|Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients
|Hernandez C, Casas A, Escarrabill J, Alonso J, Puig-Junoy J, Farrero E, Vilagut G, Collvinent B, Rodriguez-Roisin R, Roca J
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.
The study compared the home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) patients admitted to the emergency room (ER) with conventional hospitalisation. HH included a free patient access phone to a specialised nurse. Each HH patient had a nurse visit within 24 hours after discharge. A maximum of 5 nurse visits at home were permitted during the 8-week follow-up period, but the number of phone calls the patient made to the nurse was not limited. The intervention was considered a failure if either the patient relapsed and required referral to the ER, or more than 5 nurse visits at home were needed during the follow-up period. The patients in the conventional care (CC) group were either admitted or discharged. A primary care physician, who was unaware of the protocol, supervised the discharged patients.
Economic study type
The study population comprised male and female patients with COPD exacerbations who were admitted to the ER. There were two primary criteria for inclusion in the study. One was COPD exacerbation as a major cause of referral to the ER. The other was the absence of any criteria for imperative hospitalisation, as stated by the British Thoracic Society (i.e. acute chest radiographic changes, confusion, impaired level of consciousness and an arterial pH of less than 7.35). Patients were excluded if they were not living in the health care area, were admitted from a nursing home, had extremely poor social conditions, were illiterate, or had no phone at home. They were also excluded if they had lung cancer and other advanced neoplasms, or had severe neurological or cardiac co-morbidities.
The study was carried out in two tertiary hospitals. The economic study was carried out in Barcelona, Spain.
Dates to which data relate
The effectiveness and resource use data were collected between 1 November 1999 and 1 November 2000. The price year was 2000.
Source of effectiveness data
The effectiveness data were derived from a single study.
Link between effectiveness and cost data
The costing was undertaken prospectively on the same patient sample as that used in the effectiveness study.
There was no mention of the use of power calculations to determine the sample size. Of the 629 patients screened, 220 (35%) met one of the exclusion criteria while 165 (26%) had imperative hospitalisation. This left 244 (38.8%) eligible for the study, of which 22 (3.5%) did not give consent. Therefore, 222 (35.5%) were randomised. There were 121 (54.5%) patients in the HH group and 101 (45.5%) patients in the CC group.
The study was a prospective, randomised controlled trial carried out in two centres. The patients were randomised to either HH or CC using computer-generated random numbers in a 1:1 ratio. One of the hospitals used a 2:1 randomisation during the first 3 months of the study, but the reason for this was not given. The patients were followed up to 8 weeks' post-discharge, at which point all the patients were assessed.
Analysis of effectiveness
The basis for the analysis of the clinical study (intention to treat or treatment completers only) was not stated, although it was implied that it was intention to treat. The main outcomes were the number of admissions, length of inpatient hospitalisation, patient satisfaction and HRQL status. HRQL status was measured using the St. George's Respiratory Questionnaire (SGRQ) and the Short Form 12 item survey (SF-12). A questionnaire to evaluate the patients' satisfaction was administered, blind, before the study and after the 8-week follow-up period. The baseline characteristics of the groups were shown to be comparable, although a statistical analysis was not conducted.
There were no differences in the rate of inpatient hospital readmission between the two groups. There were 23 in the HH group and 26 in the CC group.
The rate of relapses requiring new ER admission without subsequent readmission was 21 (22.3%) in the CC group and 11 (9.6%) in the HH group, (p<0.05).
The mean change in total SGRQ score was -6.9 in the HH group and -2.4 in the CC group, (p<0.05). The HH group showed higher improvement.
The mean patient satisfaction score was 8.0 in the HH group and 7.5 in the CC group, p=0.03. The HH group showed greater satisfaction.
Up to 68% of the HH patients were discharged from the ER without requiring hospitalisation (24 hours), compared with 39% of the control patients, (p<0.001). Consequently, the length of hospitalisation was also significantly lower for HH, 1.7 (+/- 2.33) days versus 4.2 (+/- 4.10) days, (p<0.001).
Other significant results (all p<0.001) were compliance in inhalation technique (81% HH and 48% CC), improvement in the knowledge of disease (57% HH and 27% CC), and rehabilitation at home (51% HH and 21% CC).
The study indicated that HH generated better outcomes than CC of COPD. These included lower hospitalisation rates, lower rates of admissions, clinically relevant improvements in HRQL (as assessed in the SGRQ), a higher degree of patient satisfaction, and an important positive impact on the knowledge of disease.
Measure of benefits used in the economic analysis
No summary measure of benefit was derived. Thus, the study was classified as a cost-consequences analysis.
Discounting was not undertaken since the costs were incurred during an 8-week period. The cost analysis was restricted to the direct health care costs of the public insurer. The resources implied by the programme, such as patient labour time and informal care, were not evaluated. The categories for estimating the cost were the length of hospital stay (days of initial hospitalisation plus days during hospital readmissions), ER visits not requiring readmission, hospital outpatient visits to specialists, primary care physician visits, visits for social support, nurse visits at home, treatment prescriptions, phone calls and transportation services.
The total cost for each category was calculated as the product of the number of events multiplied by the unit costs per event. The costs for nurse visits, drug prescriptions, phone calls and transportation services were calculated using information about labour cost, market prices and overhead cost. The average observed tariffs for COPD patients in a public insurance company were used since there were no unit costs for hospital stay and visits. The quantities and cost were estimated on the basis of actual data. The resources were measured between November 1999 and 2000. The price year was 2000.
Statistical analysis of costs
The costs were treated in a stochastic way and the results were expressed as mean (+/- standard deviation) or as percentages. Comparisons between the two study groups on admission and 8 weeks after discharge, and changes during the follow-up period were performed using independent t-tests, a non-parametric test (Mann-Whitney U-test) or the chi-squared test. Statistical significance was accepted at p<0.05.
The indirect costs were not included.
A sensitivity analysis was performed to assess the impact of using the average costs to evaluate hospital care. It was assumed that the resources released by the home hospitalisation intervention (days of hospital) would be either 75% or 50% of the average cost.
Estimated benefits used in the economic analysis
No summary measure of benefit was derived. See 'Effectiveness Results' section.
Only statistically significant results are reported. The average cost per patient in terms of hospitalisation was Euro 1,795 in the CC group versus Euro 941.4 in the HH group, (p<0.001). The average cost per patient in terms of ER visits was Euro 10.31 in the CC group versus Euro 24.59 in the HH group, (p=0.01).
Conversely the control group displayed lower costs for prescription costs than HH, Euro 172.06 versus Euro 217.21, (p=0.001).
The average total health care cost per patient in the HH group was 62% of the average of the control patients, Euro 1,255 (95% confidence interval: 978.54 - 1,568.04) versus Euro 2,033 (95% confidence interval: 1,547.05 - 2,556.81, (p=0.003).
Synthesis of costs and benefits
The costs and benefits were not combined.
The study indicated that home hospitalisation (HH) of selected cardiac obstructive pulmonary disease (COPD) exacerbations generated better outcomes at lower costs than conventional care (CC). The authors also acknowledged the fact that, despite the promising results of these new approaches, the prevention of early relapses after discharge is still an important challenge.
CRD COMMENTARY - Selection of comparators
The comparator was CC, which was justified as it represented normal practice in the authors' setting. You should decide if this is a widely used health technology in your own setting.
Validity of estimate of measure of effectiveness
The study used a randomised controlled trial, which was appropriate for the study question. The study sample was representative of the population. In addition, the patient groups were shown to be comparable at analysis. Methods of randomisation, blinding, length and loss to follow-up were all reported, suggesting that the internal validity of the study is likely to be quite high. No power calculations were reported. Thus, it is not possible to ascertain whether the results obtained were due to chance.
Validity of estimate of measure of benefit
No summary measure of benefit was used in the economic evaluation. The analysis was therefore categorised as a cost-consequences study.
Validity of estimate of costs
The study was conducted from the perspective of the third-party payer and, as such, all the costs relevant were included in the analysis. The costs and the quantities were reported separately and the price year was reported. These facts will assist the reproducibility of the results in other settings. Statistical analyses of the quantities and costs were performed, as were sensitivity analyses of the costs. Discounting was unnecessary since all the costs were incurred in one year, and was not conducted.
The authors made appropriate comparisons of their effectiveness findings with those from other studies. The issue of generalisability to other setting was addressed by considering internal and external validity. The authors reported two main limitations to their study. First, the perspective adopted was that of the public health care insurer that excluded non-health care costs. Second, the average costs were used to evaluate health care. The authors do not appear to have presented their results selectively. In addition, the conclusions reached reflect the scope of the analysis.
Implications of the study
The authors indicated that their study highlighted the need for managerial aspects of COPD patients to be revisited. They proposed a patient-centred approach, with special emphasis on shared care arrangements across the health care system and within a multidisciplinary primary care team, to meet the needs of critically ill people. They indicate that the study prompts the need for the deployment of HH as a regular health care service for COPD patients under the frame of a properly designed cost-effectiveness analysis.
Source of funding
Supported by grants AATM 8/02/99 from the Agencia d'Avaluacio de Tecnologia Medica; FIS 98/0052-01 from the Fondo de Investigaciones Sanitarias; SEPAR 1998; CHRONIC project (IST-1999/12158) from the European Union (DG XIII); and, Comissionat per a Universitats i Recerca de la Generalitat de Catalunya (1999-SGR-00228). A Casas was a predoctoral research fellow supported by CHRONIC and grant-in-aid by ESTEVE group.
Hernandez C, Casas A, Escarrabill J, Alonso J, Puig-Junoy J, Farrero E, Vilagut G, Collvinent B, Rodriguez-Roisin R, Roca J. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. European Respiratory Journal 2003; 21(1): 58-67
Subject indexing assigned by NLM
Aged; Cost-Benefit Analysis; Female; Follow-Up Studies; Home Care Services, Hospital-Based /economics; Hospitalization /economics; Humans; Male; Middle Aged; Pulmonary Disease, Chronic Obstructive /therapy; Quality of Life; Time Factors
Date bibliographic record published
Date abstract record published