation of QALYs was based on the sample of patients who provided utility values (272 patients using a postal questionnaire), without any attempt to impute any missing values.
Direct costs The cost analysis was carried out from the perspective of the service providers (health and social services). Thus, only the direct medical costs were included. The health services considered in the analysis were the EDRS intervention, the initial acute hospital admission (from randomisation), inpatient readmission to hospital, hospital outpatient visits, stays in nursing and residential homes, general practitioner contact, community health services and social services. The bulk of the resource use was estimated using patient-level data that were derived from the sample of patients participating in the clinical trial. Most of the data were assessed using recorded client contacts. Resource consumption associated with social services was based on authors' assumptions. The costs were derived from typical National Health Service sources, such as reference cost schedules and the Personal Social Service Research Units. The unit costs were not presented separately from the quantities of resources used. Discounting was not relevant since the costs were incurred during a short timeframe. The costs were assessed using 2000/01 prices.
Statistical analysis of costs Statistical analyses were carried out to test the statistical significance of differences in the total costs. Owing to the skewed distribution of the costs, comparisons were adjusted using three different statistical approaches.
Indirect Costs The indirect costs were not considered in the economic evaluation.
Sensitivity analysis A simple sensitivity analysis was carried out by halving the hospitalisation cost and doubling the EDRS cost. Further, bootstrap estimates were calculated for both the costs and benefits using 2,000 iterations. These were plotted in a cost-effectiveness plane and resulted in a cost-effectiveness acceptability curve.
Estimated benefits used in the economic analysis The estimated QALYs were not reported.
Cost results In the unadjusted analysis, the average total cost per patient was 8,361 (+/- 540) (median 5,283; interquartile range, IQR 9,465; 95% confidence interval, CI: +/-1,059) with EDRS and 10,088 (+/-713) (median 6,539; IQR 9,913; 95% CI: +/-1,398). The average cost difference was 1,727 (95% CI: +/- 2,481; p=0.054).
The difference in costs reached statistical significance in the three adjusted analyses. The cost-difference ranged from 1,728 to 2,017 depending on the statistical method used.
Among the categories of resources used, the costs for initial inpatient admissions and day hospital were significantly lower in the EDRS group, while the costs for the EDRS intervention were clearly significantly lower in the UC group (only 1 patients had EDRS in the UC group). The other categories of costs did not differ significantly between the two groups.
Synthesis of costs and benefits The costs and QALYs of EDRS over UC were combined by means of a scatter plot on the cost-effectiveness plane. This showed that EDRS was predominantly cost-saving, while the incremental effect was borderline (i.e. it ranged from more effective to less effective).
The acceptability curve showed that EDRS had a high probability to be cost-effective at the usual level of willingness-to-pay per QALY.
The results of the sensitivity analysis (EDRS cost doubled) showed that the probability that EDRS was cost-effective over UC was lower but always higher than 50% for different willingness-to-pay values.
Authors' conclusions The early discharge rehabilitation service (EDRS) had already proved its effectiveness in comparison with usual care (UC) for the elderly. The current study showed that it was also cost-saving from the perspective of the service providers.
CRD COMMENTARY - Selection of comparators The rationale for the selection of the comparator was clear, as the EDRS was compared with the conventional pattern of care. You should decide whether they are valid comparators in your own setting.
Validity of estimate of measure of effectiveness The effectiveness data came from a clinical trial, which was appropriate for the study question. The use of a randomised design minimises the potential impact of confounding factors and selection bias. Further, the patient groups were comparable at baseline. Only a few details on the methods of sample selection were reported since the study had already been published. In fact, there was no information on the randomisation procedure, the methods used to assess the outcomes, the approach used to deal with patients lost to follow-up, and the appropriateness of the sample size. Moreover, the results of the effectiveness analysis were not reported. The reader is referred to the primary study for those details that are relevant to an assessment of the validity of the clinical data.
Validity of estimate of measure of benefit QALYs were the most appropriate benefit measure as they capture the impact of the intervention on quality of care and survival, which are the most relevant dimensions of care. However, limited information on the calculation of the QALYs was provided. The instrument used to assess utility weights was reported, but the estimated utility weights and QALYs were not. The use of QALYs enables comparisons with the benefits of other health care interventions.
Validity of estimate of costs The costs included were consistent with the perspective adopted in the study. The authors stated that a societal perspective could not be adopted because of the lack of information on private costs. The unit costs were not presented separately from the quantities of resources used, which limits the possibility of replicating the results in other settings. Statistical analyses were performed in order to compare differences in the costs, and three different approaches were used to deal with the skewed distribution of the costs. The results of the unadjusted analysis were reported alongside those of the adjusted one. The source of the costs was consistent with the perspective adopted. The price year was reported, which enhances the possibility of reflating the cost results in other time periods.
Other issues The authors stated that their findings were comparable with those of another English scheme, but the results of the other publication were not provided. In terms of the issue of the generalisability of the study results to other settings, the authors noted that their findings should not be transferred to other services that are under-resourced, under-skilled or badly managed; to post-discharge services that are not specifically directed towards reducing the length of hospital stay; or to services where the costs of the intervention are likely to be very much higher, such as hospital-at-home or care home rehabilitation schemes. The results of the analysis were reported selectively. In fact, since the results of the clinical trial had already been published, the analysis focused on the costs. The estimated incremental cost per QALY was not reported and only a graphical representation of the incremental effects and costs of EDRS compared with UC was provided.
Implications of the study The authors recommended the implementation of an adequately resourced, skilled and managed EDRS.
Source of funding Funded by the Nottingham Health Authority.
Bibliographic details Miller P, Gladman J R, Cunliffe A L, Husbands S L, Dewey M E, Harwood R H. Economic analysis of an early discharge rehabilitation service for older people. Age and Ageing 2005; 34(3): 274-280 Other publications of related interest Cunliffe AL, Gladman JR, Husbands SL, et al. Sooner and healthier: a randomised controlled trial of an early discharge rehabilitation service for older people. Age Ageing 2004;33:246-52.
Coast J, Richards S, Gunnell D, et al. Hospital at home or acute hospital care? A cost minimisation analysis. BMJ 1998;316:1802-6.
Iliffe S, Shepperd S. What do we know about hospital at home? Lessons from international experience. Appl Health Econ Health Policy 2002;1:141-7.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Aged, 80 and over; Algorithms; Cost-Benefit Analysis /methods; Female; Great Britain; Humans; Length of Stay; Male; Patient Discharge /economics; Quality of Life; Rehabilitation /economics; Time Factors AccessionNumber 22005000906 Date bibliographic record published 28/02/2006 Date abstract record published 28/02/2006 |
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