|A prospective study of cost, patient satisfaction, and outcome of treatment of chalazion by medical and nursing staff
|Jackson T L, Beun L
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.
Surgical and conservative treatments for chalazia, provided by either a senior nurse or a senior house officer (SHO) ophthalmologist, were studied.
Economic study type
The study population comprised all patients attending a district general eye hospital for treatment of chalazion.
The setting was secondary care. The study was undertaken at the Sussex Eye Hospital, Brighton, UK.
Dates to which data relate
The effectiveness data were collected during 1995. It appears that the resource data were collected alongside the effectiveness data. No price year was 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 using the same patient sample as that used in the effectiveness analysis.
No power calculations to determine the appropriate size of the sample were reported. All of the patients who attended the clinic between January and May 1995 were included in the study. A total of 129 patients, resulting in 217 hospital visits, were included in the study sample. Of the 217 hospital visits, 89 (41%) were with a SHO and 128 were with a nurse. Overall, 60 (47%) patients were seen exclusively by a nurse, 39 (30%) were seen exclusively by a SHO, and 30 (23%) were seen by both professionals on different hospital visits. The patients were included in the study as part of their normal treatment. Consequently, they did not explicitly agree to be included in the study. The paper did not report how the study sample compared to the whole patient population with chalazion.
The study was a non-randomised controlled trial that was carried out in a single centre. The patients were allocated to receive nurse or SHO treatment on the basis of which clinic had the earliest appointment. The patients were followed up until December 1995, a period of between 7 and 12 7 months depending on when they joined the study. A total of 32 (24.8%) patients were lost to follow-up. Of these, 19 (25.3%) were treated by a nurse and 13 (10.0%) by a SHO. Data on the outcomes were collected via mailed questionnaires. Those patients who did not respond were mailed again and contacted by phone. Discomfort with the procedure was measured with a visual analogue scale.
Analysis of effectiveness
The primary clinical measure used in this study was whether the treatment was considered to be a success. Successful treatment was defined as the cyst being completely resolved, or becoming so small that it no longer bothered the patient 3 months after treatment. Treatment failure was defined as the cyst remaining troublesome 3 months after treatment, or the patient re-presenting at any point in the 12-month study period. Patient ratings of treatment and diagnosis explanations, patient ratings of pain, and surgical complications were also assessed. The analysis reported in the paper accounted for all 129 of the patients initially included in the study sample. There were no statistically significant differences in the gender ratios, median age or median duration of symptoms between the patients in the three groups.
Overall, 54% of the treatments undertaken by the nurse were successful versus 44% of those performed by a SHO, (p=0.413).
Of the patients treated conservatively, 43% who were seen by a nurse and 13% who were seen by a SHO indicated that their treatment had been successful, (p=0.030).
Surgical treatment was successful in 64% of the cases treated by a nurse and 83% of those treated by a SHO, (p=0.197). There were no complications resulting from surgery in either group.
The mean pain score (from a 10-cm scale) was 1.7 cm (standard deviation, SD=2) for the nurse group and 3.8 cm (SD=2.7) for the SHO group, (p=0.003).
Patients treated by the nurse rated the explanations for diagnosis and treatment and overall treatment significantly higher than those treated by a SHO, (p=<0.05).
There were no surgical complications in either group.
The treatment of chalazion by a nurse using either conservative or surgical methods is safe. The only statistically significant difference in effectiveness was the higher success rate with conservative treatment if administered by a senior nurse. Consequently, it is not possible to determine whether overall treatment by a senior nurse is more or less effective than when treatment is delivered by a SHO. Patient satisfaction with the treatment itself was higher for the nurse group.
Measure of benefits used in the economic analysis
There was no summary measure of benefit. Hence, a cost-consequences analysis was conducted.
The cost/resource boundary adopted appears to have been that of the hospital. The costs included wages, disposables, topical and systemic antibiotics, dispensing, histology and treatment. Some quantities and unit costs were reported separately. It was not explicitly stated, but the resource quantities were derived from the treatment protocols in the study. The NHS Trust's prices were used to cost all items excluding antibiotics. Wage costs included an additional 11% to cover holiday pay, sickness and the employer's pension contributions. The price of antibiotics was taken from the British National Formulary. A dispensing cost of 0.81 was added to cover the cost of the container and the initial prescription fee.
None of the costs were discounted, which was appropriate since the study period was only 12 months. No price year was reported in the paper.
Statistical analysis of costs
The cost data were treated in a deterministic manner.
No indirect costs were included in the study.
No sensitivity analysis was undertaken.
Estimated benefits used in the economic analysis
See the 'Effectiveness Results' section.
The total costs per treatment group were not reported in this study.
The marginal cost of treating chalazion with surgical methods was 9.73 if performed by a senior nurse and 9.61 if undertaken by a SHO. Conservative treatment had a marginal cost of 2.73 if delivered by a senior nurse and 2.67 if performed by a SHO.
The marginal cost of treating the 60 patients seen exclusively by the nurse was 11.56 per patient and 9.91 per cyst. This compares with 12.41 per patient and 12.10 per cyst treated exclusively by the SHO.
Synthesis of costs and benefits
Not relevant as a cost-consequences analysis was undertaken.
The treatment of chalazion by a senior nurse was more cost-effective than treatment by a senior house officer (SHO), as patients treated by a nurse were less likely to require a return visit and more likely to receive cheaper treatment.
CRD COMMENTARY - Selection of comparators
The comparator used in the study was selected on the basis of usual practice in the authors' setting. You should consider whether the use of SHOs to treat chalazion represents usual practice in your own setting.
Validity of estimate of measure of effectiveness
The effectiveness data were taken from a non-randomised controlled trial with patients allocated to treatment by either a senior nurse or a SHO on the basis of appointment availability. A randomised controlled trial would have been preferable. The authors acknowledged that the lack of randomisation in the study potentially introduced bias into the effectiveness results. The two patient groups were shown to be comparable in terms of their gender, age and duration of symptoms at the start of treatment. The authors did not compare the characteristics of the study sample with those of the whole patient population presenting with chalazion. Consequently, it is not possible to identify whether the sample accurately reflected the whole patient population. The effectiveness results of this study were limited by the sample size. It is possible that the crude differences in the two treatment groups that did not prove to be statistically significant might have become clearer, and therefore statistically significant, had the sample size been larger. The difference in loss to follow-up between the groups could also have introduced bias.
Validity of estimate of measure of benefit
The authors did not derive a summary measure of benefit.
Validity of estimate of costs
The paper did not explicitly state the perspective from which the study was conducted. However, there was an implicit implication that the study was conducted from the perspective of a NHS Trust. The total costs and the units used were reported for the majority of the costs included in the study. This enhances the scope for generalising the findings of this study to other settings. On the other hand, using a setting-specific source for the cost of resources from the Trust's pricing structure, rather than a national cost structure, means that the generalisability of the study may be limited. The lack of a clear price year would hinder any future reflation exercises that might be undertaken to allow comparisons between this study and others in the same field.
The authors concluded that treatment with a nurse would, in part, be more cost-effective than with a SHO since the patients treated by the nurse would be less likely to make a return visit. This was not immediately obvious from the study. The authors stated that this study was the first prospective trial to look at chalazion treatment provided by nurses. Consequently, they were unable to compare their results to similar studies. They also did not consider whether the results of this study might be generalisable to other settings. The reporting of the results was adequate.
Implications of the study
The authors did not make any specific recommendations. However, in reporting that the treatment of chalazion by senior nurses is safe and cost-effective, they imply that it is an appropriate treatment option.
Jackson T L, Beun L. A prospective study of cost, patient satisfaction, and outcome of treatment of chalazion by medical and nursing staff. British Journal of Ophthalmology 2000; 84(7): 782-785
Subject indexing assigned by NLM
Adolescent; Adult; Aged; Chalazion /economics /therapy; Cost-Benefit Analysis; Female; Health Care Costs; Hospitals, District; Humans; Male; Medical Staff, Hospital /economics; Middle Aged; Nursing Staff, Hospital /economics; Patient Satisfaction; Prospective Studies; Treatment Outcome
Date bibliographic record published
Date abstract record published