|
Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial |
Haines TP, Hill AM, Hill KD, Brauer SG, Hoffmann T, Etherton-Beer C, McPhail SM |
|
|
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. CRD summary This study evaluated the cost-effectiveness of an intensive multimedia patient education programme to prevent falls, for cognitively intact hospital in-patients, aged over 60 years. The authors concluded that if the percentage of patients who had a fall, with usual care, was four or higher, their programme could prevent falls and reduce costs. The study appears to have been well conducted, but more detail on the trial would have been useful. The certainty of the conclusions is unclear. Type of economic evaluation Cost-effectiveness analysis Study objective This study evaluated the cost-effectiveness of an intensive multimedia patient education programme to prevent falls, for cognitively intact hospital in-patients, aged over 60 years. Interventions Intensive multimedia patient education materials were delivered with trained health professional follow-up, in addition to their usual care, and this was compared with usual care alone. Another group received the education materials without professional follow-up, but this was not included in the cost-effectiveness analysis. Usual care varied across sites, and comprised a locally developed falls risk screening tool with generic interventions, such as orienting patients to a ward. The intervention follow-up was designed as four face-to-face education sessions, but more or fewer sessions could be provided. Location/setting Australia/in-patient care. Methods Analytical approach:This economic evaluation was conducted alongside a multicentre randomised controlled trial. The differences in costs and effects were calculated from individual patient data. To explore the variability across settings, a simple decision tree was constructed, with outcomes for usual care, as well as treatment. The time horizon was the duration of the clinical trial. The authors stated that they adopted a health service perspective. Effectiveness data:The main effectiveness outcome was the reduction in the proportion of patients who fell, for those on the full programme, relative to those on usual care. A research assistant, blinded to the patients' group allocation, recorded the falls through computerised incident reports, medical notes, and weekly face-to-face interviews. There were 1,206 patients, in total; effectiveness was presented for cognitively intact patients and cognitively impaired patients, but the cost-effectiveness analysis only included the cognitively intact patients. The difference in effects between groups was estimated from a multiple regression, adjusting for admission diagnosis and whether there was admission to a rehabilitation ward. Monetary benefit and utility valuations:Not relevant. Measure of benefit:The measures of benefit were the number of falls prevented, and the reduction in the number of patients who fell (a patient could fall more than once). Cost data:The cost categories were the education programme, acute hospital care, rehabilitation, and falls. The education programme costs included start-up, training, and equipment; labour; and the ongoing costs of the education provider. The costs of acute hospitalisation were valued using Victorian diagnosis-related group data from 2008 to 2009. These costs were multiplied by 1.33 to cover the fixed costs of the hospital. In-patient rehabilitation costs were calculated using site-specific per day costs. The costs of falls included time spent completing medical assessments and documents, additional monitoring, and radiology (valued using private sector rates). All labour costs were valued at local rates and inflated by a factor of 1.3 to reflect sick and annual leave. The difference in costs between groups was calculated using multiple regression, adjusting for many covariates. All costs were reported in Australian dollars (AUD). The price year was 2008. Analysis of uncertainty:Bootstrap resampling was used to produce 95% confidence intervals around the cost-effectiveness estimates, and to calculate cost-effectiveness acceptability curves of the likelihood that an intervention is cost-effective at different thresholds. The proportion of patients who fell in the usual care arm, the cost of a patient who fell, and the effectiveness of the intervention, were varied to explore their impact on the results of the simple decision tree. The cost of a fall was estimated using adjusted multiple regression, unadjusted data, and data from an earlier analysis. Results The cost per faller and cost per fall varied by the type of regression used. In a simple ordinary least squares regression, with no outliers, the cost per fall was AUD 12,469 and the cost per faller was AUD 24,927. The authors defined outliers as patients with costs that were more than three standard deviations from the mean (29 patients). The removal of these outliers and an analysis termed a 'robust regression' produced costs per fall and costs per faller that were about a third lower. The incremental cost-effectiveness of the multimedia programme was AUD 526 per faller prevented or AUD 294 per fall prevented. There was considerable uncertainty in these results due to some patients with very long stays in hospital. The probability that the programme was cost-effective was 0.95 at a threshold of AUD 68,108 per faller prevented or AUD 38,213 per fall prevented. The probability that the programme was more effective and less costly was 0.52. The greatest uncertainty lay in the cost per faller. The three estimates of this cost varied widely: AUD 58, AUD 2,867, and AUD 14,591. When the highest cost was used, the intervention cost less than usual care in every scenario. Authors' conclusions The authors concluded that if the percentage of cognitively intact patients who had a fall, on a ward, under usual care conditions, was 4% or higher, then their multimedia programme was likely to both prevent falls and reduce costs. CRD commentary Interventions:The interventions were partly described. The authors referenced a clinical paper for more details (see Other Publications of Related Interest). Usual care was included as a comparator, which was useful for local decision makers, but the authors noted that usual care could vary significantly by setting. Effectiveness/benefits:The effectiveness data were from a large randomised controlled trial with potentially high validity, but few details were reported; the reference was given. The authors quoted at least one other trial, but there was no discussion of the possibility of synthesising the data across trials. This may be due to the fact that subgroups within the trial were selected for analysis. Costs:The methods used to calculate the costs appear to have been appropriate, but there were significant differences in cost estimates for a fall, depending on the method used and the source of data. The sample size for the subgroup analysed was not stated; it is possible that a small sample was used. The exclusion of outliers, with much higher costs, was likely to result in much lower estimates. Analysis and results:The results were mostly well reported. Appropriate sensitivity analyses appear to have been conducted. A wide range of costs per faller prevented were used, but it was not entirely clear how these costs were chosen, and how representative they were of different implementation environments. It was unclear what was meant by 'robust regression'; the methods should have been reported. This was important as it affected the cost-effectiveness of the intervention. The authors sufficiently compared their cost results to the costs for falls and fallers found in other studies. They acknowledged their study limitations, and assessed the applicability of their results to other settings. They stated that this was the first economic analysis conducted alongside a randomised controlled trial, on patient education. Concluding remarks:The study appears to have been reasonably well conducted, but more detail on the trial methods would have been useful. It is not clear how certain the authors' conclusions are. Funding Funded by the National Health and Medical Research Council, Australia. Bibliographic details Haines TP, Hill AM, Hill KD, Brauer SG, Hoffmann T, Etherton-Beer C, McPhail SM. Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial. BMC Medicine 2013; 11: 135 Other publications of related interest Haines TP, Hill AM, Hill KD, McPhail S, Oliver D, Brauer S, Hoffmann T, Beer C: Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Archives of Internal Medicine 2011; 171: 516-524. Indexing Status Subject indexing assigned by NLM MeSH Accidental Falls /economics /prevention & Aged; Aged, 80 and over; Cohort Studies; Cost-Benefit Analysis /economics /methods; Decision Trees; Female; Hospitalization /economics; Humans; Male; Middle Aged; Patient Education as Topic /economics; control AccessionNumber 22013021504 Date bibliographic record published 06/06/2013 Date abstract record published 08/10/2013 |
|
|
|